Following the Canadian Code of Ethics for Psychologists

in Resolving an Ethical Dilemma

Kelly A. DeCoste
University of Calgary

Dilemma: I feel that this youth needs a psychiatric assessment completed prior to me being
able to commence counseling. However, this is outside my area of competence and the
closest available service is 100 miles away. This would put considerable strain on the family
as they do not have the means to get to the city, and they would have trouble paying for
expenses associated with the trip (or trips; e.g., food, hotel if overnight stay required). The
grandmother has told me about her close relationship with her grandson, and has divulged
the recent death of her husband, as well as lasting effects of her experiences in residential
schools. It is the combination of these factors that I believe contributes to a highly
dependent relationship and I must ensure I do not place additional stress on these
individuals.
1. Identification of the individuals and groups potentially affected by the decision .
The youth and his grandmother are the primary individuals who will be affected by my decision.
As the principal and teacher were the individuals to bring their concerns to my attention, they will
also be impacted. Finally, if the youth does suffer from psychotic symptoms, his schoolmates and
his community as a whole may also be affected by my decision.

2. Identification of ethically relevant issues and practices, including the interests, rights, and
any relevant characteristics of the individuals and groups involved and of the system or
circumstances in which the ethical problem arose.
Principle/Value

My Thoughts

Principle I: Respect for the Dignity of

Persons
No specific standard. Values statements:
With respect to psychologists, this concept

This youths location should not exclude him

implies that all persons are entitled to

benefit equally from the contributions of
psychology and to equal quality in the
processes, procedures, and services being
conducted by psychologists, regardless of
the persons characteristics, condition, or
status.

from receiving the best possible treatment.

psychologists recognize that as individual,

family, group, or community vulnerabilities
increase, or as the power of persons to
control their environment or their lives
decreases, psychologists have an increasing
responsibility to seek ethical advice and to
establish safeguards to protect the rights of
the persons involved.

It is my opinion that both the youth and his

grandmother are dealing with several factors
that place them in a vulnerable
position/classify them as vulnerable persons
(e.g., death, abandonment, traumatic events,
etc.).

General Respect
I.1 Demonstrate appropriate respect for
the knowledge, insight, experience, and
areas of expertise of others

- I must ensure I am respectful to the

grandmother in my decision. She has specific
knowledge and experience, and I am not fully
aware of the relationship between her and her
grandson, nor the circumstances surrounding
her guardianship. She is also coping with her
own issues surrounding past experiences in
residential schools, and as such, I feel that I
have increased responsibility to establish
safeguards for them both. However, as the
youth is the most vulnerable, my greatest
responsibility is to him.
- I must also be cognizant of this familys
cultural system and ensure I am showing
appropriate respect to, and develop an
understanding of, this community and their
practices and beliefs. It is possible that the
experiences that concern me are viewed as
normal in this culture/community.

General Rights
I.8 - Respect the right of research
participants, clients, employees, supervisees,
students, trainees, and others to safeguard
their own dignity.
Non-discrimination

I must keep in mind that the

experiences/symptoms reported by this youth
may be considered normal in his culture.

I must ensure this youth is not excluded from

the benefits of a psychiatric assessment
because of his rural location.

I.9: Not practice, condone, facilitate, or

collaborate with any form of unjust
discrimination.
I.11 Seek to design research, teaching,
practice, and business activities in such a
way that they contribute to the fair
distribution of benefits to individuals and
groups, and that they do not unfairly
exclude those who are vulnerable or might
be disadvantaged.
Informed Consent
I.16 - Seek as full and active participation as
possible from others in decisions that affect
them, respecting and integrating as much as
possible their opinions and wishes.

I.17 - Recognize that informed consent is the

result of a process of reaching an agreement
to work collaboratively, rather than of
simply having a consent form signed.

I.23 - Provide, in obtaining informed

consent, as much information as reasonable
or prudent persons would want to know
before making a decision or consenting to
the activity. The psychologist would relay
this information in language that the
persons understand (including providing
translation into another language, if
necessary) and would take whatever
reasonable steps are needed to ensure that
the information was, in fact, understood.

As I do not share their cultural background,

this family may feel unequal in their
interactions with me. Also, the grandmothers
vulnerabilities as a result of her experiences in
residential schools may further contribute to
her feeling in a position of lesser power.

