ROCKY MOUNTAIN REGION DISASTER MENTAL HEALTH NEWSLETTER

Learning From The Past and Planning For The Future


MENTAL HEALTH MOMENT
August 31, 2001

"It is better to know some of the questions than all of the answers."
                      - James Thurber

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Behavioral Sciences and the Law has issued a call for papers for a special issue
about "end of life issues", such as euthanasia and surrogate decision-making. Papers promoting
international perspectives are encouraged. Deadline: Sept. 1. Contact: James L. Werth, Jr., PhD,
Department of Psychology, Third Floor Polsky Building, University of Akron, Akron, OH 44325-4301;
(330) 972-2505; fax: (330) 972-5174; EMAIL: jwerth@uakron.edu
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Free Access to Quality of Life Information
http://acqol.deakin.edu.au
The Australian Center on Quality of Life's (QOL) Web site, which aims to provide resources
to researchers, students and practitioners on QOL-related matters, offers free QOL materials,
including QOL instruments and an extensive searchable list of references and information
about QOL conferences. The site can also be used as a portal to other QOL-related sites, and 
members can receive updates about new material.
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The Red Cross Disaster Mental Health Services-I (DMHS-I) course will
          be offered in Casper, WY on Friday-Saturday, September 14-15, 2001.
          If you want to take this course as a Disaster Mental Health 
          Professional, please send an email for further details on how to
          register to: larlion@hotmail.com   The enrollment is limited to 20
          participants. APA has approved this course for 12 CEUs. Other
          mental health professions have also approved it for continuing
          education.                                    
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CRITICAL INCIDENT STRESS WORKSHOP sponsored by The University of Wyoming Counseling Center 
and The Rocky Mountain Region Disaster Mental Health Institute will be held in Laramie, WY 
on November 16, 17, 2001. There will be two workshops. One will be in Basic Critical Incident 
Stress Management (CISM) on 11/16-11/17 and will be a certification course taught by 
International Critical Incident Stress Foundation (ICISF) certified trainers. The Advanced 
Issues in Critical Incident Stress Debriefing will be taught by U.S. Navy Psychologist 
CDR Bryce Lefever, PhD, ABPP. Enrollment in both workshops is limited. There is an early bird 
registration period. If you wish to receive a printed brochure, please email:
larlion@callatherapist.com  with your name and mailing address. 
Online Brochure can be accessed at: https://www.angelfire.com/biz3/news/cismuw.html                                         

 MUDSLIDES IN TAIWAN 

 At least 85 people have died, 183 have been injured and
 another 131 are missing after Typhoon Toraji, packing
 winds of 150 km/h, swept Taiwan early Monday morning.
 The strongest storm to have hit the island in 50 years
 triggered mudslides severely damaging the eastern
 Taiwanese county of Hualien and the mountainous county
 of Nantou in central Taiwan. Villages disappeared
 overnight and damage to property has been estimated at
 more than USD$ 150 million, including a USD$50 million
 loss in agricultural products.

 Following a typhoon alert on 29 July, some 800 Red
 Cross relief volunteers were on stand by in the cities
 and counties of Taipei, Kaohsiung, Taichung, Nantou,
 Yilan, and Hualien – areas that were expected to be
 affected by the wrath of Toraji.
More at: http://www.ifrc.org/Docs/News/01/080301/

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ETHICAL ISSUES IN SPECIAL CLINICAL FUNCTIONS

In many ways it is implicit in many of the ethical principles that the consumer of psychological
services is:

          1. an individual adult

          2. competent to negotiate a contract to

          3. meet personal needs for

          4. treatment that is well established and known to be effective, to be

          5. provided to that individual.

There are some variations to this that are important to note:

          1. Consumers who are not individuals, but are groups or families.

          2. Consumers who are not competent to give informed consent for services
             (e.g. minors, psychotic or retarded individuals).

          3. Consumers who are third parties rather than the target client.

          4. Treatments that are not well established.

GROUP AND FAMILY THERAPIES

Ethical Issues

There are two primary issues that are important in considering group and family therapy
that are distinct from the general obligation to provide ethical clinical services. The
first involves the special problems associated with protecting confidentiality and
preserving privileged communication in group and family settings. The second is the fact
that these are specialty services requiring advanced training in order to ensure the
competence of the provider.

