The Voc Rehab Counselor
Lucy Chambliss works as a vocational rehabilitation counselor at a residential training center in Miami, Oklahoma. One of her clients, Larry Delgado, is a 13-year-old with mild developmental disability and conduct disorder. Larry was placed by his parents at the residential program about six months ago and has received individual counseling from Lucy during that time. Lucy also serves as a house parent at the cottage in which Larry is housed.
During the six months that Lucy has worked with Larry, she has observed substantial improvement both in Larry’s behavior and in his attention to his schoolwork. The Delgados visit Larry twice a month, at which time they confer with Lucy concerning their son’s progress. As a result of her work with Larry, Lucy has begun to feel that further institutional care is not appropriate and that Larry belongs at home with his family. In conversations with Larry, Lucy has noted that he wants to be home with his parents.
During their most recent meeting with Lucy, the Delgados have expressed their pleasure at the apparent improvement in Larry’s conduct. When Lucy suggests that further institutionalization might not be helpful for Larry, the Delgados disagree, noting that Larry has made great strides in the preceding six months. Moreover, they note, Larry has been the primary source of friction in their marriage, and the respite Larry’s residency at the center has given them has made home life more bearable for them and their other young children.
Lucy’s options in this scenario are most easily addressed if she first considers her duty to identify the primary client. Despite the role of Larry’s parents in placing Larry in institutional care, Lucy’s primary client is Larry. Consequently, she owes Larry a duty to practice reasonably competently. Although the interests of Larry’s parents are peripherally important in the sense that they have the authority to provide informed consent for any treatment on Larry’s behalf, it is Larry’s well-being that must be of paramount concern to Lucy. If, in her professional judgment, Larry’s best interests are not served by continuing placement at the training center, then she must so advise the Delgados. They may have important personal reasons for Larry’s continued placement out of the home, but if, in Lucy’s independent clinical judgment, placement does not correspond with Larry’s health and continued progress, she cannot proceed to provide reasonably competent services; indeed, her services would become unnecessary.
Lucy may well regard her position in this scenario as an uncomfortable one. She may have developed a friendly working relationship with the Delgados and may feel obliged to honor their choices regarding Larry’s care. These impressions may be strengthened by cross-cultural considerations that suggest to Lucy, a compassionate counselor who believes in client self-determination, that she must demonstrate respect for the Delgados’ right to make autonomous choices on behalf of their family. In honoring her duty to the primary client, however, Lucy must give voice to her central concern with Larry’s progress.
In identifying her primary client, Lucy should consider the impact of informed consent. The Delgados have the legal capacity to make decisions on Larry’s behalf, and Lucy must discuss with them all reasonable risks and benefits of the care options available for Larry. As the guidelines for informed consent indicate, Lucy has the responsibility to discuss fully her own professional opinions with the client—or those responsible for making decisions on the client’s behalf—especially when those views contradict the client’s or decision maker’s interpretation of the problem. In the present case example, the duty to seek informed consent requires Lucy not to allow her respect for the Delgados’ self-guidance to silence her communication of a professional opinion. How effectively and sensitively Lucy expresses this judgment to the Delgados may well determine what decisions they make about Larry’s care.
Lucy must recognize from the outset of her conversations with the Delgados that her duty to practice reasonably competently mandates that she identify, assess, and, if necessary, report, instances of suspected child abuse and neglect. It may be the case that Lucy regards the Delgados’ preference that Larry remain at the center as an abdication of parental authority for Larry’s care. In the unfortunate event that the Delgados are unable or unwilling to assume responsibility for Larry’s supervision, it is incumbent upon Lucy and her supervisors to report the threat posed to Larry’s well-being. Cautious communication of this point to the Delgados may help them to reassess their position concerning Larry’s institutionalization.
Staff counselors and other behavioral health providers in the lower echelon of employee responsibility at mental health institutions may feel overwhelmed at the responsibility placed on them to identify and represent the best interests of the primary client. They may be familiar with the administrative routine at their agencies, may contemplate the temptation that third-party funding places on agencies to continue to receive that funding, and therefore may actively participate in their institutions’ zealous solicitation of new clients and continued housing of long-standing clients. These issues may place pressure on employees and administrators to maintain amicable relationships with the families of clients. The inducements created by funding considerations may be a powerful incentive in the decisions made on their clients’ behalf, and cautious agency employees may not be anxious to make waves. Nevertheless, every behavioral health professional involved in long-term care for institutionalized clients must be prepared to answer the following question: Can the provider lawfully maintain a professional relationship with a client for whom no further services are available, or who is not likely to benefit from further treatment? The answer, under a strict interpretation of the duty to practice reasonably competently, is plainly no.
The question Lucy is called upon to ask in the present case example has been posed in a variety of legal contexts. For instance, in several court cases, an advocate’s decision to ask a judge to examine the sufficiency of services in a hospital setting has been at least partly responsible for the deinstitutionalization of many chronically mentally ill patients who had previously been consigned to “warehousing” in state facilities.