It is important that I involve the grandmother

and her grandson in all steps involved in
developing an appropriate course of action. I
will share my concerns with her, the process of
a referral and possible outcomes. I must ensure
that I provide lots of opportunities for them to
share their thoughts/wishes surrounding this
course of action, as well as making sure I am
looking for nonverbal cues.
I must ensure that they both fully understand,
and are in approval of, whatever course of
action we decide and do not feel pressured to
comply. I must be cognizant of the potential
effects of a power differential, cultural
differences and residual effects from her past
experiences.
The youths grandmother speaks English as a
second language, and I am not sure of the level
of education she received in the residential
schools (or elsewhere). I must make sure that I
am using language that she is likely to
understand, asking if clarification is needed,
and watching for nonverbal cues that she does
not understand in case she is not comfortable
asking for clarification. I also need to make
sure that she understands my concerns about
the youths symptoms and why I feel the
assessment is important. I must describe what
this assessment entails, and what a diagnosis
would mean in terms of possible treatment, etc.
so that, if it turns out that he does suffer from a
psychiatric disorder, they are prepared for this

diagnosis (this goes with Standard I.24 as

well). This will result in less stress on them, as
well as increasing the likelihood of continuing
with the necessary treatment.
Principle II: Responsible Caring
General Caring
II.1 - Protect and promote the welfare of
clients, research participants, employees,
supervisees, students, trainees, colleagues,
and others.

II.3 - Accept responsibility for the

consequences of their actions.

I must make sure I choose the best course of

action to protect and promote the welfare of
this youth. As his grandmother (his guardian) is
also vulnerable, I must ensure my decision
promotes her welfare/does not cause her undue
stress, which could also cause increased stress
for the youth (Standard II.2 applies here as
well).
Despite my best efforts in planning the best
course of action, there may be consequences I
hadnt planned for. For example, if the
assessment reveals a psychiatric disorder, the
grandmother may choose not to consent to
further treatment (even though the
process/possible outcomes were explained) and
I will need to decide on remedial action.

Competence & Self-Knowledge

II.6 - Offer or carry out (without
supervision) only those activities for which
they have established their competence to
carry them out to the benefit of others.

I know that I am not qualified to

assess/diagnose a psychiatric disorder and must
seek the services of a professional who is (II.7
applies here as well).

II.8 - Take immediate steps to obtain

consultation or to refer a client to a
colleague or other appropriate professional,
whichever is more likely to result in
providing the client with competent service,
if it becomes apparent that a clients
problems are beyond their competence.

When the youth mentioned what could be

psychotic symptoms, I knew I had to arrange
an assessment as this is beyond my
competence. Counseling without pursuing this
assessment would not be providing the youth
with the best possible service and could be
placing him or others in harms way.

II.10 - Evaluate how their own experiences,

attitudes, culture, beliefs, values, social
context, individual differences, specific
training, and stresses influence their
interactions with others, and integrate this
awareness into all efforts to benefit and not
harm others.

Though I believe the youth has described

possible psychiatric symptoms, it is also
possible that these experiences are viewed as
normal in his culture. I must be careful not to
make assumptions/say things that are
discriminatory against their beliefs. Also, I
recognize that I feel strongly about child

Risk/benefit Analysis
II.13 - Assess the individuals, families,
groups, and communities involved in their
activities adequately enough to ensure that
they will be able to discern what will benefit
and not harm the persons involved.

II.14: Be sufficiently sensitive to and

knowledgeable about individual, group,
community, and cultural differences and
vulnerabilities to discern what will benefit
and not harm persons involved in their
activities.

abandonment and must ensure I do not make

assumptions about this familys circumstances.
My feelings cannot interfere with my
objectivity.
I cannot say I have done this without having
my questions answered surrounding the youths
symptoms (not pursuing an assessment could
cause serious harm to him or others if he does
suffer from a psychiatric disorder). The results
of the assessment will answer these questions
for me and I will be in a better position to
determine what will benefit/harm him.
I am new to this community and now realize
that I know only the basics/common
knowledge about residential schools. With a
high aboriginal population in this community, I
am likely to encounter other individuals also
suffering effects from these experiences in my
practice. I must do some research in this area.

Maximize Benefit
II.18 - Provide services that are coordinated
over time and with other service providers,
in order to avoid duplication or working at
cross-purposes.

I will need to work in collaboration with the

professional who is providing treatment for the
youths psychiatric disorder, if present. Ongoing, clear communication is a necessity.

