Assignment 2: Ethical Decision Making Exercise By: Shawna Sjoquist University of Calgary July 30, 2010

Ethical Dilemma: As a practicing psychologist, you are approached by the grandmother of a youth in your community. The grandmother discloses that she is concerned for her grandson stating that she has seen a significant change in his behaviour. The grandmother notes that her grandson has stopped participating in extracurricular activities, socializing with family and friends, has become disinterested in activities that previously had given him pleasure and overall seems depressed. Up until a few months ago the grandson had lived with his grandmother and her husband however the grandmothers husband had recently passed. The grandmother discloses that she has not been eating or sleeping well since her husbands passing. The grandmother shares with you that she frequently thinks about traumatic events that have been experienced in the residential school in her community. The grandmother reveals that her grandson has recently been complaining of hearing voices but that this is seen as a great honor by those of authority in her community. The grandmother states that she is not concerned about her grandson hearing voices and does not want her grandson to undergo a psychiatric assessment however she is concerned with her grandsons change in behavior.

Step 1. Identification of the Individuals and Groups Potentially Affected by the Decision. I need to determine who the primary and secondary individuals/ groups are that will inevitably be affected by my decision. In deciding how to respond to the grandmother and the youth, the primary individuals involved, as I see it, are the youth, grandmother and I as the psychologist. Secondary individuals that may also be affected by my decision are the school community (relevant teachers, administrative team and/or the peers of the youth I am working with) and also the aboriginal community members (relevant family members, community members, elders, etc.). Step2. 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. In this step I have used a chart that outlines the four main ethical principles organized with their corresponding values and standards of the Canadian Code of Ethics for Psychologists. Using this chart I have identified a total of seventeen ethical values that I consider relevant to my current ethical dilemma. The seventeen values are distributed amongst the four main ethical principles. I have identified six ethical values that are included under the first principle, Respect for the Dignity of Persons, and five ethical values for each of the following two principles outlined in the code; Responsible Caring and Integrity in Relationships. Under the fourth principle of the code, Responsibility to Society, I have identified one ethical value that I feel is germane to the ethical dilemma I am presented with.

The Four Ethical Principles Of the Canadian Code of Ethics for Psychologists with their Respective Values and Standards I. Respect for the Dignity of Persons II. Responsible Caring III. Integrity in Relationships IV. Responsibility to Society 1. Development of Knowledge (IV.1IV.3) 2. Beneficial Activities (IV.4IV.14) 3. Respect for Society (IV. 15IV.18) 4. Development of Society (IV.19Iv.29) 5. Extended Responsibility (IV.30-IV.31)

1. General Respect (I.1-I.4) 2. General Rights (I.5-I.8) 3. Nondiscrimination (I.9-I.11) 4. Fair Treatment/ Due Process (I.12I.15) 5. Informed Consent (I.16-I.26). 6. Freedom of Consent (I.27-I.30) 7. Protection for Vulnerable Persons (I.31-I.36) 8. Privacy (I.37-I.42) 9. Confidentiality (I.43-I.45) 10. Extended Responsibility (I.46-I.47)

1. General Caring (II.1-II.5) 2. Competence and Self-Knowledge (II.6-II.12) 3. Risk/Benefit Analysis (II.13II.17) 4. Maximize Benefit (II.18-II.26) 5. Minimize Harm (II.27-II.36) 6. Offset/ Correct Harm (II.37-II.44) 7. Care of Animals (II.45-II.48) 8. Extended Responsibility (II.49-II.50)

1. Accuracy/ Honesty (III.I-III.9) 2. Objectivity/ Lack of Bias (III.10-III.13) 3. Straightforwardness/ Openness (III.14III.22) 4. Avoidance of Incomplete Disclosure (III.23-III.30) 5. Avoidance of Conflict of Interest (III.31-III.35) 6. Reliance on the Discipline (III.36III.38) 7. Extended Responsibility (III.39III.40)

Discussion of Principle/Value and My Corresponding Thoughts Principle/Value: PRINCIPLE I: RESPECT FOR THE DIGNITY OF PERSONS Value: General Respect I.1 Demonstrate appropriate respect for the knowledge, insight, experience, and areas of expertise of others. My Thoughts: Regardless of the decision I choose, I need to be conscious of and demonstrate respect for youth as well as the grandmother. In addition, should they become involved, I need to demonstrate respect for any members of the psychiatric team and/or perhaps elders of the aboriginal community.

