Testing a Transcultural Model of Ethical Decision Making with Rehabilitation Counselors

Article excerpt

As it has been widely reported, minority populations are growing quickly and are expected to exceed the populations of current majorities in the next 50 years (Welfel, 2006). In part as a response to this trend, in 2005 the Governing Council of the American Counseling Association (ACA) published several changes to the ACA Code of Ethics. Among these changes were significant alterations in the code regarding multicultural issues. The ACA is requiring counselors to be better trained and more aware of multicultural issues in counseling (Kocet, 2005). The position of the ACA is that there is an "ethical mandate" for counselors to be culturally competent and take into account diversity standards included under almost every section of the new ethics code (Kocet).

The need to be inclusive of cultural variables extends to the development of ethical decision-making models, which, to date, have not incorporated such factors systematically. To reflect this need, a team led by the main author of this study developed a model called the transcultural integrative model (TIM) for ethical decision-making (Garcia, Cartwright, Winston & Borzuchowska, 2003). The argument is that counselors will be better prepared to address ethical dilemmas, particularly those involving stakeholders from different cultural backgrounds, if they follow resolution models that integrate cultural factors methodically.

The transcultural model draws primarily from the integrated model of ethical decision-making developed by Tarvydas (1998), but added significant aspects that reflect multicultural theory. Following the integrated model, the transcultural model incorporates both principle and virtue ethics. Consistent with principle ethics, the integrated and transcultural models define an ethical dilemma in part as a conflict involving ethical principles that are in opposition to each other, such as when client autonomy conflicts with client nonmaleficence (i.e., clients choosing vocational goals that may lead to serious harm). Virtue ethics theory emphasizes that certain counselor characteristics (or virtues) account for the way counselors resolve ethical dilemmas. Virtues such as balance, reflection, attention to context, a collaboration attitude, and tolerance are necessary for counselors to make more sensible and fair ethical decisions (Tarvydas, 1998). In addition, the transcultural model draws from the social constructivist (Cottone, 2001) and collaborative (Davis, 1997) models. The main components of these models are reflected in the incorporation of arbitrating, negotiating, consensus seeking and relational strategies as essential aspects of the transcultural integrative model presented in this article.

Most importantly, the transcultural approach adds analytical components that reflect basic concepts of multicultural counseling under each of the stages that comprise this model. Some key concepts include minority and diversity constructs, cultural worldviews, cultural self-awareness, cultural values, cultural identity, acculturation, gender role socialization, and cultural barriers such as biased assumptions, racism, discrimination, stereotypes and prejudices. These concepts are found in the multicultural counseling literature that emerged in the early 60s and has grown exponentially in the decades that followed until today. Prominent authors discussing such concepts include Ivey, D'Andrea, Ivey, and Simek-Morgan (2002), Ponterotto, Casas, Suzuki, and Alexander (1995), and Sue and Sue (2003), among many others. In a study looking at multicultural articles in the Journal of Counseling and Development between 1990 and 2001, Arredondo, Rosen, Rice, Perez, and Tovar-Gamero (2005) found that there is a significant focus on multiculturalism. They reported a wealth of theoretical and empirical research focusing on multicultural topics similar to the ones mentioned above. The main areas of research mentioned in this review were worldview, interventions, psychosocial adjustment/development, cultural influences, identity development and profession issues, training/curriculum/education, acculturation, multicultural competency, and contextual issues.

Description of the Transcultural Integrative Model

As summarized in an article by Garcia, Winston, Borzuchowska, and McGuire-Kuletz (2004), the TIM includes four major steps. The first step depicted in the model is awareness and fact-finding. Enhancing sensitivity and awareness means not only becoming aware of the ethical component of a dilemma but also how a dilemma may affect the different stakeholders involved who may have different or even opposing worldviews.