II.21 - Strive to provide and/or obtain the

best possible service for those needing and
seeking psychological service

I must pursue a psychiatric assessment before

beginning counseling so that I can ensure the
youth receives the best course of treatment
possible.

Minimize Harm
II.31 - Give reasonable assistance to secure
needed psychological services or activities, if
personally unable to meet requests for
needed psychological services or activities.

II.32 - Provide a client, if appropriate and if

The psychiatric assessment is out of my area of

competence, but it is reasonable for me to
arrange one with someone who is qualified. I
hope to find someone who is willing to make
the commute to do the assessment (or who has
experience with these assessments via
videoconferences). This may require a little
more effort, but is still not unreasonable.
This family does not have the (transportation)
means to access a psychiatric assessment, and

desired by the client, with reasonable

assistance to find a way to receive needed
services in the event that third party
payments are exhausted and the client
cannot afford the fees involved.

II.33 - Maintain appropriate contact,

support, and responsibility for caring until a
colleague or other professional begins
service, if referring a client to a colleague or
other professional.

their financial situation is a concern if trips to

the city are required. With their consent, I can
try to arrange an assessment with a psychiatrist
who is willing to come here, or use
videoconferencing technology to do the
assessment. I can also help secure a means to
the city if required.
It is important that I continue to provide
contact/support for the youth until the
assessment has been completed, at which time
I can proceed with counseling, provided it is in
his best interests and within my competence.

Principle III: Integrity in Relationships

Accuracy and Honesty
III.8 - Acknowledge the limitations of their
own and their colleagues knowledge,
methods, findings, interventions, and views.
Objectivity/Lack of Bias
III.10 - Evaluate how their personal
experiences, attitudes, values, social context,
individual differences, stresses, and specific
training influence their activities and
thinking, integrating this awareness into all
attempts to be objective and unbiased in
their research, service, and other activities.
III.11 - Take care to communicate as
completely and objectively as possible, and
to clearly differentiate facts, opinions,
theories, hypotheses, and ideas, when
communicating knowledge, findings, and
views.

Straightforwardness/Openness
III.14 - Be clear and straightforward about
all information needed to establish informed

I know that a psychiatric assessment is outside

of my competence. I must be open and honest
and accept responsibility for any consequences
that result from this disclosure, be they positive
or negative.
I recognize that I feel strongly about child
abandonment and must ensure I do not make
assumptions about this familys circumstances,
or let my feelings interfere with my objectivity.

I must ensure that this family knows that I am

concerned about the symptoms the youth
described, but that it is outside my competence
to diagnose/identify a psychiatric disorder. It is
my opinion that he should undergo an
assessment, which will confirm/rule out my
concerns and I must make this clear.

I must be clear about what a psychiatric

assessment entails and its possible
outcomes/consequences. I must also ensure
they are clear that I will try to arrange for the
assessment to take place here, or through a

consent or any other valid written or

unwritten agreement

videoconference, but that I cannot guarantee I

will be successful. Also, they need to be aware
of the possibility of a period of hospitalization
if he is diagnosed with a psychiatric disorder.

Principle IV: Responsibility to Society

Beneficial Activities IV.12 - Contribute to
the general welfare of society (e.g.,
improving accessibility of services,
regardless of ability to pay) and/or to the
general welfare of their discipline, by
offering a portion of their time to work for
which they receive little or no financial
return.
Respect For Society IV.15 - Acquire an
adequate knowledge of the culture, social
structure, and customs of a community
before beginning any major work there.
IV.20: Be sensitive to the needs, current
issues, and problems of society, when
determining research questions to be asked,
services to be developed, content to be
taught, information to be collected, or
appropriate interpretation of results

I am attempting to improve accessibility of

services by arranging for this assessment to
take place. I will make a point of networking
with multiple professionals in various
specialties who may be of help to other
individuals in this rural community in the
future.

I realize I may not have done this as thoroughly

as I should have. I need to correct this error.
A lack of services in rural areas (aboriginal and
otherwise) is a serious problem and makes
individuals living in these areas vulnerable to
not receiving much needed services.

3. Consideration of how personal biases, stresses or self-interest might influence the

development of or choice between courses of action
- Though the youths experiences may indicate a possible psychiatric disorder, I must also
consider that some symptoms (hearing voices singing and the voice of an old man speaking to
him in the tribal dialect) may actually be valid memories. It is also possible that this is considered
normal in this community. I must be careful not to make assumptions, especially as I do not share
their cultural background/experiences.