Value: General Rights I.8 Respect the right of the research participants, clients, employees, supervisees, students, trainees, and other to safeguard their own dignity.

If it is the view of the youth that the auditory hallucinations he has been experiencing have cultural connotations and, in his opinion, are not generating fear, thoughts of violence, harm and/or the like I need to recognize that the youth may be concerned about his dignity. Should he be referred for psychiatric assessment given his disclosure of auditory hallucinations there may be some concern of shame. The community may see the auditory hallucinations as culturally appropriate and potentially a cultural privilege. In this event, I will need to demonstrate respect for the youth to safeguard his own dignity.

Value: 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 need to conscious of including all those that are affected by this dilemma. Therefore, as there has been an identified area of trauma, death of the grandmothers husband, that seems to be, at minimum, a contributing factor to the concerns of both the youth and his grandmother, I need to be sure to include both the youth and the grandmother in the decisions that affect them. Also, the youth has identified experiencing some auditory hallucinations that may or may not have some cultural connotations. It may also be beneficial to potentially include an elder from the community in the decision that I make regarding the auditory hallucinations and psychiatric assessment.

I.21 Establish and use signed consent forms that specify the dimensions of informed consent or that acknowledge that such dimensions have been explained and are understood, if such forms are required by law or is such forms are desired by the psychologist, the person(s) giving consent, or the organization for whom the psychologist works.

Given that I have stated that I feel uncomfortable about counselling without first obtaining a psychiatric assessment I feel that I should establish and use a signed consent that outlines these concerns. I do recognize that access to a mental health unit for a psychiatric assessment may not be possible for the grandmother and youth. Therefore, if I decide to counsel without gaining a psychiatric assessment I will need to outline my suggestions, concerns, risk factors of not obtaining psychiatric assessment, etc. in an appropriate consent form. In relation to the informed consent that I use during this process I must ensure that the consent acknowledges appropriate points. I want to pay particular attention to the areas of mutual responsibilities (youth, grandparent, other potentially involved parties such as psychiatric assessment team and/or elders, and myself). I want to identify the limits to confidentiality, for example if the youth discloses information that may lead to severe physical harm or death. I want to call attention to the benefits and risks associated with obtaining a psychiatric assessment and counselling and also the consequences of not obtaining the like.

I. 24 Ensure, in the process of obtaining informed consent, that at least the following points are understood: purpose and nature of the activity; mutual responsibilities; confidentiality protections and limitations; likely benefits and risks; alternatives; the likely consequences of non-action; the option to refuse or withdraw at any time, without prejudice; over what period of time the consent applies; and, how to rescind consent if desired.

Value: Protection for Vulnerable Persons I.34.Carry out informed consent processes with those persons who are legally responsible or appointed to give informed consent on behalf of persons not competent to consent on their own behalf, seeking to ensure respect for any previously expressed preferences of persons not competent to consent. As the youth resides with his grandmother I will need to seek to carry out the consent process with the individual(s) whom are legally responsible or appointed to give informed consent on the behalf of the youth. If it is the grandmother I will pursue consent with her.

Value: Privacy I.38 Take care not to infringe, in research, teaching, or service activities, on the personally, developmentally, or culturally defined private space of individuals or groups, unless clear permission is granted to do so.

Recognizing that it is common in aboriginal cultures for elders to become involved during times of distress, concern or need I have to acknowledge that there may already be an elder involved with this youth and grandmother. Also, if there isnt currently an elder involved, I have to acknowledge that there may likely be an elder involved as things progress. As such, I must take care not to infringe on the culturally defined private space of individuals or groups unless clear permission is granted to do so.

Value: Confidentiality I.45 Share confidential information with others only with the informed consent of those involved, or in a manner that the persons involved cannot be identified, except as required or justified by law, or in circumstances of actual or possible serious physical harm or death. Depending on my decision, it may become relevant for me to discuss confidential information with other parties involved. For instance, should a psychiatric assessment team become involved it may become relevant for me to discuss confidential information with them and as such I will need to secure consent to do so. Likewise, should I see fit to consult with other professionals or culturally relevant members I will need to either share confidential information with informed consent to do so or take care to discuss matters in a way that protects the identity of those involved

. Principle/Value: PRINCIPLE II: RESPONSIBLE CARING Value: General Caring II.1 Protect and promote the welfare of clients, research participants, employees, supervisees, students, trainees, colleagues, and others. My Thoughts

