The DO ART Model in Action: A Case Exploration

Introduction

The DO ART model is a helpful structure for assessing ethical dilemmas in Art Therapy and Counseling. The DO ART acronym stands for Dilemma, Options and Outcomes, Assistance, Responsibility, and Take Action (Hauck & Ling, 2016). The ethical dilemma is identified, possible options and courses of action are explored, potential impacts on stakeholders are examined, consultation is obtained, options are again revisited in terms of stakeholders, responsibility, and liability exposure, a course of action is decided on, and action is taken (Hauck & Ling, 2016). One of the benefits of applying this model is that it walks the art therapist through a process that details thought progression and, in the face of an ethical complaint or violation accusation, illustrates how decisions evolved.

This paper aims to apply the DO ART model to the hypothetical case of Ray in an exercise to showcase the benefits of applying the model and the thought processes needed to examine all sides of a potential ethical dilemma thoroughly. Ray is a 30-year-old white female client who identifies as queer, has recently expressed interest in masculinizing hormones and possible transition, is a long-term client of one and a half years, has a history of abuse, is struggling financially, and is currently working as a sex worker while caring for their ailing mother. There was a recent encounter with Ray outside of therapy at a community meditation night where a mutual friend introduced us, attempting to cultivate a friendship between two people caring for ailing family members, unaware of our professional relationship. While the meditation night has long been a vital community, I felt uncomfortable and left the event early. Afterward, Ray began asking unusual personal questions in therapy, and an ethical dilemma was born.

Dilemma

Addressing the ethical dilemma is the first step in the case of Ray. In their case, there are multiple potential dilemmas, including approaching Ray’s sex work as a harmful versus empowering situation, offering a sliding fee scale or pro bono work versus the standard fees given Ray’s financial difficulties, and how to navigate questions from a mutual friend without breaking confidentiality and disclosing Ray as a client. However, the most immediate and significant dilemma relates to the questionable ethics surrounding a potential dual relationship at the monthly community meditation night and whether to refer Ray to another therapist.

Unclear and differing ethical codes in the field complicate the best path forward. For example, the American Counseling Association (ACA) and the American Art Therapy Association (AATA) are in agreement that counselors should not engage in a professional relationship with friends or family where objectivity is compromised (ACA, 2014, A.5.d.; AATA, 2013, 1.4), or where “the multiple relationships could reasonably be expected to impair competence or effectiveness of the art therapist to perform… or otherwise risks exploitation or harm to the person with whom the professional relationship exists” (AATA, 2013, 1.4). Here, difficult questions arise: Is objectivity possible if I become friends with Ray? Might a friendship unintentionally cause Ray harm or impact the therapeutic alliance?

However, the Texas State Board of Examiners of Professional Counselors (TXSBEPC, 2023) takes a different and much more aggressive stance on multiple relationships. They adopted a new rule effective September 21, 2023, which explicitly states that “non-therapeutic relationships with clients are prohibited” (TXSBEPC, 2023, 681.38.d). They go on to outline that “the licensee must not provide counseling services to previous or current family members, personal friends, educational associates, or business associates… [and] may not engage in a non-therapeutic relationship with a client if the relationship begins less than two (2) years after the end of the counseling relationship” (TXSBEPC, 2023, 681.38). Here, additional questions arise: To which code must I adhere? Does shared membership in the monthly meditation community classify us as having an educational or business relationship, regardless of the presence or absence of any personal friendship? Should I refer Ray to another therapist? Would severing the therapeutic relationship with Ray cause them harm?

However, before weighing in on the ethics and possible courses of action, there are other cultural, identity, and values-based considerations to evaluate, as these areas can impact the lens through which the primary ethical dilemma is observed. Regarding cultural and values-based considerations, Ray and I both come from white American cultures; we were both assigned female at birth, we share an interest in meditation and community involvement, and we share a mutual friend. From an identity standpoint, Ray and I additionally hold commonality as primary caregivers to an ailing family member. We differ in terms of gender identity and sexual orientation as I am a heterosexual, cisgender woman, and Ray identifies as queer, they/them, and potentially trans. This difference is notable because social connectedness directly correlates with self-esteem (Austin & Goodman, 2017), and Ray may find more benefit from a therapist from the LGBTQ+ community. In contrast, there may be limitations in terms of relatability and rapport with a heterosexual cisgender woman, particularly should Ray decide to transition.

