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The following article describes a hypothetical situation faced by a counselor at a community based clinic. The presenting problem is one of domestic violence. The article explores the ethical responsibilities of the counselor as well as presents a multitude of ways in which the counselor can assist the client in coping with her situation.
A community mental health clinic is a diverse environment where clients present varied assortment of issues. The duty of the counselor in this environment is to provide treatment which is ethically sound and which takes into account the clients’ best interest. Domestic violence is an important subject because of its far reaching impact on victims and their children, presenting itself with a unique set of ethical issues. In order to successfully treat victims of domestic violence the counselor must use a multitude of approaches, account for multicultural issues, and engage in self-examination.

The Environment
The environment is a Mental Health Clinic called United Mental Health Association. The clinic is located in the suburbs not far from the urban area of a larger city in the state of New York. The clinic serves a diverse population consisting of clients with various income levels and various clinical diagnoses. The clinic charges a sliding-scale fee based on income and insurance. It is an HMO facility.

The Ethical Dilemma: Domestic Violence

Karla is a newly appointed counselor at the above clinic. She is seeing a client, Ebony, an African American woman in her early thirties, who is suffering from depression. One day, Ebony comes in with visible bruises. Karla inquires of Ebony what happened and after some hesitation, Ebony confides that her husband is physically abusive. She further adds that sometimes she fears for her life, her husband’s temper is so explosive. Ebony also states that she fears how this affects her children, five and six years old in age; Karla is shocked and asks Ebony why she doesn’t leave, take her children with her and get a divorce? Ebony replies that she cannot because she doesn’t have anywhere to go and her husband threatened her on numerous occasions that if she leaves, he will find her and kill her. Karla insists that Ebony must leave, if only for the safety of her children. Karla is unable to figure out how she should handle this case. She fears for her client’s and her children’s safety, and doesn’t know whether she should notify authorities. What should Karla do?

The main ethical dilemma in this case is one of protecting the parties in danger. Although the main client is Ebony, the other parties involved are the children, who may also be in grave danger, and to a certain extent the abusive husband, who is not in danger but who may benefit from counseling as an abuser. Other ethical concerns is whether authorities should be notified and the professional competence of the counselor. The counselor is very inexperienced and does not seem to be able to handle the complexity of this case, nor does she appear to have any experience with domestic violence cases. Her option would be to refer the case to a more experienced colleague, or to seek consultation and supervision. Consultation should be sought in any case. One of the first things the counselor should do is assess her own personal bias concerning the domestic violence case. Another step the counselor has to take is understand the domestic violence cycle in which the victim blames herself.
Since the client is already being seen by the counselor, the counselor’s ethical responsibility is to assure the safety of all victims. The counselor must understand her own personal bias as well as the cultural and ethnic background of the client. Finally, as with all other cases, confidentiality, informed consent, and limits to confidentiality must be discussed with the client. Informed consent form must be prepared and signed by the client before counseling can proceed.

The client’s empowerment is a fundamental value for engaging persons experiencing abuse. In a study of students of social work, some of the students state, “dealing with battered women [is] like a contagious disease” , indicating a difficulty with maintaining professional boundaries. A blurring of boundaries may become problematic, as can the desire to control the client’s situation and decision making, contradicting the social work value of self-determination (Bent-Goodley, 2007). This is evident in this counselor’s case as she asks the client why she doesn’t just leave.

Another ethical concern is that the counselor can develop negative feelings about a batterer after seeing a survivor with physical remnants of violence. The worker may become angered with a mother when hearing her child’s accounts of violence, or the worker may wonder why the survivor does not leave the relationship. At these moments, ensuring the client’s self-determination becomes a challenge. The worker may want to persuade the survivor to leave or may become frustrated with the survivor’s decision to stay in the relationship. Preserving confidentiality can pose an additional ethical issue when working in the area of domestic violence (Bent-Goodley, 2007).