When more than one nontherapist is present for treatment, mental health professionals
must take special care to protect confidentiality since the other nontherapists are
not bound by a code of professional ethics. Participants in treatment must be informed 
of this limitation. Additionally, the mental health professional must be aware that in
many states there is no legal privilege existing when more than one person is present,
and must take steps to inform the clients of this.

Since group and family treatments are specialized services, therapists must be competent
in delivering them. With regard to family therapy, where the issue of coercion arises. 
the mental health professional has an obligation to inform family members of their right 
to choose participation in treatment. If family therapists are from the school that 
requires all family members to be present before treatment can be provided, they should 
inform the family of this and note that not all therapists enforce this rule.

SOME EXAMPLES OF UNETHICAL DECISIONS

1. A child clinical psychologist with no training in family therapy has been working with
a seven year old boy. The client begins to talk about arguments that the parents have in
his presence, and the psychologist decides to invite the family into the sessions.
(Problem of competence).

2. A member of a therapy group discusses the content of previous sessions with her friend.
The friend is a co-worker of another member of the group. The group therapist has not
discussed issues of confidentiality with the group members. )Problem of protecting
confidentiality).

3. A family counselor firmly adheres to the principle that unless all members of the 
family are present, no family session will be held. A family is referred for concerns
about their withdrawn 11 year old son. The family includes a 16 year old daughter who 
is reluctant to attend. The counselor does not inform her of her freedom to leave the
session. (Problem of denying voluntary participation).

4. A counselor is subpoena'd to testify about a parent's fitness to retain custody after
he has been seeing the couple in marital treatment. The counselor agrees to testify, even
though no discussion of this possibility had taken place either partner. (Problem of
failure to obtain informed consent).

Some Related Legal Principles

The mental health professional should become familiar with emerging case law regarding 
group counseling and therapy. These precedents involve the difficulty ensuring that
members of therapy groups (who are not professionals) are subject to the same obligations
to protect confidentiality as is the counselor. Privileged communication is likely not
applicable in group settings. Privileged communication statutes for the state in which
the counselor practices should be reviewed. For family counselors, the above will be
useful, as will a review of child custody statutes.

Some Current Controversies

1. The question of court testimony about parental fitness or child custody decisions 
when family or marital therapy has been conducted presents a number of ethical dilemnas.
Counselors should carefully consider how to proceed when requested to testify and should
explain their policies clearly to clients at the beginning of therapy.

2. Counselors who lead groups should consider how best to protect the confidentiality of
group members. Haas & Malouf (1989) suggest some options in this regard, particularly
involving "contracts" among members.

Ethical Principles

In spite of the obligation to provide informed consent, not all persons who consume
mental health or counseling services are capable of doing so. These include minors, 
involuntarily committed patients, prisoners, and psychotic and retarded individuals
and others who exhibit a diminished capacity. In these cases, the counselor works to 
uphold the best interests of the client and to avoid violating or diminishing the
individual's rights. In cases where competence to consent may make the protection of
confidentiality an issue, counselors should negotiate suitable arrangements with a
legal guardian or representative of the individual. However, attempts should be made
to clarify the nature of treatment arrangements with clients regardless of whether
or not they have the capacity to provide truly informed consent.

Some Examples Of Ethical Problems In Procedure

1. A 16 year old girl requests counseling from a private practitioner to discuss aspects
of her sexuality. Her parents are very strict in these matters and she does not want them
informed. She does not ask and the counselor does not describe his practices regarding
condidentiality. The parents call to inquire about the progress of treatment and the
counselor informs them fully. (Failure to consider how to protect confidentiality).

2. A psychotic patient who has not responded to various conventional treatments, including
medications, is a candidate for an aversive conditioning paradigm designed by the ward
psychologist. The treatment involves administration of painful shocks. The psychologist
decides to administer the shocks without discussion with the patient because the patient
is incompetent. (Failure to obtain even substituted consent).

3. The warden of te prison in which a psychologist works requests the names of any 
prisoners who have discussed their involvement in a recent riot. The psychologist 
provides these names. (Loyalty to employing agency versus loyalty to clients; question 
of who is the client.).

Some Related Legal Principles

The counselor should become familiar with the notion of substituted consent and with
relevant case law in the area of informed consent and its management.