I need to protect and promote the welfare of the youth and the grandmother. Not only do I need to ensure that I take action to care for the wellbeing of the youth but I also need to take action to ensure the same for the grandmother as she has identified that she has not been eating or sleeping well and also thinks a lot about traumatic events experienced in residential school. A problem that I am dealing with II.2 Avoid doing harm to clients, research participants, employees, supervisees, students, trainees, colleagues, and others.

here is that I feel the grandmother need support just as the youth does. I am unsure as to how to proceed with helping them? In recognizing that the cultural way of doing things is to keep communities or families together to work through concerns I also recognize that I would be embarking on a situation of dual or multiple relationships. I must avoid doing harm to the youth, grandmother and also aboriginal community. Whether I choose to insist upon psychiatric assessment and refuse counsel without, counsel without psychiatric assessment, choose to counsel the grandmother together, apart or with another psychologist will have potential repercussions. For example, insisting on psychiatric assessment may provoke the aboriginal community as they may view auditory hallucinations as a cultural privilege to be revered and not counselling the youth because of lack of psychiatric assessment may result in harm if no help is sought.

II.3 Accept responsibility for the consequences of their actions.

For whatever decision I choose I must accept responsibility for any consequences that may result.

Value: Competence and 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 must discern whether or not I have established competence in this area. As this dilemma includes possible auditory hallucinations, aboriginal culture, trauma and depression I must only proceed with those activities I am competent to carry out to the benefit of the youth and grandmother.

II.8 Take immediate step 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.

Given the nature and complexity of this ethical dilemma I find it beneficial to, at minimum, consult with a colleague in order to ensure I am offering competent service to the youth and grandmother. There are several factors that come into play here:

aboriginal culture, trauma due to loss, auditory hallucinations, etc. If I deem myself not competent in any of these areas I will need to take immediate steps to ensure competent service. If there is a colleague in the area that I know specializes in this area I should consider referring the youth and grandmother on or if I am the only professional available I must take action in consultation to provide the utmost competent service. order that their service or research activities and conclusions will benefit and not harm others. In being presented with this ethical dilemma I have taken care to research literature relevant to this topic area, in particular, mental health assessment with regard to auditory hallucinations in the aboriginal community. I must continue to keep myself up to date with research advancements and current assessment referral processes in this area utilizing whatever means are available to me.

II.9 Keep themselves up to date with a broad range of relevant knowledge, research methods, and techniques, and their impact on persons and society, through the reading of relevant literature, peer consultation, and continuing education activities, in

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.

As I come from a very small community where I came to know, very well, an individual that was eventually diagnosed with schizophrenia I must recognize that in knowing first-hand the strife and very real danger that hallucinations can have on the individual, family and community those experiences will have an effect on my decisions in this dilemma. Also, I have to recognize that, from a personal standpoint, I cannot completely reject the possibility that the youth is actually experiencing what has been described as hallucinations as I remain undecided about the topic area. Also, I am not a member of the aboriginal community or culture and this fact may also have relevance to my decision in this matter. So, I must acknowledge my own experiences, beliefs,

culture and social context, taking care to evaluate how these factors partake in this dilemma and

integrate this awareness into my efforts to benefit and not harm the youth and grandmother.

Value: 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.

I must make sure that I take appropriate action to assess all areas relevant to the youth and grandmother so that I can adequately determine what will be of benefit or potentially produce harm. For instance, how is the relationship between the grandmother and the youth, is there a history of mental illness in the family, have there been episodes of depression in the past, etc. Knowledge such as this will help me to better determine my stance on the issue of psychiatric assessment and counsel.

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 in their activities.

I need to ensure that I have adequate knowledge of the individual and cultural differences of this youth and grandmother in order to decide on what will benefit and not harm. Is the youth a danger to himself, his grandmother and/or his community? Is the grandmothers potential depression harming the youth? Will move for psychiatric assessment promote discontent in the aboriginal community and potentially with the youth and grandmother? Are these auditory hallucinations cause for serious concern? Are they culturally ingrained or symptomatic of trauma or depression? If I choose to counsel without psychiatric assessment, I must ensure that the benefits of the counselling outweigh the risks involved with not getting a psychiatric assessment.

II.17 Not carry out any scientific or professional activity unless the probable benefit is proportionately greater than the risk involved.