Counselors' own cultural values, cultural identity, acculturation, and gender role socialization may influence their view of the dilemma and the degree to which they perceive a situation as a dilemma. For example, a counselor with strong affiliation to the value of family interdependence may perceive the situation of a male client with HIV who recently immigrated to this country and who is seeking vocational services as one that requires advising the client to return to his original country where he would find family support. In contrast, another counselor valuing individual autonomy would view this situation as one posing a conflict where the freedom of choice (autonomy) of the client could be in opposition to what the counselor believes would be best for the client. In the latter case, the counselor contemplates both conflicting courses of action before deciding which one is best. From a gender role socialization perspective, a feminist counselor and a non-feminist counselor may view the dilemma of a female client differently. There is also the possibility that a counselor may ignore the acculturation pattern of the client and follow a course of action that assumes a higher level of acculturation. Cultural identity is another variable to consider, particularly since cultural identity not only applies to race or ethnic identity but also to gender, sexual orientation, and even disability identity development (Julia, 2000; Lee, 1999; Sue & Sue, 2003). Counselors may assume, mistakenly, that a client is viewing a situation from an ethnic identity perspective when in fact he/she may view it from a gender identity perspective. Finally, the client's culture may elicit particular emotional reactions in the counselor depending on how much the client's values or behaviors contradict those of the counselor. This emotional reaction may affect the perception of a particular situation, thereby influencing the counseling process.

The second step of the model involves the formulation of courses of action and determination of the best possible ethical decision. Under each one of the strategies to complete this step, this model incorporates specific cultural elements. Accordingly, counselors should: (a) analyze all cultural information gathered in step one; (b) study potential discriminatory laws or institutional regulations; (c) ensure that the potential courses of action reflect the stakeholders' different worldviews; (d) examine the positive and negative consequences of opposing courses of action from the cultural perspective of the parties involved; (e) seek the advice of cultural experts if necessary, and (f) select and agree on the best course of action. If agreement appears to be difficult, counselors can use Cottone's (2001) three-step interpersonal process that involves negotiating, consensus-seeking, and arbitrating. Negotiating refers to the discussion and debate of an issue about which two or more individuals disagree. Consensus-seeking is a strategy of agreement and coordination between two or more individuals on a specific issue. If the disagreement persists, Cottone suggests using a consensually accepted arbitrator; who can make the final judgment. In addition, the use of relational methods (Davis, 1997) and social constructivism techniques (Cottone) are key elements of the model since these are particularly applicable to situations requiring a group agreement.

The third step of the model refers to identifying potentially competing, non-moral values, which may interfere with the implementation of the course of action selected. Cultural values are particularly relevant here. For example, implementing a particular course of action may imply a level of client competence in dealing with the healthcare system that is not consistent with his/her acculturation level. Alternatively, a course of action selected may contradict the female client's learned gender role. Contextual influences are also critical during this step. In the case of the client with HIV presented earlier in this section, counselors need to be aware of potential prejudice against persons with HIV/AIDS as well as against immigrants. In recommending a course of action that includes a vocational goal, counselors should consider whether the client is ready to confront such attitudes as well as anticipate possible negative reactions from employers or vocational service providers.

The fourth and final step is to implement, document, and evaluate the plan of action. Culturally, this involves securing resources that are culturally relevant for the client and developing countermeasures for the potential contextual barriers identified above. For example, in the case of the aforementioned client with HIV, counselors should educate future employers and service providers about the client's cultural identity, level of acculturation, and gender role socialization. They also should prepare the client and other stakeholders to deal with potential biases, discrimination, stereotypes, and prejudices.

Finally, in addition to the virtues of attention to context, balance, and reflection mentioned under the Tarvydas (1998) model, the transcultural model adds other pertinent virtues such as tolerance, sensitivity, and openness. These virtues are essential in completing the steps outlined under this model, which implies an understanding of clients from different cultural backgrounds.

To assess the value of this transcultural model, it is important to understand prior ethical-decision making models, for they provide the background in which the transcultural model was developed. Counselors and ethics researchers should pay particular attention to those founded on a rational approach, which is the predominant model today. As described in the next section, this approach does not explicitly include cultural variables as part of the decision-making process. An understanding of this model is important because the authors chose it as a comparison model as part of the research design of this study.