Additionally, Ray and I are in different socioeconomic classes. Roy and Walsh (2020) underscore the importance of addressing differences in socioeconomic class as these statuses shape both client and therapist worldviews, and misunderstandings can fracture the therapeutic alliance. While these differences could be worked through under supervision, the multiple relationship ethical dilemma further underscores the need to question if I am the best therapist for Ray and if they might have a better therapeutic outcome with a different therapist more suited to their identities. Throughout the following process, it is essential to note that careful and detailed documentation along the way is critical.

Options and Outcomes

The multiple relationships ethical dilemma, in this case, presents five options for consideration: 1) adhere to the ACA and ATTA codes but risk potential TXSBEPC repercussions due to shared community participation and continue counseling Ray while not having an outside friendship; 2) adhere to the ACA and ATTA codes but break the TXSBEPC rules and objectively continue counseling Ray while also having an outside friendship; 3) ignore the flexibility of the ACA and ATTA codes and break the TXSBEPC rules by referring Ray to another therapist and having an outside friendship; 4) more strictly adhere to the TXSBEPC rules by referring Ray to another therapist and not having an outside friendship, but still attend the meditation nights; 5) strictly adhere to the TXSBEPC rules by referring Ray out, not having a friendship, and also stop attending meditation nights for good measure.

First, I would have a conversation with Ray in the next session to discuss the ethical dilemma, how to potentially interact at future community meditation nights, work through what to say to our mutual friend, access Ray’s openness to a referral, and let Ray know that I will need to seek supervision on the dilemma. I would then move on to the second step in the DO ART model by assessing possible positive and negative consequences for all stakeholders under each option. In this scenario, the primary stakeholders are Ray and me; the secondary stakeholders are our mutual friend, the potential referral therapist, and, more loosely, the meditation community.

1. Continue counseling Ray and not have an outside friendship. This option adheres to the ACA and ATTA codes because it removes the main multiple relationship component by not having a dual relationship with Ray. If Ray wants a friendship, this decision could cause Ray distress and affect therapeutic rapport. It might also cause friction or additional complications with our mutual friend and possible awkwardness at community meditation nights. However, continued counseling with Ray puts me at risk with the TXSBEPC because it is unclear if shared membership in the community meditation nights is considered an educational or business relationship.

2. Continue counseling Ray objectively and have an outside friendship. This option also adheres to the ACA and ATTA codes so long as I can remain objective and competent in our professional relationship and the duality does not cause harm to Ray. However, I feel uncomfortable here because there is too much room for our professional relationship to be influenced by a personal relationship. Additionally, this course would directly oppose the TXSBEPC rule that forbids dual relationships with current clients, meaning my license would be in jeopardy. Lastly, such action exacerbates confidentiality concerns with our mutual friend.

3. Refer Ray to another therapist and have an outside friendship. Much like the previous option, this option directly opposes the TXSBEPC rule to abstain from engaging in a nontherapeutic relationship with a former client for at least two years. The potential violation of ACA and ATTA codes concerning multiple relationships is removed through referral. As long as the referral is made because it is reasonably possible that continuing the therapeutic relationship would cause harm to Ray, it meets both ACA (2014, A.11.c.) and ATTA (2013, 14.3) termination standards, as well as the looser TXSBEPC (2023, 681.38.g.) termination standards. However, referral also calls into question, given the long-term established relationship with Ray, if referring Ray would do more harm than good. Regardless, this option jeopardizes my license due to a direct violation of the TXSBEPC rules. 

4. Refer Ray to another therapist and not have an outside friendship, but still attend the meditation nights. This option mostly adheres to all the codes. Still, it poses potential issues: referring Ray to another therapist could cause them harm given our long-established professional relationship, Ray might feel rejected if friendship is turned down, Ray might feel uncomfortable at meditation nights moving forward, and there is some risk in attending the meditation nights conflicting with the TXSBEPC rules if doing so constitutes an educational or business relationship with Ray. However, this is not clearly defined in the rules regarding this situation.