Value 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.

Should I choose to refuse counsel without prior psychiatric assessment and the family consents to assessment, I will need to work to provide service that coordinates with any involvement of the psychiatric team. Likewise, should an elder become

involved, it may also be beneficial to seek to avoid working at cross purposes with the elder. Also, should I deem it necessary to seek separate counsel for either the grandmother or the youth it may be beneficial to provide service that coordinates over time for the family unit as a whole.

II.19 Create and maintain records relating to their activities that are sufficient to support continuity and appropriate coordination of their activities with the activities of others.

This may be especially appropriate if the family is receiving service from an elder or psychiatric team. I must generate and keep my records so as to support the activities of this family outside of my counsel.

reasonable theoretical or empirically supported efficacy in light of those needs and characteristics; consulting with, or including in service delivery, persons relevant to the culture or belief systems of those served; advocating on behalf of the client; and, recommending professionals other than psychologists when appropriate.

II.21 Strive to provide and/or obtain the best possible service for those needing and seeking psychological service. This may include, but is not limited to selecting interventions that are relevant to the needs and characteristics of the client and that have

If I counsel I should choose to strive to provide the best service for the youth and grandmother. It may be beneficial to include interventions that are culturally relevant as the auditory hallucinations seem to have a largely cultural base (voices speaking in tribal dialect). These interventions may include use of an elder or psychologist fluent in aboriginal culture and spiritual belief

Value: Minimize Harm II.29 Be careful not to engage in activities in a way that could place incidentally involved persons at risk.

If I choose not to persist with psychiatric assessment I must ensure that any activities I encourage during counsel will pose no harm to the youth, his grandmother and/or the community. For example, ensuring that exploring trauma further will not cause

further harm to the youth or the youth to his grandmother/community.

II.31 Give reasonable assistance to secure needed psychological services or activities, if personally unable to meet requests for needed psychological services or activities. . Principle/Value: PRINCIPLE III: INTEGRITY OF RELATIONSHIPS Value Accuracy/ Honesty III.8 Acknowledge the limitations of their won and their colleagues knowledge, methods, findings, interventions, and views.

If I chose to refuse counsel based on the lack of psychiatric assessment then I must take action to secure needed psychological services from another source

My Thoughts Through conducting a review of recent research in the area of mental health assessment regarding auditory hallucinations in aboriginal cultures it would appear that there are limits to available knowledge in this topic area.

III.9 Not suppress disconfirming evidence of their own and their colleagues findings and views, acknowledging alternative hypotheses and explanations.

There is the perception that auditory hallucinations of this nature are not hallucinations at all, but experiences germane to those of the aboriginal culture, practice and belief system. Given this perception, I must acknowledge this as a potential hypothesis and explanation for the auditory hallucinations. unbiased in their research, service, and other activities.

Value: Objectivity/ Lack of Bias III.10 Evaluate how their personal experiences, attitudes, values, social context, individual difference, stresses, and specific training influence their activities and thinking, integrating this awareness into all attempts to be objective and

Similar to my thoughts pertaining to value II.10, I need to incorporate the same into all of my attempts to remain objective and unbiased throughout my interactions with the youth and grandmother.

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.

I must take care to completely communicate any knowledge I share. For instance, anything I choose to share with regard to knowledge of psychiatric

assessment of aboriginal cultures and/or knowledge of auditory hallucinations during times of trauma or depression

Value: Straightforwardness/ Openness III.14 Be clear and straightforward about all information needed to establish informed consent or any other valid written or unwritten agreement

I must clearly and openly make statements with the youth and grandmother regardless of whether or not I predict the information will be well received. For instance, open and honest about the alternatives of a pro or con psychiatric assessment stance.

III.18 Make clear whether they are acting ass private citizens, as members of specific organizations or groups, or as representatives of the discipline of psychology, when making statements or when involved in public activities.

I need to make it clear when I make statement who I am acting as. For instance, acting as a representative of the discipline of psychology when I make statements regarding research/knowledge of auditory hallucinations and links to trauma or depression and/or private citizen/ member of the community should I make statements about auditory hallucinations and relevance to the aboriginal culture.

Value: Avoidance of Conflict of Interest III.33 Avoid dual or multiple relationships and other situations that might present a conflict of interest or that might reduce their ability to be objective and unbiased in their determinations of what might be in the best interests of others.