Description of a Rational Model

Rational models derive primarily from principle ethics (Kitchener, 1984). Once the principles in a conflict have been identified, the professional chooses the best course of action. This choice is based on a rational evaluation of the advantages and disadvantages of choosing one course of action over another. In following a rational model, professionals must use rational justification to compromise one ethical principle over another (Bersoff, 1996) when faced with a dilemma. The essentials of a rational model are described by Forester-Miller and Davis (1995) as a sequence of the following seven steps: (a) identify the problem; (b) refer to the code of ethics and professional guidelines: (c) determine the nature and dimensions of the dilemma; (d) generate potential courses of action; (e) consider the potential consequences of all options and then choose a course of action; (f) evaluate the course of action, and (g) implement the course of action. An examination of the narrative under each of the steps listed yields the conclusion that no cultural variables are included in the analysis of a dilemma under this model. The assumption here may be that only one set of values applies to all cultures, as stated by Pedersen (1997). The rational model described by ForesterMiller and Davis (1995) has been published by the American Counseling Association and is the primary model learned by counseling students and professionals.

The purpose of this study was to evaluate the perception of acceptability of the transcultural integrative model as compared to the perception of acceptability of the rational model described by Forester-Miller and Davis in 1995. There is a precedent in the use of this model as a comparison for testing other ethical decision-making models, as done in a previous study by Garcia et al. (2004). In that study, the rational model received high acceptability ratings by rehabilitation professionals across 13 selected model characteristics, and these scores were significantly higher than those received by the integrative model (Tarvydas 1998) which was taught to another group of participants selected randomly. The present study replicated that design but this time the researchers compared a transcultural integrative model to the rational model. Participants' perception of acceptability is important not only to facilitate the adoption of a particular model but it provides information to the ethics trainer about what aspects of the model seem to be in need of change or receive more attention in order to improve the training.

The research question of this study was whether there was a significant difference between the participants' ratings of the transcultural ethical decision-making model and the participants' ratings of the rational ethical decision-making model. All participants used the same rating form, which is described later in this section.

Methodology

Participants

The researchers recruited participants from state vocational rehabilitation agencies in the Mid-Atlantic region by contacting the training directors of the state vocational rehabilitation office, who posted flyers and sent electronic announcements to the professional staff working in those agencies. Target participants were professionals who provided direct rehabilitation counseling services or related services, and supervisors. All those who volunteered and met these characteristics were selected for this study. Sixty professionals agreed to participate in this study and each received 10 Continuing Education Units towards certification in rehabilitation counseling. Most participants were rehabilitation counselors (60%) while the other were direct service rehabilitation professionals such as vocational evaluators, rehabilitation technicians, and supervisors (40%). About 85% had Masters Degrees and 15% had Advanced Certificate or Bachelors degrees. The majority of the participants (65%) had taken an ethics course before as part of their education, and the others (35%) only had a workshop or less of previous ethics training. The gender distribution showed that about 82% of the participants were female, and identified themselves as Caucasians (76%), African Americans (12%), or Latinas (2%). Thus, the typical participant in this study (across both groups) was a Caucasian female with a Master's Degree in rehabilitation counseling who had one course or less as previous ethics training, and worked in a vocational rehabilitation agency in the Virginia Commonwealth.

Since the total number of 60 participants was too high from a pedagogical standpoint, the researchers divided the group into three cohorts of 20. Each cohort received exactly the same training. Within each cohort, the researchers assigned the participants randomly to one of two groups, with one group receiving training on the rational model of ethical decision-making and the other receiving training on the TIM. Attrition was 13% (n=8) and distributed evenly across the three cohorts. The total number of participants who completed the training in each of the three cohorts was 18 for the first cohort (9 in the rational and 9 in the transcultural group), 17 for the second cohort 2 (9 in rational group and 8 in transcultural group), and 17 for the third cohort (9 in the rational group and 8 in the transcultural group).

Training

The independent variable was type of training, with two levels: training on the transcultural model and training on the rational model of ethical decision-making. The training was conducted online using BlackBoard[R] software. The training consisted of seven online sessions lasting seven weeks. In the first four weeks, participants received training on general ethics theory, principles and main ethical issues concerning the counseling/client relationship; on week five, one group received training on the specific features of the transcultural model and the other group received training on the rational model. In weeks 6 and 7, participants practiced the use of the model they learned by solving two case scenarios provided by the researchers and receiving feedback on how well they applied the model to each case.