The counselor must examine her competency in working with this case. Critical professional values related to domestic violence and resolving ethical dilemmas are being non-judgmental, self-determination, confidentiality, and maintaining the client’s agenda.

Provide a safety Plan
One of the most important things the counselor must do is ensure the safety of all parties. This can be accomplished by providing a safety plan and make the client aware of resources available to her. The counselor must assess the immediate needs of the victim and involve her in a strategy for intervention.
New York state does not have a law requiring mandatory reporting of domestic violence. It is important to note that child protection services is not mandated to be called for reports of domestic violence in New York. However, children are involved and they are exposed to detrimental effects of this violence.

Domestic Violence Advocate

Part of the safety plan should be that Karla gets Ebony in touch with a Domestic violence advocate. The functions of Domestic violence advocate include assisting victims of domestic violence in determining an appropriate course of action for their family, which may include legal, housing and/or child protection services; providing crisis intervention by linkage to Legal Services, Children’s Services, Child Protection Services and Adult and Family Services; supporting victims of domestic violence by accompanying them to all court proceedings as well as explaining all hearing and trial procedures; providing legal and social service advocacy; providing home visits when necessary; escorting victims to service plan reviews and other meetings when necessary; providing advocacy to victims with the Department of Social Services, such as Food Stamps, and Medicaid; providing support counseling for victims and their families; assessing the client’s need and making appropriate referrals; assisting the client in obtaining shelter, food and emergency care; collaborating with various agencies in the community such as Crisis Services, Police Department, Housing for Battered Women, etc. ; maintaining records and preparing reports of all activities (Domestic Violence Advocate Exam, 2008).

Domestic Violence Handbook
Another important step as part of a safety plan is giving Ebony a domestic violence handbook published by (Reference) which describes what domestic violence is, safety planning ,what to do if you decide to leave, what the police can do for you, criminal court and civil court, why orders of protection can be helpful, getting help from social services, places where you can get help in New York State, program listing by county, and a lot of other useful information (Domestic Violence Handbook, 2004).

Order of Protection
A powerful resource for Ebony is getting an order of protection. Karla should definitely let Ebony know about this option. An order of protection issued by a court would allow Ebony and her children to be safe from the abuser. The abuser would be required to:
(a) to stay away from the home, school, business or place of employment of the other parent and/or children, and to stay away from any other specific location designated by the court;
(b) to refrain from committing a family offense or any criminal offense against the children or against the other parent or against any person to whom custody of the children is awarded, or from harassing, intimidating or threatening such persons;
(c) to refrain from acts of commission or omission that create an unreasonable risk to the health, safety or welfare of a child/children;
(d) to provide, either directly or by means of medical and health insurance, for expenses incurred for medical care and treatment arising from the incident or incidents forming the basis for the issuance of the order;
(e) to pay the reasonable counsel fees and disbursements involved in obtaining or enforcing the order of the person who is protected by such order if such order is issued or enforced;
(f) to observe such other conditions as are necessary to further the purposes of protection.
The court may also award custody of the child, during the term of the order of protection to either parent, or to an appropriate relative within the second degree. Nothing in this section gives the court power to place or board out any child or to commit a child to an institution or agency (Smith, Nickles, et. al. 2001) .

Multicultural issues of domestic violence – African American community views
The counselor in this case must be culturally sensitive to the client. It is critical to understand how the client perceives domestic violence. This may require workers to help clients first describe the situation before identifying it as domestic violence. Although it is important to help the client put the abuse in the larger context of domestic violence, it is far more important to begin where the client is and allow her to define her reality. In studies of African American attitudes about domestic violence the participants identified the need to protect the image of the community, demonstrating the persistence of racial loyalty despite personal physical and mental health risks. Two techniques were identified to address racial loyalty. First, the worker may need to accept that the client may have internalized traditional sex-role stereotypes and could see the violence as a man’s right to keep order in the home (Bent-Goodley, 1998). In other words, the counselor cannot simply assume that the client sees the violence as being wrong. Instead, the counselor should help the client empower herself by exploring sex-role perceptions and expectations of the relationship. Providing clients with information that is not judgmental allows them to analyze and think critically for themselves with more information at their disposal. Helping the client define her own reality and connecting that with the larger context of violence against women can help the counselor better understand and connect with African American women experiencing abuse. Providing the client with more information so that she can make an informed choice is of utmost importance (Bent-Goodley, 2007).