I believe that both the grandmother and the youth could benefit from some counselling. Working with both may prove to be a multiple relationship and make it difficult to be unbiased in my determinations of what is best for each individual party. I should make an effort to avoid the multiple relationship.

III.34 Manage dual or multiple relationships that are unavoidable due to cultural norms or other circumstances in such a manner that bias, lack of objectivity, and risk of exploitation are minimized. This might include obtaining ongoing supervision or consultation for the duration of the dual or multiple relationship, or involving a third party in obtaining consent.

If I am in a small area where I am the only psychologist I may need to counsel the grandmother as well as the youth. Also, culturally it may be more appropriate to counsel the grandmother and the youth together. In either event, I will seek to obtain ongoing consultation for the duration of the multiple relationship

Value: Reliance on the Discipline III.36 Familiarize themselves with their disciplines rules and regulations, and abide by them, unless abiding by them would be seriously detrimental to the rights or welfare of others as demonstrate in the . Principle/Value: RESPONSIBILITY TO SOCIETY Value: Respect for Society IV.16 Convey respect for and abide by prevailing community mores, social customs, and cultural expectations in their scientific and professional activities, provided that this does not contravene any of the ethical principles of this code.

Principles of Respect for the Dignity of persons or Responsible Caring. Given the importance of making an ethically responsible decision in this manner I think it would be appropriate for me to contact my college for support, guidance and advice on this matter

I must demonstrate respect for the aboriginal community, their customs, beliefs and spiritual system. It may be customary for a community elder to become involved in this situation and I must respect this so long as I am confident that involvement does not harm the welfare of the youth.

3. Consideration of How Personal Biases, Stresses, or Self-interest Might Influence the Development of or Choice Between Courses of Action. In all honesty, my initial reaction to this dilemma was, Oh please dont say you are hearing voices. Of all that is presented in this ethical dilemma; obtaining appropriate consent if given the grandmother is not the legal guardian, multiple relationships if I am to counsel both parties, the concerns of trauma and potential depression, restriction of access to mental health resources, the part that concerned me the most was the issue of the hallucinations. I have to look at why that caused me the most concern. I was scared that I would not choose a decision that the profession would approve of. I was stressed and a little self-interested in how I would be perceived by the psychological community if I was to consider the auditory hallucinations simply a truth or product of the aboriginal spiritual belief or culture. I was also concerned about my choice or action would be

received by the aboriginal community and also the connotations that may exist for the youth and his own spiritual journey within his culture. Step 4. Development of Alternative Courses of Action (Please note that all alternatives are based on the assumption that the youth has not expressed any negative associations with the auditory hallucinations, not expressed that the voices are telling him to do bad things, frightening him and/or the like. I am also assuming that there has been no history of past medical history of mental illness to make note of.) Alternative 1. After discussing my hesitations regarding conducting counselling without obtaining a psychiatric assessment first, I would discuss the risks and benefits associated with the psychiatric assessment. Next I would seek to source out any third party assistance that may be available to either fund bringing the mental health assessment unit out to conduct the assessment in the youths community or assist in getting the youth to the mental health assessment unit 100 miles away. I would allow the grandmother and youth to make the decision regarding pursuing or foregoing psychiatric assessment. I chose to agree to counsel only where there has been a psychiatric assessment conducted. Where no psychiatric assessment has been completed or agreed to be complete support and facilitate referral of the youth and grandmother onto other psychological service. Alternative 2. After discussing my hesitations regarding conducting counselling without obtaining a psychiatric assessment first, I would discuss the risks and benefits associated with the psychiatric assessment. . I would allow the grandmother and youth to make the decision regarding pursuing or foregoing psychiatric assessment. I would agree to counsel in the absence of psychiatric assessment so long as the benefits to counsel outweigh the risks associated with not obtaining a psychiatric assessment. I would seek consultation of both a colleague in the field of psychology, perhaps one that has specialized knowledge in this area of counsel, and also the consultation of a