- I must be aware of the potential effects of the power differential, especially given the cultural
differences and vulnerability of the grandmothers emotional state as a result of her previous
experiences and recent loss of her husband. I am concerned that she may refuse to provide
consent to services outside of their community or by non-community members.
- I recognize my strong feelings on child abandonment and must ensure that I remain objective in
my decisions and not let my personal beliefs influence my professional behaviours.

4. Development of alternative courses of action

I have ruled out the following alternative:
A psychiatric assessment is outside of my area of competence and the youth and his grandmother
do not have the means to pursue one in the city. These symptoms may actually be valid memories
so I will counsel him, addressing the initial concerns. Through our sessions, I will hopefully gain
insight into these symptoms/memories and we can try to arrange a psychiatric assessment at a
later date if needed.
Beginning counseling immediately might yield short-term gains in addressing the initial
concerns. However, to counsel the youth without a psychiatric assessment would not be in his
best interests, nor would it provide him with the best possible treatment. If he does suffer from a
psychiatric disorder, his treatment is outside my area of competence, and I could be placing him
and/or others in harms way, creating lasting negative effects. I cannot assume that these
symptoms are memories of real events. This is not an ethical option.
Alternative 1: Discuss with the family my concerns surrounding the youths symptoms, ensuring
they understand what the assessment entails, as well as what a diagnosis would mean in terms of

possible treatment, etc. Arrange for a psychiatrist to complete the assessment in his/her office,
and help the grandmother arrange a drive into the city from someone in the community (if she
cannot do so on her own). If hospitalization/further treatment is necessary, this will not be their
only commute, and it is possible that financial costs will ensue (e.g., food, lodging for the
grandmother) and I must be clear that they understand this.
Alternative 2: Discuss with the family my concerns surrounding the youths symptoms, ensuring
they understand what the assessment entails, as well as what a diagnosis would mean in terms of
possible treatment, etc. The grandmother and youth do not have a vehicle and trying to arrange a
drive will likely cause added stress for the grandmother. I will try to find someone who is willing
to make the commute to do the assessment locally. However, given our rural location, this may
not be possible. It is more likely that I can find someone who has experience conducting these
assessments via videoconferences, so neither they nor the family will have to make the long
commute. I will begin to contact possible individuals immediately. I will inform the grandmother
of my plan, but will be clear that, despite my best efforts, this may not be possible and we will
have to pursue alternative one. xx

5. Analysis of likely short-term, ongoing, and long-term risks and benefits of each course of
action on the individual(s)/group(s) involved or likely to be affected (e.g., client, clients
family or employees, employing institution, students, research participants, colleagues, the
discipline, society, self)
Possible Positive Consequences

Possible Negative Consequences

Alternative 1
- Beginning with the psychiatric assessment
will provide the information needed to

- Strain on the grandmother as a result of trying

to arrange for a way into the city, as well as the

determine the best course of treatment for the

youth.
- If a diagnosis of a psychiatric disorder is
made and hospitalization required, this family
will have to make this commute. Doing so now
gives them exposure to the city, help them
form a relationship with the psychiatrist and
may help alleviate some of their concerns,
resulting in an increased likelihood of
consenting to subsequent treatment, if needed.

commute itself. This will add to the

grandmothers frail emotional state, and may
result in her not providing informed consent.
- Even if she is able to find a way into the city
for the assessment, this may not be feasible on
an ongoing basis for subsequent treatment (if
needed). This would cause her personal and
financial stress.
- It is possible that, given a diagnosis of a
psychiatric disorder, the grandmother may not
give consent for subsequent treatment. This
may be a result of the commute or personal
beliefs.
- This may be our only option if I cannot find a
colleague who is willing to make the commute,
or one who has experience and competence
doing the assessment via videoconferencing
technology.

Alternative 2
- Beginning with the psychiatric assessment
will provide the information needed to
determine the best course of treatment for the
youth.

- If the youth requires hospitalization, it will

not be possible to avoid financial cost and
emotional strain for the grandmother (e.g.,
finding a way to visit him).

- By locating a psychologist who is willing to

provide these services locally or via a
videoconference, I am not creating additional
stress for the grandmother (or youth) to find a
way into the city.

- The use of videoconferencing technology

may present a cultural barrier. It would be ideal
to have face-to-face treatment sessions, but this
may not be possible.