Diagnostically Assessing Domestic Violence

The presence of depression in traumatized victims of abuse has been well documented . Depressive symptoms are often reported as are hyperarousal, intrusive thoughts of the abuse or perpetrator, confusion, disorganization, denial, insomnia, psychosomatic symptomatology, and dissociative features related to the victim’s effort to cope with the trauma. Apathy and a source of helplessness, the intense internalized anger, the debased self-image, and ruminations of guilt, all are recognized within the cluster of depressive symptomatology frequently recognized in victims of prolonged abusive relationships (Miller, Veltkamp, et. al., 1997).
Long-term traumatized victims of family violence may show anxiety, agitation, and hypervigilance that is most recognizable not only in their insomnia and startle reactions, but in tension headaches, abdominal pain, gastrointestinal disturbances, and other forms of somatization. Victims of domestic violence may well experience a more complex picture of psychopathology. They are, in fact, victims of a disorder of extreme stress that captures the manifestations of repeated and prolonged traumatization and its resultant impact on personality development that is not usually seen in situations of a more acute stressful nature (Miller & Veltkamp, 1996).
Several behavioral indicators of abuse in the family frequently are seen in spouses and children who have been abused. Any one of these behavioral indicators may by the victim’s way of communicating to the clinician or healthcare professional that something is wrong and that he or she is being abused. A mistake frequently made by healthcare professionals is that these behaviors are viewed as the problem, rather than the symptom of a far greater family problem, namely domestic violence.
These behavioral indicators include isolation from others, feelings of helplessness, vulnerability, maintaining secrecy, indecision/uncertainty, poor self-confidence, low self-esteem, fear, anxiety, depression, impaired ability to judge trustworthiness in others, and accommodation to the victimization (Miller & Veltkamp,1996).

The Impact on Children who Witness Violence
Children exposed to domestic violence often suffer psychological and behavioral difficulties that if left untreated can severely impact on their lives and may ultimately result in perpetuating an intergenerational cycle of violence. With help, many children can be saved from a downward spiral.
Children exposed to domestic violence should receive therapy through group/peer counseling, play/art/sand therapy, in-home counseling, and anger management classes.
Children who live in battering relationships experience the most insidious form of child abuse. Whether or not they are physically abused by either parent is less important than the psychological scars they bear from watching their fathers beat their mothers. A child living in a home with domestic violence lives in a world of terror, uncertainty, and self-blame. Too often, the authorities focus on the abuser and the abused, and neglect the young innocent bystander. We know, however, that exposure to domestic violence frequently results in severe immediate, short-term, and long-term effects on children.
Review of the literature on children who witnessed domestic violence found that children suffer behavioral, emotional, and cognitive problems. Children exposed to domestic violence demonstrate aggressive and antisocial behavior as well as fearful and inhibited behaviors. Further, these children have fewer social skills than children not exposed to domestic violence. Children who witness domestic violence were also more likely to suffer from anxiety, depression, trauma symptoms, and temperament problems. It has also been found that increased exposure to violence is associated with lower cognitive functioning and had significantly more behavioral problems and less social competence than those children whose mothers were not battered.
The American Psychological Association has stated that abusers are psychologically
maltreating children by exposing them to domestic violence. Experts in family violence are
concerned that children who are exposed to domestic violence in their home begin to see violence
as an acceptable way to behave towards other persons.
Children exposed to domestic violence have been referred to as forgotten victims or silent victims.
Often the domestic violence victim and the batterer receive services. However, the child who is
exposed to it is frequently overlooked and too often falls through the cracks of the system (Smith, Nickels, et. al., 2001).