community elder, fluent in aboriginal culture and spiritual belief. I would then suggest, as both the youth and the grandmother have identified areas of personal concern, that both parties receive counselling from separate psychologists. Counsel in this way would minimize the risk of conflict of interest while helping to uphold unbiased counsel and the individual welfare of both clients. Alternative 3. After discussing my hesitations regarding conducting counselling without obtaining a psychiatric assessment first, I would discuss the risks and benefits associated with the psychiatric assessment. . I would allow the grandmother and youth to make the decision regarding pursuing or foregoing psychiatric assessment. I would agree to counsel in the absence of psychiatric assessment so long as the benefits to counsel outweigh the risks associated with not obtaining a psychiatric assessment. I would seek consultation of both a colleague in the field of psychology, perhaps one that has specialized knowledge in this area of counsel, and also the consultation of a community elder, fluent in aboriginal culture and spiritual belief. I would then suggest, as both the youth and the grandmother have identified areas of personal concern, that both parties receive counselling and proceed to provide counselling to both clients. As I am entering into a multiple relationship I would then take every step available to me to declare the potential conflict of interest and seek ongoing supervision and/or consultation where possible. Step 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 Alternative 1 In the short term, the youth and grandmother learn about the possible risks and benefits of obtaining psychiatric assessment relevant to their concerns. Youth and grandmother are motivated to obtain the psychiatric assessment.

The youth and grandmother do not receive counsel where counsel may have been needed. There may be a significant risk to the wellbeing of the youth and grandparent if left unsupported. Possible Negative Consequences Alternative 1 In the short term, the youth and grandmother feel unsupported and do not obtain a psychiatric assessment. The youth and grandmother decide not to pursue any further psychological services even though a referral to another psychologist has been made. In the long term, the youth and the grandmother loose trust in the field of psychology.

Possible Positive Consequences Alternative 2 In the short term, the youth and grandmother learn about the possible risks and benefits of obtaining psychiatric assessment relevant to their concerns. Youth and grandmother are motivated to obtain the psychiatric assessment. Youth and grandmother both individually receive counsel regardless of psychiatric assessment so long as the benefits of counsel outweigh the risks associated with not obtaining a psychiatric assessment. Youth and grandmother receive the cultural and spiritual support of an elder. Sense of support and community is re-established after the loss of the family member. In the long term, there is a possibility of establishing a stronger relationship with both grandmother and youth so that in the event auditory hallucinations or other related symptoms of mental illness present or increase the youth and/or grandmother may be more likely to obtain a psychiatric assessment. Youth and grandmother feel reassured and supported. Their view of the field of psychology is strengthened.

Possible Negative Consequences Alternative 2 Youth and grandmother feel that counsel from separate psychologists is contrary to their customary ways of doing things. Culturally they are taught to face concerns or strive together. There is the possibility that opinion of the elder will come into conflict with my own professional opinion. In the short term, youth and grandmother are angered and decide not to continue to pursue support from a psychologist. In the long term, youth and grandmother feel that the field of psychology is not supportive of their cultural values/needs and their trust in the psychological discipline is negatively affected.

as the benefits of counsel outweigh the risks associated with not obtaining a psychiatric assessment. In the long term, there is a possibility of establishing a stronger relationship with both grandmother and youth so that in the event auditory hallucinations or other related symptoms of mental illness present or increase the youth and/or grandmother may be more likely to obtain a psychiatric assessment. Youth and grandmother feel reassured and supported. Their view of the field of psychology is strengthened.

Possible Negative Consequences Alternative 3 Where the same psychologist is providing counsel to both the youth and the grandmother there is a risk of a conflict of interest. Possible Positive Consequences Alternative 3 In the short term, the youth and grandmother learn about the possible risks and benefits of obtaining psychiatric assessment relevant to their concerns. Youth and grandmother are motivated to obtain the psychiatric assessment. Youth and grandmother receive the cultural and spiritual support of an elder. Sense of support and community is re-established after the loss of the family member. Youth and grandmother both individually receive counsel regardless of psychiatric assessment so long Likewise, it may also be more difficult to remain unbiased during counsel. There is the possibility that opinion of the elder will come into conflict with my own professional opinion