The counselor should also become familiar with legal considerations that may compromise
the rights of persons receiving services at the request of third parties. This would be
a particularly important concern in schools and in federally supported institutions. There
are two federal statutes that are of relevance here. One is PL 94-142, the Education for
All Handicapped Children Act (1975), which guarantees the rights of parents to approve
or withhold approval for services proposed for their children. The second, PL 93-380, is
the Family Education Rights and Privacy Act (or Buckley Amendment) of 1974, which
guarantees parents access to their children's records.

Therapists working with clients who may have been involuntarily committed should review
the federal court cases concerned with patients' rights to both participate in and refuse
treatment. In addition, state law regarding emancipated minor status is relevant to the
issue of children's ability to provide informed consent. Court cases at the federal level
have focused on (and generally upheld) the rights of minors to consent to treatment, and 
counselors who work with minors should review these findings. Haas & Malouf (1989) and 
Cohen & Mariano (1982) are useful resources in this area.

Some Controverseries

1. Providing too detailed a statement of informed consent can actually reduce prospective
clients' motivation for treatment. Counselors must carefully consider how to balance the
arousal of hope with the provision of accurate information.

2. Not only failure to provide informed consent, but also providing too detailed a
promise of benefit may expose the counselor to risk. The nature of the information
provided, and the form -written or verbal - needs to be carefully considered.

PROVIDING SERVICES AT THE REQUEST OF THIRD PARTIES

Ethical Principles

The fact that mental health professionals frequently provide organizational consultation,
community interventions, court-ordered psychological services, school psychology services,
and other such third party requested services makes a focus on the special ethical 
considerations in these situations important. The general ethical obligations discussed
previously all hold in these circumstances. Additionally, the following ethical principles
are also relevant.

Informed consent of the directly affected individuals is often difficult to obtain in
third party requested services. Nevertheless, counselors work to provide as much opportunity
for it as possible. If the nature of the service is such that individuals involved in it
may not have the opportunity to provide informed consent (organizational development
efforts and prevention programs are particularly relevant here), counselors have an
obligation to protect the interests of such individuals.

Conflicts of interest between the demands of the organization, payor, or third party and
the needs of the particular person with whom the counselor is interacting may arise. 
In such cases, the counselor works to inform all "stakeholders" of the situation and to 
work toward a resolution.

In organizational and community work, the counselor has an obligation to be aware of 
individual differences in client groups. If the initiators of community or organizational
intervention request assessment results, counselors take responsibility for the
consequences of the assessments or diagnoses that are delivered. 

If in the course of community or organization work counselors become aware of practices 
that diminish the rights of members, they attempt to rectify the situation. Counselors
also have an obligation to clarify the nature of their services to organizational members
who may come in contact with them.

Counselors are also obliged to ensure that the organizations that employ them will not
misuse the results of their work or exploit them or their work. When providing training
to community or organization members, counselors have an obligation to avoid misleading
them into believing that they possess competence in counseling service delivery that
they do not possess.

Some Examples of Poor Ethical or Legal Decision Making With Third Parties

1. A counselor is developing a community intervention to prevent drug abuse. It involves
   interviewing junior high school students about their parents' use of illegal substances.
   The plan is for paraprofessionals to visit the homes of high-risk parents and discuss
   alternative stress reduction methods.

2. An EAP counselor discovers that several middle management employees are "burned out".
   When she proposes to develop a support group for these managers, upper level executives
   decide that it would be more cost effective to replace them, and on the basis of her
   findings, fires them.

3. An organizational consultant discovers that one of the consultees with whom he is
   working is severely suicidal. He begins weekly treatment sessions with the person.

4. A community counselor feels that many of the lower class black parents with whom she
   is working in a poverty reduction program discipline their children too harshly. She
   refers several of them for investigation of child abuse.

5. An EAP counselor is hired to conduct stress reduction workshops in an organization.
   He discovers routine sexual harassment in the course of his efforts but decides not
   to do anything about it for fear of being fired.

6. An EAP counselor is hired to improve the management skills of supervisors in a
   manufacturing plant. Many of them begin to confide in him about marital problems and
   alcohol abuse. Because a portion of his job involves screening for employees with
   greater managerial potential, he reports those with more problems as having less
   potential. He does not inform them of these reports.

