Case Analysis Summary

In the foregoing clinical case analysis procedure, although too condensed to include all the professionals involved, most of the known clinical details have been identified and discussed, and bioethical issues and principles have been identified. Areas of incomplete clinical information have been noted. In this complex polyethical problem-solving process the Solomonic challenge is to understand the interests, moral assumptions, and intensity of each party's issues, estimate the competency of each party, and keep focused on the optimal outcome for the client. The clinical ethics process attempts to resolve moral dilemmas without the use of force by seeking agreement among parties or peaceable negotiation.

The data can now be used for a variety of clinical needs. In any case the analysis is saved as a record in case of future need, discussed within the institutional professional staff's regular staff meetings, placed on the schedule for discussion in a periodic institutional ethics committee meeting, or submitted to the institutional risk committee or malpractice insurance carrier. An addendum should be added to the analysis to record the further use made of the analysis.

The case analysis may also be used as the agenda for an interdisciplinary meeting of all responsible parties. For example, if the client struggles with bioethical issues in the care given or the choices for future care, the clinical case analysis gives a framework for consideration and discussion, especially to help the client or other responsible parties to understand the ethical choices as well as the treatment choices, and who has the authority to make the choices of autonomy, beneficence, nonmaleficence, and justice. In the case of this adolescent the watchword of prudence is always to ask, "Who speaks for the best interests of the child?"

Three additional professional integrity issues not discussed in the text or case analysis should be mentioned. The first concerns ethics regarding colleagues such as co-workers, supervisors, and supervisees. In these relationships therapists should always be expected to keep the best interest of the client in mind, avoid boundary infringements, avoid personal conflicts of interest, and meticulously respect confidentiality. Such considerations are especially relevant to team relationships. This means keeping team roles clear, being mindful that a healthy milieu is the best treatment vehicle, being aware of transference, not acting out in colleague relationships in a way detrimental to clients, not exploiting supervisees, not "dumping" cases, keeping educational objectives in mind, keeping track of what may come up about being responsible for the training of students, and keeping track of the potentially unhealthy side of mentoring.

The second issue concerns the ethical use of the "special knowledge" of psychotherapy and the rhetorical power of expert language. The theoretical frameworks and special vocabulary of psychotherapy can be used to elucidate issues, and to teach important ideas and skills that are helpful to clients. Unfortunately they can also be used to enforce a power differential for the power/control/expertise/status needs of the therapist, which can be damaging and disabling for clients. The latter is a problematic, unethical use of our professional skills and status.

The third issue concerns the ethics of using the special intimacy of psychotherapy for personal gratification. It is safe to say that what makes a therapeutic relationship therapeutic is that it exists for the benefit of the clients, and for their growth and achievement of confident autonomy. The therapeutic relationship is not for meeting the personal needs of the therapist. The therapist uses aspects of herself or himself in service of the professional work, and that needs to be the priority. This is an area in which damage and retraumatization of clients can easily occur, and as professionals, psychotherapists need to set clear standards and hold one another accountable.

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