Beneficence and Nonmalificence

“We need to do everything within our professional power to aid and assist the client.”

~John McHenry

Welcome back, dear reader! Since my last post, I added resources to my webpage on school mental health, presented on mental health competencies for school mental health professionals, and read up on useful theories for providing services to children dealing with emotional regulation challenges during the school day.

            In this post, I want to cover two similar (but different) ethical principles: beneficence and nonmaleficence. I like to talk about them together because they are like two sides of the same coin. Both need to be considered when aspiring to truly help clients. These principles are as ancient as the medical profession they came from, and can be attributed to Hippocrates in 400 BC. In The Epidemics (https://classics.mit.edu/Hippocrates/epidemics.1.i.html), he writes,

The physician must be able to tell the antecedents, know the present, and foretell the future- must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm. 

            Expanding on these simple statements, to do good is beneficence, the responsibility of mental health professionals to contribute to the welfare of clients (Forester-Miller & Davis, 2016). This means actively considering and working toward the best possible outcomes for clients. To do no harm is to avoid any actions that might impair, endanger, or weaken clients, or to take action to prevent such harm.

            Although these principles are described simply, if you look back at Hippocrates’ statement in The Epidemics, you will catch a glimpse of the true difficulty of these principles. How can I, a mere human with limited hindsight, insight, and foresight, accurately predict what is beneficial or harmful for another human? Everyday life is full of examples of how well-intentioned people unintentionally do others no good or even harm them! Even when we are sincere, we can be sincerely wrong! This is why humility needs to be fostered in our graduate training much more than it is. Without humility, an awareness of our own limits in even our most virtuous attempts, we will not carefully consider the true weight of beneficence and nonmalificence.

However, if you approach these principles with appropriate humility, you can do much good, especially coupled with the knowledge of your field. Seeking the good of your clients and seeking not to injure them should spur you on to learn the best theories you can and apply them as well as you can, and continue to learn throughout your career. Keep reading, keep consulting, keep seeking learning opportunities, and keep carefully considering possible outcomes to enhance your clients’ lives. To borrow a phrase from DBT, we must control what we can control. That is, we can’t control the future. But we can control our own levels of expertise, self-monitoring, and professional excellence.

Finally, in working with children and adolescents, it is important to consider the role of parents, families, and caregivers. Child and adolescent clients are rarely consenting to their own treatment, and their developmental stage means the gap between their therapist and themselves in terms of authority, influence, and power is great. If I am working with a vulnerable adult client, and treatment is not going well, that client may be able to leave and get a different therapist. But for children and adolescents, they don’t usually get to choose which adult is in their life as a therapist. Often, when there is a poor fit between a therapist and a minor client, there is pressure for the therapist to continue building rapport and encouraging the minor to engage, even if the minor explicitly states they are not interested or don’t like the assigned adult. In these instances, we run the risk of exacerbating minors who are then turned off to therapy for the rest of their lives, who believe it doesn’t work, because they kept getting forced to be in a room with someone they didn’t like, no matter the cause of that dislike. Worse yet, the way they express that dislike may be viewed as another “symptom,” leading to more treatment and further pathologizing.

As I mentioned above, there can be lifelong detriments for minors who have a poor fit with their mental health professionals and are still pushed into treatment. Additionally, there can be challenges if there is a good fit, but the mental health professional is a poor influence on the minor, or if they create barriers instead of bridges between the minor and their families. Minors must be viewed within a family context. For this reason, Sartor et al. (2016) proposed an ethical decision-making model when working with children and adolescents that considers the parent-child relationship. They encouraged the following 9 steps when working with minors:

“1. Determine the ethical dilemma.

2.      Evaluate how the dilemma can impact the child-parent relationship.

3.      Evaluate how the dilemma can impact the child-therapist relationship.

4.      Consider and determine how relevant ethical codes and theories (especially developmental) impact the possible directions.

5.      Review similar court cases and rulings in your state and nationally.

6.      Consult with other professional counselors.

7.      Create a plan.

8.      Follow through with the plan and continuously reevaluate potential relationship concerns.

9.      Revise plan with needed, and repeat Step 8.”

(Sartor et al., 2016, p.15).

It is a tall order for humans to seek the good of others and avoid harming them. Yet trying leads to more success than giving up! After all, just because we can’t prevent every car accident doesn’t mean seatbelts don’t help prevent serious injury. In the same way, while we can’t control all aspects of our clients’ states of wellness, we can control what we do and how we do it. As Jim McHenry concluded after decades of work as a professional counselor, “the client, whether he or she is 2 or 15 or even 77, comes first,” and “we need to do everything within our professional power to aid and assist the client.” (Sartor et al., 2016, p.174). My dear friends, continue practicing humility and striving for excellence, and you will surely do much good and avoid much harm!

References

Forester-Miller, H., & Davis, T. E. (2016). Practitioner’s guide to ethical decision making (Rev.        ed.). 

Hippocrates (400 BC). Of the epidemics. [Francis Adams translation; Internet Archive].             https://classics.mit.edu/Hippocrates/epidemics.1.i.html

Sartor, T.A., McHenry, B., & McHenry, J. (Eds.). (2016). Ethical and Legal Issues in Counseling        Children and Adolescents (1st ed.). Routledge. https://doi.org/10.4324/9781315660714