The training was designed by the research team, which consisted of three rehabilitation counseling educators and a graduate student. They adapted the training format from the one utilized and validated in a previous study by Garcia et al. (2003). One of the researchers was responsible for the training. This researcher was the least familiar with the transcultural model since he did not participate in the actual development of this model. By having the same and least invested researcher deliver the training to both groups, the authors attempted to control for the confounding factor of potential researcher bias in delivering the training.

Measures and Data Collection

The dependent variable was participants' perception of acceptability ratings of the model learned through the training. At the end of the study, each participant was asked to rate the model they learned across 13 items contained in the Model Ratings Form (see items in Tables l, 2 and 3). Nine of these items refer to characteristics of the model and four to self-efficacy in using the learned model. This measure was validated by the authors by extracting items from the relevant literature, consulting experts on ethical decision making in the counseling field, and by using a pilot study to validate the nature of the items. The Alpha coefficient for the ratings of the transcultural model was .97 and for the rational model it was .96. This shows a very high internal consistency.

Data Analysis

The researchers used descriptive statistics and a multivariate test to analyze the data. For a two-group comparison, the multivariate test chosen was the Hotelling's Trace. Significance level was set at .05.

Results

In Table 1, the authors show the means across the 13 items in the Model Rating Form across the two groups, rational and transcultural, for cohort 1. The multivariate analysis (Hotelling's Trace) yielded no significant differences across groups (F = 2.175; df = 13; Sig = .053).

The mean ratings across items and groups for cohort 2 are shown in Table 2. The Hotelling's Trace yielded no significant differences across groups (F = 1.052; df = 13; Sig = .588).

The mean ratings for cohort 3 are shown in Table 3. Again, the multivariate analysis yielded no significant differences across groups (F = .617; df = 13; Sig = .767).

Discussion

The main research question in this study was whether there were significant differences between a group receiving training on a transcultural integrative model of ethical decision-making and a group receiving training on a rational model on the model ratings completed by participants after the training. The results of a multivariate analysis showed no group differences for all three training cohorts. The means reflected high ratings (approximately 4 out of a maximum of 5) for each model across the 13 items, which generally means that participants across the three cohorts viewed both models quite favorably. The finding of no differences across groups represents an increase in favorability of an integrative model as previous findings showed the rational model as preferred by similar participants over an integrative model of ethical decision-making (Garcia et al., 2003). This integrative model provided the foundation for the transcultural model evaluated in this study, but it was devoid of the cultural variables incorporated to the transcultural model. Thus, a plausible explanation for this improvement can be that the addition of cultural components made the integrative model developed by Tarvydas (1998) more useful and attractive to professionals in the vocational rehabilitation field. From a practitioners' perspective, the finding that the transcultural model is equal to the rational model is relevant because, traditionally, the rational model has been the accepted practice. This will allow professionals to choose what model to use depending on the nature of the ethical dilemma they are facing or the cultural context in which it occurs.

Still, several limitations of this study need to be addressed. Perhaps it would have been reasonable to add a no-training comparison group to investigate whether training was better than no training at all. However, the authors had ethical concerns associated with having a group that would not benefit from the study. In addition, there has been consistent evidence that training is significantly better than no training in helping professionals to deal effectively with ethical dilemmas, particularly when that training includes the use of ethical decision-making models (Garcia et al., 2004).

Another limitation is statistical power. The size of the groups under each cohort was not sufficient to have at least a .80 power. The authors could have aggregated the group data from the three cohorts and compare the transcultural data to the rational data without considering the cohort they came from. In this case, the size of each group would have been around 26, which is the number required to meet a power of .80 for a comparison analysis with two groups, an alpha of .05 and a large effect size. However, the authors thought that this procedure would bias the interpretation of the results since the cohorts received training at different times. In addition, the researchers attempted to control for researcher bias in training delivery by having one researcher train both groups and choosing the researcher who was not a member of the original authors of the transcultural integrative model to conduct the training. However, this bias could still play a factor since the trainer was aware of the purpose of the study.

Selection of the sample is another potential limitation. Even though they were randomly assigned to groups, the authors did not have control of the selection process as it was essentially self-selection. Characteristics such as education, previous training on ethics, and even demographics such as ethnicity or age were not subject to manipulation by the researchers. For example, it would have been valuable as a research question to test whether ethnicity played a role in the evaluation of the models, given the cultural aspects of this study. However, this was not possible to investigate given that the vast majority of the sample belonged to one ethnic group (Caucasian).