. Step 6. Choice of Course of Action after Conscientious Application of Existing Principles, Values, and Standards At review of the three alternatives, potential positive and negative consequences I think that the second alternative would prove to be the best alternative. Principle I, Respect for the Dignity of Persons, identifies that the psychologists greatest responsibility is to the most dependent. While I have two arguably dependent individuals, a youth and a grandmother, I place the highest level of dependence with the youth. Principle I also acknowledges the role of the family and community in decision making is different for some cultures. Alternative 2 abides by this principles position to promote the involvement of community individuals such as the elder. Principle II, Responsible Caring, outlines that psychologists should proceed only in situations where an analysis of potential benefit outweigh the potential harm. Even though Alternative 2 chooses to proceed with counsel despite not obtaining psychiatric assessment I feel that providing counsel in this situation, at this point in time, outweigh the risks from not obtaining assessment. Principle II also includes the importance of infusing self-reflection, personal experience, view, etc. into the decision making process. Alternative 2 includes both the psychological knowledge of counsel with regard to auditory hallucinations as well as cultural views and support for the same. Principle III, Integrity in Relationships, calls attention to those situations whereby the risk levels associated with conflicts of interest, such as incurred by Alternative 3 may be partially dependent on cultural factors. Although this Principle supports the selection of the third alternative the Code also emphasizes that Principles I and II carry more weight than do the Principles III and IV. That said, Principle IV, Responsibility to Society, identifies that the psychologist has a higher duty to protect society than to protect the self. Therefore, it is important I make a decision that holds the welfare of society and its members than to make a decision that would uphold my own dignity or self-interest.

Step 7. Action with a Commitment to Assume Responsibility for the Consequences of the Action Given that I am choosing to proceed with Alternative 2, I recognize that I must assume responsibility for proceeding with counselling without first obtaining a psychiatric assessment. Also, as I am suggesting that both the grandmother and the youth receiving counselling services from different service providers, myself another and I, I must accept responsibility should the grandmother take cultural offense to the suggestion of separate counsel. In taking responsibility I will commit to repair any damage to my relationship with the grandmother should the need arise. Step 8. Evaluation of the Results of the Course of Action I will need to evaluate the results of my chosen course of action. Do the youth and grandmother appear to be benefiting from counsel? Are they benefiting from involvement of the elder? Has a relationship been established that would increase the likelihood of the youth obtaining a psychiatric assessment, understanding the risks/ benefits and trusting my professional opinion? Are there further actions that need to be taken? I also need to take a look at whether or not any negative consequences that I had not accounted for have arisen. Step 9. Assumption of Responsibility for the Consequences of Action, Including Correction of Negative Consequences, If Any, or Re-engaging in the Decision-making Process If Ethical Issue Is Not Resolved Even though I have made my decision based on ethical consideration of weight, risks and benefits there is still the possibility that my decision will not result in the desired outcome. It may turn out that by suggesting that grandmother and youth receive separate counsel I will have broken the relationship between the family and myself and the family and the discipline itself. It may also turn out that before I am able to establish strong rapport with the family, the youths symptoms my increase to where I must again push for a psychiatric assessment and I am back to square one. In any event, I feel that I have based my decision on sound ethical principles and have chosen a path from which to begin with this family.

Step 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) It may be time to work with the college to generate a document outlining suggested courses of action for situations such as these. Perhaps a compilation of research relevant to the area of mental health assessment with regard to auditory hallucinations in the aboriginal culture would be of benefit if made available to those psychologist practicing in areas where they may encounter aboriginal cultures. It would also be beneficial to the field of psychology if I were to begin communication with colleagues about my experiences in hopes of preventing similar future dilemma occurrence.

References Canadian Psychological Association (2000). Canadian code of ethics for psychologists (3rd ed.). Ottawa: Author. Also included in the course text: Sinclair, C., & Pettifor, J. (2001). Companion Manual to the Canadian Code of Ethics for Psychologists (3rd ed.). Ottawa: Canadian Psychological Association. Website Direct Link E.M. Andrew, N.S. Gray and R.J.Snowden, (2008). The relationship between trauma and beliefs about hearing voices: a study of psychiatric and non psychiatric voice hearers. Psychological Medicine, 38, pp14091417 doi:10.1017/S003329170700253X

Smye, V., & Mussell, B., (2001). Aboriginal Mental Health: what works best? Retrieved from http://www.london.cmha.ca/data/1/rec_docs/1598_Aboriginal%20Mental%20Health%20What%20Wor ks%20Best.pdf Stiegelbauer, S.M. (1996). What is an elder? What do elders do?: First Nations elders as teachers in culturebased urban organizations. Retrieved from http://www2.brandonu.ca/Library/cjns/16.1/Stiegelbauer.pdf Wand, A., Corr, M., & Eades, S. (2009). Liaison psychiatry with Aboriginal and Torres Strait Islander peoples. Australian & New Zealand Journal of Psychiatry, 43(6), 509-517. Retrieved from CINAHL Plus with Full Text databa