Scenario one: Firearm disclosure and suicidal thoughts
The Scenario: In a rural community in New South Wales, a young farmer sought counselling while grappling with suicidal thoughts. The farmer reluctantly disclosed that he had firearms on his property and that if he did attempt suicide, he would use a firearm to end his life. The counsellor wrestled with the decision of whether to report the presence of guns to the police or not, as it was a risk to his safety. The farmer was reluctant to come to therapy in the first place because he had heard that if you go to therapy, they take your guns away. The counsellor is concerned that if she reports the guns to the police, it will break the trust of the client and discourage more farmers from coming to therapy. If she does not report the guns, she is worried that he may use them to end his life, and she will not be fulfilling her duty of care.
Using the ETHICS model to make a decision
E – Evaluate the dilemma: The ethical dilemma in this scenario is whether to report the firearms to the police or not. There are no direct instructions from the codes of ethics, but it seems as though they are leaning more towards reporting and protecting the client’s safety, referring the client on, and upholding state laws rather than keeping the confidentiality and trust of the client.
The ethical principles and standards that have been breached in this scenario pertain to the duty of care, client safety, the law, and the safety of others. Section 4.2 of the ACA Code of Ethics and Practice highlights the responsibilities that the counsellor has to the client in ensuring the client’s physical and psychological safety (a, i) and not acting on behalf of the client except in exceptional circumstances (b, ii) (Australian Counselling Association [ACA], 2022). Additionally, reporting the presence of guns to the police would be breaking confidentiality, so section 4.7 “exceptional circumstances” would come into play. This section provides some guidance around the ethical decision, stating that there needs to be a balance between the best interests of the client and the counsellor’s responsibilities to the wider community and law when making ethical decisions (ACA, 2022). Another document that would pertain to this situation is the ACA Suicidal Client Guidelines and it is imperative that the treating counsellor stays within their scope of practice at all times as only level 3 and 4 counsellors are advised to treat this risk group and never in isolation (ACA, 2013). The Psychotherapy and Counselling Federation of Australia (PACFA) Code of Ethics has a similar structure regarding best practices. Section 1 (a and b) highlights that practitioners are to respect the wishes of the client to be involved in decisions and foster a relationship with clients built on trust (PACFA, 2017). However, sections 1e, 5d and 5e recognise the limitations of confidentiality, stating that practitioners take action to protect clients from self-harm (PACFA, 2017).
T – Think ahead: Option one is to discontinue therapy, report the use of firearms and refer the client, as it is not recommended to see suicidal clients in isolation. As it is in a regional area, there are limited options to refer the client to and often lengthy waitlists are involved. This also puts the client at risk of harm but protects the counsellor from breaching their scope of practice. However, it is important to consider the impact that reporting would have on the wider farming community as it would further discourage help-seeking behaviour (Reynders et al., 2014; Fiore & Kordic, 2023). Option two is to continue seeing the client with additional support from other practitioners. To work together as a multidisciplinary team and involve the counsellor’s supervisor in collaboratively finding a direction they should take in reporting the presence of firearms. This would support both the client and the counsellor to ensure the safety of everyone involved.
H – Help: Taking this to a supervisor will support with clarity of the situation and emotional support for the counsellor as it may be distressing. In this situation, all four categories of help would be relative. Firstly, clinical questions concern how actions affect the client’s best interests. Secondly, legal questions would be around the laws involved in the situation. Thirdly, risk management would be concerned with liability exposure and ethical questions related to the interpretation and application of the Code of Ethics. Some potential people who could be involved in the consultation process are a legal attorney, supervisor, ethics board, and insurance companies.
I – Information: Health professionals are encouraged to remove firearms from people with mental health concerns because when firearms are involved, 90% of suicide attempts result in death, and the odds of dying by suicide are three times higher for those with access to firearms compared to those without (Pallin & Barnhorst, 2021). A recent report suggested that close to half of Australian farmers (45%) have had thoughts of self-harm or suicide, making them twice as likely to die by suicide than any other employed Australian (Norco & National Farmers Federation, 2023). Depending on the state, there are different laws about the disclosure of firearms and mental health. In NSW, Section 79 of the NSW Firearms Act (1996) states that health professionals may inform police of those who are considered to be at risk of harm to themselves or others and have access to firearms without any liability for breaching confidentiality. Section 38 of the NSW Weapons Prohibition Act 1998 also highlights that if a health practitioner thinks that a person is unsuitable to have access to firearms because they think they are going to attempt suicide, nothing is preventing them from informing the police commissioner. The NSW Police Force (2019) states it is a matter of discretion once an opinion is formed. However, it is made clear in the document that if someone has made threats of suicide and is in the position of a firearm, you should notify the Commissioner of Police. In NSW, firearms reporting is highly encouraged but not necessarily a legal requirement.
C – Calculate Risk: If the counsellor does nothing and continues to see the client without involving additional support, there will be a high risk for everyone involved. The minimum risk to the counsellor would be to report the firearms and refer the client. However, this puts the client at a higher risk of harm due to breaking trust and feelings of abandonment. Additionally, this puts the farming community at higher risk as it will discourage such a vulnerable population from seeking help even more.
S – Select Action: The most ethical course of action in this scenario would be to conduct a thorough risk assessment with the client to determine their level of risk and stage of suicidal thoughts. If assessed as low risk with minimal risk factors, note in the file that guns are present, monitor the situation for risk and check in with their supervisor regularly. If the client is medium to high risk, it will be pertinent to involve other health professionals in the case and proceed with a multidisciplinary team continuing to monitor the level of suicidality and risk factors. If the risk escalates, a team decision upon consultation with a supervisor can be made on whether to report the firearms to the police commissioner or not. If the client is assessed as an imminent risk, the police commissioner should be immediately notified, and the client should be referred to the hospital for inpatient treatment.
References
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Fiore, B. & Kordic, M. (2023, Feb 7). WA farmer who survived childhood sexual abuse says gun laws may worsen stigma around getting help. ABC Great Southern. https://www.abc.net.au/news/2023-02-07/mental-health-stigma-gun-laws-farmer/101938136
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