In light of these effects of domestic violence, the counselor should provide ongoing therapy to Ebony and her children. Additionally, the abuser should be held accountable through some combination of batterer treatment, community corrections, and/or incarceration (Miller, Veltkamp, et, al., 1997).

Seek consultation
While many supervisors may not have adequate information about domestic violence, practitioners should still consult with their supervisors before attempting to resolve an ethical dilemma. The supervisor might be able to offer other venues for decision making. In addition, one can consult with domestic violence experts as part of resolving ethical dilemmas, expanding the notion of supervision to include outside expertise (Bent-Goodley, 2007).

Documentation to provide to Ethics Committee

Documentation in Social work – whether it concerns clinical, supervisory, management or administrative duties, now serves six primary functions: 1) assessment and planning – clear and comprehensive documentation of all case-related facts and circumstances; 2) service delivery – records of clinical, community-based and agency-based services and interventions; 3) continuity and coordination of services – records of services coordinated with members of other disciplines such as doctors, nurses, counselors etc.; 4) supervision; 5) service evaluation; and 6) accountability to clients, insurers, agencies, other providers, courts, and utilization review bodies.
Practitioners’ first rule of thumb when documenting cases should be to include sufficient detail to facilitate the delivery of services and protect themselves in the event of an ethics complaint or lawsuit.
Such details involve social histories, assessments, and treatment plans; informed consent procedures; contacts with clients; contacts with third parties; consultations with other professionals;decisions made and services provided; critical incidents; instructions, recommendations, advice, and referrals to specialists; failed and canceled appointments; previous or current psychological or psychiatric and medical evaluations; information concerning fees; termination of services; final assessment; and other relevant documents (Reamer, 2005).

Conclusion
Treating domestic violence cases involves a number of ethical dilemmas which must be resolved by the counselor. Domestic violence has serious and far-reaching consequences for those involved. The counselor needs to address their personal bias, their own ability to competently handle the situation, ensure the safety of all involved, address multicultural issues, provide on-going support to the client and her family, and provide referrals where necessary. The counselor has to address issues of informed consent and record keeping. The counselor must seek supervision and consultation where necessary.
References

Bent-Goodley, T. B. (2007). Teaching Social Work Students to Resolve Ethical Dilemmas in Domestic Violence. Journal of Teaching in Social Work, Vol. 27 Issue 1/2, p73-88, 16p;

Bent-Goodley, T. B. (2007); Perceptions of Domestic Violence: A Dialogue with African American Women. Journal of Health & Social Work/ Volume 29, Number 4

Bledsoe, L. K; Yankeelov, P. A.; Barbee, A. P.; Antle, B. F.; Understanding the Impact of Intimate Partner Violence Mandatory Reporting Law. Sage Journals
Domestic Violence Advocate Exam NO. 64-469 (2008). New York State Department of Civil Service

http://www.cs.state.ny.us

Domestic Violence Handbook (2004); New York State Coalition Against Domestic Violence; http://www.nyscadv.org; retrieved 9/4/2008

Miller, T. W., Veltkamp, L. J.; Kraus, R. F. (1997); Clinical Pathways For Diagnosing and Treating Victims of Domestic Violence. Journal of Psychotherapy; Volume 34/Number 4

Miller, T. W., & Veltkamp, L. J. (1996). Theories, assessment, and treatment of domestic violence. Directions in clinical and counseling psychology. New York: Hatherleigh Company.

Reamer, F. G. (2005); Documentation in Social Work: Evolving Ethical and Risk-Management Standards. Journal of Social Work; 50; 4

Smith B. E.; Nickles, L. B.; Mulmat D. H.; Davies H. J. (2001). Helping Children Exposed to Domestic Violence: Law Enforcement and Community Partnerships; American Bar Association.