7. A counselor has developed a peer support group for preventing drug abuse among airline
   employees. A drug abuse scandal hits the airline, and the counselor is asked to provide
   the names of group members to management. She does so.

8. A counselor has trained several paraprofessional community groups in stress management
   techniques for poverty level mothers. She finds that group members are promoting their
   services to other community groups (e.g. drug abusers) with the claim that they are
   "relaxation experts". She does nothing to halt this practice.

9. A school counselor is assigned a group of high school teachers who have discipline
   problems in their classrooms. Her job is to help them learn new classroom management
   techniques. The counselor discovers that the teachers have been told that if they
   refuse to attend the group, they will be reassigned to less desirable schools. She
   does nothing about this.

10. A masters level psychologist is hired by a state institution for developmentally
   disabled persons to provide assessments to re-certify residents for state services.
   He provides the testing and reports with appropriate recommendations. There is no
   supervision provided by the institution, even though the masters level psychologist
   has repeatedly requested this. Two administrative personnel read his reports and
   request him to change the content and his recommendations to suggest that the
   persons assessed can live in a community placement. The psychologist refuses to
   change his reports stating that the assessments conclusively demonstrate that the
   persons in question could not possibly be able to take care of themselves as they
   were profoundly mentally retarded. He is told that he must either change the reports
   or be placed on suspension. He refuses and appeals to higher authorities to no avail.
   Receiving no support, the psychologist resigns his position stating that it would
   be unethical and even illegal for him to change the assessment results as requested.

Some Related Legal Principles

The counselor who works in organizational consulting or in school contexts should become
familiar with case law and statutory law regarding civil rights and informed consent.
Again, the work of Cohen & Mariano (1982) on legal issues may be helpful.

Some Controversies

1. Third parties may expect (and may have legal rights to expect) access to data regarding
   services. Counselors on the other hand have an obligation to protect confidentiality and 
   should be clear with all parties about such obligations. This raises questions about 
   balancing customary practice in non-professional contexts with ethical obligations.

2. Licensure and credentialing for organizational and community counselors is hotly debated,
   since the type of service (and the level of regulation needed to protect consumers) may
   be quite different from traditional clinical work.

3. Employers increasingly demand that counselors perform services outside their areas of
   competence. Ethical practitioners face the dilemna of protecting their jobs versus
   upholding their professional standards. 

INNOVATIVE TREATMENTS AND SERVICES

Ethical Principles

Counselors have a general obligation to provide competent service. In specialty areas where
established standards exist, counselors who wish to deliver such services have an obligation
to obtain training or supervision in the new specialty. However, many forms of counseling
involve new or innovative techniques for which clear standards of competence have not as
yet been established. Three forms of innovative services are discussed briefly below: novel
forms of clinical treatment; "media counseling"; and computerized testing.

With regard to novel clinical techniques, counselors should become aware of them as a part
of their general obligation to be competent providers of services and use them as needed. 
Insofar as possible, counselors attempt to allow the prospective client to give informed
consent.

Media counseling, in which counselors provide personal advice or general opinions about
particular problems via electronic or print media, is emerging as a specialty service. 
Counselors are obliged to be aware of possible negative impacts on the audience and to
exercise careful professional judgment. Counselors also have a duty to avoid exploiting 
the needs of callers or writers seeking advice, and must take care not to overstep the
boundaries of their competence. Some usefule guidelines are presented by Haas & Malouf
(1989).

In the area of computerized testing, counselors are obligated to maintain high standards.
The counselor should become familiar with the continually emerging standards of practice
in computerized services and obtain the American Psychological Association guidelines for
the provision of automated testing services. 

Some Examples of Ethical Violations

1. A group therapist has developed a technique entitled "deprivation breakthrough", which
   requires that group members restrain the person who is "it" until he/she becomes
   emotionally aroused. The technique has not been used elsewhere, and clients report
   that it is terrifying.

2. A counselor who has read about "neurolinguistic programming" in a recent journal article
   begins to employ it with her clients.

3. A counselor who has had one course in sex therapy during graduate school decides to
   continue treatment with a female client who has sexual concerns even though the
   presenting problem was smoking cessation, which is his specialty.

4. A counselor who is the host of a call-in radio show complies with instructions to limit
   the time he spends with the "less interesting cases" presented by callers.