- Having the assessment completed in their

community may also make this whole
experience less intimidating for the youth and
grandmother, and may make it more likely that
they will follow-through with subsequent
treatment, if needed (even if this means a
commute/commutes to the city).
- This is the most realistic option for a
professional whose practice is based some 100
miles away, especially given the fact that this
youth is not his/her only client. The youths
location and the commute to see him would
mean that he/she could not see other clients
that day (and possibly the following day, too, if
an overnight stay was required). Though it

- If this alternative is not possible, the family

will likely be disappointed, and this may have a
negative impact on future interactions with the
psychiatrist.
- It is still possible that, given a diagnosis of a
psychiatric disorder, the grandmother is
unwilling to give consent for subsequent
treatment. This may be a result of the increased
stress on her already vulnerable emotional
state, or the fact that her grandsons
experiences are considered normal in her
community.

would be ideal for (at least) the assessment to

be done face-to-face, I realize that the youths
rural location poses as a major obstacle.

6. Choice of course of action after conscientious application of existing principles, values,

and standards.
After thorough consideration, I have decided on the second alternative. This option is the most
respectful of my client (and the other parties involved), and most closely aligns with the
Canadian Code of Ethics for Psychologists. This alternative clearly supports the values of
Principle I (Respect the Dignity of Persons) and Principle II (Responsible Caring) for both
members of this family. This is also the most realistic option (and most respectful of the other
clients assessments and treatment) considering the possibility of the psychiatrist needing to
maintain contact for follow-up treatment. I feel that this is also the option that is most likely to be
sustainable (for both sides).
Even if the youth requires a subsequent period of hospitalization, I believe that having had the
assessment done locally will have positive effects on the familys relationship with the
psychiatrist and will lead to an increased likelihood of follow-through with treatment. Though I
acknowledge that if it turns out that this alternative is not possible, there may be possible negative
consequences, these are outweighed by the potential benefits of the assessment being able to be
completed locally/through a videoconference. In this case, I will have to fall back on alternative
one, but can be confident that my decision-making process was most closely aligned with the
Code with my clients wellbeing in mind.
Given my concern of possible psychiatric symptoms, I will need to make sure I keep the school
(teacher/principal) informed so that they can watch for any troubling behaviours (or changes in

his behaviour). In addition, the youth will likely have to miss school, and the psychiatrist will
need a private area to conduct the assessment (whether in person or through a videoconference).

7. Action, with a commitment to assume responsibility for the consequences of the action
Without the results of a psychiatric assessment, I cannot know the best option for treatment and
whether or not it is within my area of competence. Thus, I must proceed with what I consider to
be the best initial course of action - securing an assessment.

8. Evaluation of the results of the course of action

Regardless of my initial course of action, future steps will depend on the information I receive
from the psychiatric assessment, as well as the grandmother and youths responses to the results.
Evaluation will be ongoing.

9. Assumption of responsibility for consequences of action, including correction of negative

consequences, if any, or re-engaging in the decision-making process if the ethical issue is not
resolved
The results of the assessment may reveal a psychiatric disorder and the grandmother/youth may
decide to refuse to consent to/participate in treatment to manage this disorder. If this happens, I
will have to decide what future actions I can take so that the youth gets the treatment he needs. If
the results do not reveal a psychiatric disorder, I can provide my counseling services, as was
initially intended.

10. Appropriate action, as warranted and feasible, to prevent future occurrences of the
dilemma (e.g., communication and problem solving with colleagues; changes in procedures
and practices.
I must consider the fact that other individuals I encounter in the future may require psychiatric
services. I should begin to network now so that I am better prepared to deal with this in the
future. Whether delivering interventions face-to-face or via videoconferencing technology, I need
to find competent professionals who are willing to make the commute and/or have competence in
the use of this technology.

Grading Criteria

18/20

Addresses all steps in the model.

4/4 marks

Demonstrates understanding of the ethical issues.

3/5 marks

In addressing the ethical dilemma, recognizes personal

interactions.

5/5 marks

Provides clear rationale for the decision

3/3 marks

Recognizes responsibility for the consequences of the

decision

3/3 marks

Hi Kelly ~
I thought you did a really good job overall! I know this process can be overwhelming at first, but it gets
easier as you practice with it more. I can see how you carefully thought things through and
incorporated many relevant codes to guide your decision. Remember that its really important to be
explicit in identifying what principles are in conflict. Illuminating the ethical dilemma (whats in conflict)
as early as possible is the best place to start and will impact all the following steps.

Sumerlee