5. Refer Ray to another therapist, do not have a friendship, and discontinue attending meditation nights. The last option is the strictest, and while it meets all the codes and rules (unless referring Ray would cause them harm), it also robs me of attending community events that are meaningful and valuable to me. It seems unfair to lose out on community and spending time with my existing friend in meditation because a client also attends the same event. Additionally, the TXSBEPC rules do not explicitly state that attending the same events or being a member of the same organization as a current or recently former client is prohibited. They only call out business and educational relationships as being prohibited. Therefore, membership and shared community are not necessarily in violation.

Assistance, Responsibility, and Take Action (ART)

After weighing in on all the abovementioned options, the next step in the DO ART model is to seek consultation. Seeking consultation in ethical dilemmas is not only suggested but also required to meet the ACA (2014) code, which states, “Counselors take reasonable steps to consult with other counselors… or related professionals when they have questions regarding their ethical obligations or professional practice” (C.2.e.). The complexity and lack of clear guidance in the case of Ray make obtaining consultation critical. Hauck and Ling (2016) underscore the importance of not seeking the answer from someone, which shifts responsibility away from me as the therapist, but instead seeking out how others see the situation and might handle it. Reading relevant literature is also paramount in understanding how others in the field have approached similar situations.

After obtaining consultation and reading available literature, the next step is to revisit all the options, take responsibility, and make a decision. In the case of Ray, options two and three both include having a personal friendship with Ray, which directly violates the TXSBEPC rules and puts me at risk of losing my license. Therefore, I would remove these as options. That leaves three options: continue counseling Ray and not have an outside friendship; refer Ray to another therapist and not have an outside friendship but still attend the meditation nights; or refer Ray to another therapist, not have a friendship, and discontinue attending meditation nights. 

Given the onset of personal questions asked by Ray in the following session, I would err on the side of caution and consider that rejecting a friendship with Ray would complicate the therapeutic relationship. That, combined with erring on the side of caution concerning the stricter rules in Texas, means I would also rule out the continuation of our therapeutic relationship. I would refer Ray to an art therapist in the LGBTQ+ community who specializes in working with queer and trans individuals and who also offers a sliding scale fee structure or does pro bono work. Lastly, I would continue to attend the monthly community meditation nights. While there is some risk that it could constitute a business or educational relationship with a former client, should Ray continue to attend, it does not explicitly define that. The risk would be minimal. In this case, more harm would be done by not attending and losing a deeply meaningful sense of community. 

Finally, the last step in the DO ART model is to take action. I would discuss this with Ray in session and walk them through how I arrived at the decision. I would do my best to address Ray’s concerns while maintaining proper boundaries. From there, we would work out how to handle further interactions with our mutual friend and how we will conduct ourselves should we run into each other at future meditations or elsewhere in the community. I would make the referral, ensure a smooth transition with Ray’s new therapist, and document the entire process. 

Conclusion

The DO ART model applied to the case of Ray highlights how complex an ethical dilemma can be. However, the model provided a solid framework from which to operate, making the process much less intimidating. Additionally, the documentation throughout the process offers a thick layer of protection should the final decision ever be questioned. While there were no easy answers, the DO ART model helped to solidify the options and arrive at a decision that feels more ethically sound to me and holds the least potential for harm.

References:

American Art Therapy Association. (2013). Ethical principles for art therapists. AATA. http://www.arttherapy.org/upload/ethicalprinciples.pdf

American Counseling Association. (2014). 2014 ACA code of ethics. ACA. http://www.counseling.org/resources/aca-code-of-ethics.pdf

Austin, A., & Goodman, R. (2017). The impact of social connectedness and internalized transphobic stigma on self-esteem among transgender and gender non-conforming adults. Journal of Homosexuality. 64:6, 825-841. http://doi.org/10.1080/00918369.2016.1236587

Hauck, J., & Ling, T. (2016). The DO ART model: An ethical decision-making model applicable to art therapy. Art Therapy. 33:4, 1-6. http://doi.org/10.1080/07421656.2016.1231544

Roy, A., & Walsh, K. (2020). The intersectionality of socioeconomic status (SES) and social class on the therapeutic alliance with older adult clients. Smith College Studies in Social Work. 90:1-2, 96-114. http://doi.org/10.1080/00377317.2020.1706417

Texas State Board of Examiners of Professional Counselors. (2023). Texas administrative code. TXSBEPC. https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=30&ch=681&rl=38

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