From a training perspective, the results of no difference across model ratings appear to warrant the need to conduct training on the transcultural model, in addition to training on the rational model. The high participants' ratings across all items for both models seems to suggest also that ethics trainers need not pay more attention to some aspects over others. When averaging the item means across all three cohorts the picture of similar ratings remains the same, although three items have the larger differences (albeit non significant). Two of these items have to do with the transcultural model being rated as clearly distinct and founded in sound theory, more so than the rational model. The other item concerns how easy is for participants to learn these models. Again, based on observation of the data, it appears that participants have more difficulty learning the transcultural model, which may speak to the need to spend more time teaching this model. One strategy to make the training on this model more effective would be to add more case scenarios in order to increase the practice of case resolution using this model. Conversely, in conducting training on the rational model, it appears that trainers should consider spending more time focusing on its theoretical foundations that would make this model clearly distinct from others.

Future research in this line of study would benefit from considering the limitations regarding design, statistical power, and characteristics of the sample. In addition, researchers should use several measures instead of just ratings by participants of the characteristics of the models. Particularly, the use of a measure to test the ability of participants to resolve ethical dilemmas effectively by using either model would enhance the value of this research for practitioners. Beyond addressing the limitations of this study, future researchers could examine other factors of theoretical and practical value. Some of them include the comparison of face-to-face versus online training, variations in duration or intensity levels of instructions, addition of a variety of practical training sessions in resolving actual ethical dilemmas, or testing particular theories underlying ethical decision-making models, such as multicultural theory, virtue ethics, principle ethics, constructionist approaches, or self-efficacy theory. Such studies, or others that researchers could pursue after reading this study, would definitely advance the knowledge about ethical decision-making and its impact on effective rehabilitation practice.

References

American Counseling Association (2005). ACA Code of Ethics. Alexandria, VA: ACA

Arredondo, R, Rosen, D. C., Rice, T., Perez, R, & Tovar-Gamero, Z. G. (2005) Multicultural Counseling: A 10-Year Content Analysis of the Journal of Counseling & Development. Journal of Counseling and Development, 83, 3, 155.

Bersoff, D. N. (1996). The virtue of principle ethics. The Counseling Psychologist, 24, 86-91.

Cottone, R. R. (2001) A social constructivism model of ethical decision-making in counseling. Journal of Counseling and Development, 79, 39-45.

Davis, A. H. (1997). The ethics of caring: A collaborative approach to resolving Ethical dilemmas. Journal of Applied Rehabilitation Counseling, 28, 36-41.

Forrester-Miller, H., & Davis, T. E. (1995). A practitioner's guide to ethical decision-making. Alexandria, VA: American Counseling Association.

Garcia, J., Cartwright, B., Winston, S., & Borchukowska, B. (2003). A transcultural integrative ethical decision-making model in counseling. Journal of Counseling and Development, 81, 268-276.

Garcia, J., Winston, S., Borzuchowska, B., & McGuire-Kuletz, M. (2004). Evaluating the integrative model of ethical decision-making. Rehabilitation Education, 18(3), 147-164.

Ivey, A. E., D'Andrea, M., Ivey, M. B., & Simek-Morgan, L. (2002). Counseling and Psychotherapy. Needham Heights, Mass: Allyn and Bacon.

Julia, M. (2000). Constructing Gender: Multicultural Perspectives in Working With Women. Belmont, CA: Wadsworth/Thompson Learning.

Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundations for ethical decisions in counseling psychology. The Counseling Psychologist, 12, 43-55.

Kocet, M. M. (2005). Ethical challenges in a complex world: Highlights of the 2005 ACA Code of Ethics. Journal of Counseling and Development, 84(2), 228-234.

Lee, W. M. (1999). An Introduction to Multicultural Counseling. Philadelphia, PA: Accelerated Development.

Pedersen, P. E. (1997). The cultural context of the American Counseling Association Code of Ethics. Journal of Counseling and Development, 76, 23-28.

Ponterotto, J.G., Casas, J.M., Suzuki, L.A., & Alexander, C.M. (1995). Handbook of Multicultural Counseling. Thousand Oaks, CA: Sage.