5. A counselor on a radio talk show receives a call from a woman whom he thinks is in
   treatment with an incompetent therapist. He advises her (on the air) to quit the
   therapist and read some self-help books.

6. A counselor develops her own scoring system for the Bender-Gestalt test and markets it
   as a "repressor screening protocol". Purchasers receive printed paragraphs describing
   the personality characteristics of the test takers. No validation has been undertaken 
   on the descriptors.

Some Related Legal Principles

The counselor should become familiar with case law regarding novel treatments. Examples
include state law regulating the use of sexual surrogates (almost always illegal, as a
form of pandering) and court cases that establish precedents for providers' liability
for damages in the case of untried services. In addition, the counselor may want to refer
such cases as Hammer v, Rosen and Abraham v. Zaslow, which establish the notion
that certain actions (in this case, striking a patient) are in and of themselves evidence
of malpractice regardless of professional justifications. In addition, legal standards for
informed consent should be reviewed here.

Some Controversies

1. Some critics have questioned whether "media counseling" should be conducted at all.
   Does it cause too many problems for the profession? Or is it a way to reach previously
   underserved populations?

2. Counselors and psychologists have been on the forefront of computerized testing, but 
   currently risk loss of control over testing procedures. At issue is the best way to 
   provide testing services without allowing unqualified individuals to offer such services.

3. What constitute a specialty in counseling or in psychology? Are the existing specialties
   clearly distinct from one another? The American Psychological Association declared a 
   moratorium on recognizing new specialties in the late 1980s. However, other credentialing
   bodies (and quasi-credentialing bodise) continue to certify specialists. The practitioner
   must decide whether, and how, to specialize in areas where additional credentials are
   offered, and must decide how to best promote the public's understanding of what various
   "specialists" can do.
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REFERENCES

American Psychological Association (1986). Guidelines for computer based tests and 
interpretations. Wasahington, D.C.: Author.

Bloch, S. & Chodoff, P. (1981). Psychiatric ethics. New York: Oxford University Press.
This edited volume covers a wide variety of topics in it 18 chapters. Of particular 
relevance to the present discussion are chapters focused on ethics in suicide and
involuntary hospitalization. Other chapters that may be of interest focus on drug
treatment and psychosurgery.

Cohen, R.J. & Mariano, W.E. (1982). Legal guidebook in mental health. New York: Free Press.

Faden, R., Beauchamp, T. & King, N. (1986). A history and theory of informed consent. New
York: Oxford University Press. This volume covers both legal and ethical theory of informed
consent and reviews cases from both research and practice.

Haas, L.J. & Malouf, J.L. (1989). Keeping up the good work: A practitioner's guide to mental
health ethics. Sarasota, FL: Professional Resource Exchange.

Lowman, R. L. (1985). Casebook on ethics and standards for the practice of psychology in
organizations. Society for Industrial and Organizational Psychology. Compilation of cases
that illustrate ethical issues for organizational psychologists and consultants. 

Monahan, J. (Ed.) (1980). Who is the client? The ethics of psychosocial intervention in the
criminal justice system. Washington, D.C. American Psychological Association. This edited
volume is a product of the APA task force on psychologists in the correctional system. It
provides a series of useful papers focused on the roles, difficulties, and ethical 
obligations of psychologists in such correctional settings as courts, prisons, police 
agencies, and the juvenile justice system. Included is a set of recommendations from the
task force, and an interesting survey regarding ethical dilemnas (mostly focused on 
confidentiality) that occur to psychologists practicing in such settings.

Public Law 93-380 (1974). The family educational rights and privacy act (The Buckley
Amendment). United States Code.

Public Law 94-142 (1975). The education for all handicapped children act. United 
State Code.


To search for books on disasters and disaster mental health topics and purchase them online,
go to the following url:
https://www.angelfire.com/biz/odochartaigh/searchbooks.html
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               Contact your local Mental Health Center or   
               check the yellow pages for counselors, psychologists,   
               therapists, and other Mental health Professionals in   
               your area for further information.
*****************************************************************************************
                        George W. Doherty
                        O'Dochartaigh Associates
                        Box 786
                        Laramie, WY 82073-0786

MENTAL HEALTH MOMENT Online: https://www.angelfire.com/biz3/news