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may result in a conflict of loyalties for the therapist, or the double agent dilemma, also known as double agency or dual roles (Chodoff 1996: 299). Roberson and Walter describe this as ‘the dilemma of conflicting expectations or responsibilities, between the therapeutic relationship on the one hand and the interests of third parties on the other’ (2008: 229a). They suggest that HCPs (psychiatrists, in their study) adjust to changing times and find an ethically defensible way to manage third party interests, as it is a strong and lasting phenomenon in modern health care (2008 :234).
The strong paternalistic stance of a third party which may very well be based on beneficence must therefore not be confused with the beneficent duty the therapist owes towards a client. Therapists should have the client’s best interest at heart, not that of the third party. The relationship between the client and the therapist is different from the relationship between the institution and the student/client.
Therapist-client relationships are seen as ‘fiduciary’, mutual or equitable (Adshead
& Sarkar 2005: 1012a), implying that the relationship is based on trust. However, that is not to say that we do not owe duties towards the university as an employer. As Rachels explain, there are however different duties, associated with different virtues (2003: 181). The relationship with a client is different and in a sense more unique than the relationship with an employer. Furthermore, if the trust and fiduciary relationship is perceived to be disregarded by clients, in this case the student population, it is possible that future clients will refrain from seeking help or from divulging important information (Freeman et al. 2004: 166). As such, neither the institution, nor the client, or even potential clients, benefit in the long run.
not be necessary. Deliberation of potential risk must be assessed in terms of threat to others, the means in which to achieve it, past behaviour and the like.
Therapists working within student health environments would be wise to consult with psychiatry and have well established psychiatric referral systems in place.
Involvement of parents usually occurs with the consent of the client. Even after initial refusal, most clients do consent that third parties be contacted after discussion and explanation. If consent is absent and assessment of immediate threat is made, confidentiality could be broken and relevant parties contacted on the grounds of an emergency situation. The challenge for the therapist would be to help the client towards optimal treatment in the least invasive way.
Secondly, clients may be seriously ill, but nevertheless non-psychotic and currently stable. Resistance, denial and refusal of therapeutic engagement are unfortunate, but common phenomena of many diagnostic categories. In many cases it may be a way of coping or attempts at adaptive responses. For therapists, this is ‘business as usual’. If attempts to engage such clients in therapy fail, clients should be allowed to exercise autonomous choice and exit therapy. The unfortunate, but unavoidable outcome will probably be that the illness or condition will ‘get worse, before it can get better’.
Thirdly, suicidal threats and attempts pose an obvious risk to clients. Duties of beneficence compel us to act responsibly and assess risk and autonomy. In this respect, official and well publicised suicidal policies on university campuses may be helpful (see Meilman & Pattis 1994, for an explanation of such policies). Pillay et al. (2004: 352-360) describe the ‘responsible caring’ concept in the Canadian Ethical code. This means that the clinician’s judgement is not over-determined by autonomous decision making in the client. It allows for routine referral and assessment of clients who displayed non-fatal suicide behaviour. They contend that this does not diminish respect for persons under these circumstances and may comply with a beneficence ideal. Emergency referral options should be available and psychiatric consultant services must be in place and accessible to Student Health Centres, in case of suicide attempts and threats. Many students do not have access to private care and accessing state facilities can be frustrating, slow and dependant on the geographical positioning of the campus. Until such time as these services are optimised, university management may have to come to an agreement with local service providers in their immediate vicinity regarding assistance for students who make suicide attempts and serious threats.
Fourthly, students registered and governed by a professional body, such as the HPCSA, should be made aware of the requirements of the Health Professions Act. Faculties who train these students have an obligation to manage and protect students that may have become impaired. Students must be made aware that they
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too, ought to manage serious psychiatric (and physical) conditions responsibly, to avoid impairment. If necessary, such students should be registered at the HPCSA Health Committee on completion of their training, for further supervision and management if the impairment persists. Policies that govern and protect HPCSA registered students should therefore be in place at universities.
Fifthly, therapists should not obscure their role to clients and need to take care to explain their function to the client. If clients are referred for an assessment with a report as the expected outcome (as in the case of disciplinary procedures), there cannot be therapeutic expectations and process. Equally important, requests for reports and disclosure of confidential information often occur during therapeutic involvement. Therapists must receive written consent before any information is made available to third parties. It is also important to be able to deny clinical reports to third parties if clients do not consent.
In the sixth place, Jennings et al. (2005: 44) state that one of the core values of a good therapist is to be open to complexity and ambiguity, be adaptive and open to find answers and constantly try to overcome obstacles. It seems sensible to acknowledge third parties as important and legitimate role players. Their duties are however not always the same as the duty of the therapist. It may be counterproductive to ignore requests, or take a defensive stance to institutional or parental interests in clients because of one’s own anxieties and discomfort. It may be better to manage this pro-actively, in cooperation with the client.
Lastly, it may be helpful to take a preventative, and again not defensive, stance to autonomy and beneficence issues. Therapists may be in a better ethical position if time is routinely taken to discuss issues of autonomy, consent, confidentiality and access to client information, (as well as exceptions to it), therapy contracts, costs and the like, with new clients. Thus consent can be given freely, or not, without due influence and through autonomous choice. This is best done before commencement of the therapeutic process and in a written format to which clients can refer back. Any potential or anticipated problems relating to the referrals can be ironed out by initial discussion. In light of the more problematic cases this process may be imperative. Therapists are in a best position to reframe the referral for a patient. In a sense, cooperation can be negotiated which may be to the benefit of the student as well the institution.
Conclusion
When we return to the problem statement and the ethical questions posed in the beginning of the discussion, we may be in a better position to address the
dilemmas we were confronted with. These questions will occasionally come our way when working in a student support environment. Even though the answers are never crystal clear, we should be equipped to negotiate and manage them in a responsible and ethical manner. That is what I intended to achieve through this paper.
Notes
1. A ‘profession’ has to do with the scope of practice and behaviours associated with a profession, while ‘professionalism’ refers to the implicit or explicit code of conduct and norms associated with a profession.
2. Bailey (2010) discussed the policy-research nexus and explored the utilisation of research and its impact on policy and in particular the role ‘networks’ (such as associations) in terms of the interplay between research and policy.
3. The human capabilities approach was originally developed by Amartya Sen (1984, 1995, 2001) and has since been a leading paradigm for policy development around human development issues and was the basis for the United Nations Human Development Index.
4. South African higher education is governed by a policy context which constructs ‘Student Development and Support’ (the equivalent to student affairs) in a particular way, and any meta- framework needs to comply with national policy. The National Commission on Higher Education:
An overview of a new policy framework for higher education transformation (DoE 1996: 12) is particularly informative in this regard.
5. Globalisation means the global mobility and transnational circulation of information, education, culture, and economics, through the increase in exchange and the opening of borders by the reduction of barriers and the increase of open access to information via the internet and other virtual platforms.
6. The term neo-liberalism was coined to describe the period after socio-economic liberalism, which dominated the first world with its emphasis on civil liberty and economic freedom, while protecting individual rights. The removal of the protective regulations sheltering economic monopolies is considered the onset of the neo-liberal economic order.
7. Du Toit (2007) discusses the issues arising from considering, what he called, higher education’s
‘social contract’. He argued that the social contract safeguards academic freedom and self- determination, a key element for student affairs within the institutions.