Sue, D. W. & Sue, D. (2003). Counseling the Culturally Diverse: Theory and Practice. New York, NY: John Wiley and Sons.

Tarvydas, V. M. (1998). Ethical decision-making processes. In R. R. Cottone & V. M. Tarvydas (Eds.), Ethical and professional issues in counseling (pp. 144-158). Upper Saddle River, NJ: Prentice Hall.

Welfel, E.R. (2002). Ethics in counseling and psychotherapy: Standards, research, and emerging issues. Pacific Grove, CA: Brooks/Cole.

Welfel, E. R. (2006). Ethics in counseling and psychotherapy: Standards, research and emerging issues. Belmont, CA: Thomson Brooks/Cole.

Jorge Garcia

The George Washington University

Maureen McGuire-Kuletz

The George Washington University

Robert Froehlich

The George Washington University

Pooja Dave

The George Washington University

Jorge Garcia, Director, Rehabilitation Counseling Programs, The George Washington University, 2134 G. St., NW, Washington, DC 20052.

Email: garcia@gwu.edu

Table 1.
Mean ratings across items, by group, for cohort I

Items                                                    Rational (N=9)
                                                            M     SD

1. Easy to follow                                          4.0    .90
2. Clearly distinct                                        3.7    .89
3. Easy to learn                                           3.8    .85
4. Useful for me                                           4.2    .61
5. Increases my awareness of values and morals             4.1    .75
6. Inclusive of other perspectives                         3.9    .96
7. Founded in sound theory                                 4.1    .99
8. Increases my awareness of ethical decision-making       4.1    .99
9. Leads to feasible courses of action                     3.8    .86
10. Increases my confidence in making ethical decisions    3.9    .80
11. Satisfies my expectations                              3.9    .90
12. Decreases my anxiety in making ethical decisions       4.0    .76
13. Increases my chances that I will perform ethically     4.2    .78

Items                                                    Transcultural
                                                              (N=9)
                                                           M      SD

1. Easy to follow                                         3.5     1.0
2. Clearly distinct                                       4.1     .80
3. Easy to learn                                          3.3     1.2
4. Useful for me                                          3.8     .88
5. Increases my awareness of values and morals            3.5     1.0
6. Inclusive of other perspectives                        3.8     .94
7. Founded in sound theory                                3.9     .83
8. Increases my awareness of ethical decision-making      3.9     .83
9. Leads to feasible courses of action                    3.6     .86
1O. Increases my confidence in making ethical decisions   3.7     .90
11. Satisfies my expectations                             3.6     .97
12. Decreases my anxiety in making ethical decisions      3.5     .98
13. Increases my chances that I will perform ethically    3.6     1.2

Table 2.
Mean ratings across items, by group, for cohort 2

Items   Rational (N=9)   Transcultural (N=9)
          M      SD          M        SD

1.       4.1    1.26        4.0      1.30
2.       3.4    .72         4.0      .53
3.       3.9    1.27        3.5      1.30
4.       4.0    1.32        4.1      1.35
5.       3.8    .92         4.1      .99
6.       3.9    1.1         4.0      1.41
7.       3.7    1.2         4.6      .51
8.       4.0    .86         4.0      1.41
9.       4.0    .86         4.0      1.41
10.      4.0    1.22        3.7      1.28
11.      4.0    .70         3.6      1.18
12.      3.8    1.10        3.5      1.20
13.      3.9    1.26        3.8      1.24

Table 3.
Mean ratings across items, by group, for cohort 3

Items     Rational      Transcultural
          M      SD       M      SD

1.       3.5    1.30     3.7    1.03
2.       4.0    .87      3.9    .83
3.       3.5    1.13     3.6    .91
4.       4.2    1.10     4.0    1.06
5.       4.4    .88      4.5    .75
6.       4.2    .97      4.0    .75
7.       4.3    .86      4.6    .74
8.       4.4    .72      4.5    .75
9.       3.9    1.05     4.4    .74
10.      4.2    .97      4.3    .88
11.      3.9    1.05     4.0    .75
12.      3.9    1.26     4.1    .83
13.      4.3    .86      4.2    1.03

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