Ethical Biases Discussion Essay
Ethical Biases Discussion Essay
A minimum of 3 scholarly peered reviewed article must be sited using APA format 500 words for each topic 81 and 82
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Topic 81
Biases are something we all have, and it is important to be aware of what biases you have in order to monitor them carefully. Biases can be personal or professional in nature and confronting biases can help to overcome them. Discuss some areas on which you hold biases (divorce, domestic violence, death penalty, spanking, etc.)
What are your personal/professional biases? What harm can result from not being aware of them? What standards are violated if they are not acknowledged and addressed?
Topic 82
Dr. Jones has a client who is of a different culture and faith. He is not comfortable dealing with this patient due to past negative feelings from childhood. What are his ethical and legal obligations? Why are these legal and ethical obligations in place?
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Topic71spiritualorientedinterventi65
3 ETHICAL GUIDELINES FOR USING
SPIRITUALLY ORIENTED INTERVENTIONS
WILLIAM L. HATHAWAY
The empirical literature pertaining to clinical practice with religious and spiritual issues is still at a relatively early stage, but in recent years a substantial amount of attention has been paid to ethical issues in this domain (Gonsiorek, Richards, Pargament, & McMinn, 2009; Hathaway & Ripley, 2009; Plante, 2007, 2009; Richards & Bergin, 2005; Sperry & Shafranske, 2005). This liter- ature has focused on a wide range of ethical concerns, such as protecting against harmful bias, practicing within one’s boundaries of competence, and exploring role considerations in working with religious issues.
In this chapter, I begin by bringing attention to how psychologists’ rela- tive lack of religious commitment has the potential for creating and introduc- ing biases into treatment. A brief introduction provides readers with common conceptualizations of spiritually oriented interventions in the recent psycho- logical literature. This is followed by an examination and application of rele- vant ethical codes to the use of spiritually oriented interventions. Spiritually oriented interventions are then discussed from an accountable practice perspec- tive. Training recommendations are also provided to help facilitate the ethical application of such interventions. Brief clinical examples and questions are also offered to help readers delve deeper into thinking about the ethical issues that
To the psychologist the religious propensities of man must be at least as interesting as any other of the facts pertaining to his mental constitution.
—William James (1997)
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http://dx.doi.org/10.1037/12313-003 Spiritually Oriented Interventions for Counseling and Psychotherapy, by J. D. Aten, M. R. McMinn, and E. L. Worthington, Jr. Copyright © 2011 American Psychological Association. All rights reserved.
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must be considered before using spiritually oriented interventions in clinical practice.
POTENTIAL FOR PROBLEMATIC BIASES
It has been frequently noted that professional psychologists appear to be atypically irreligious compared with the general North American popu- lation. Plante (2009), for instance, cited Gallup polls indicating that 95% of Americans believe in God and 40% of attend religious services on a weekly basis. Despite a widespread prevalence of religiousness in the general popula- tion, researchers (Bergin & Jensen, 1990; Delaney, Miller, & Bisono, 2007; Hathaway, Scott, & Garver, 2004; Shafranske, 2000) have noted that, relative to the general population, psychologists (a) have double the rate of claiming no religion, (b) are more likely by a factor of three to report religion being unim- portant in their life, (c) have a five-fold higher rate of denying belief in God, and (d) report lower likelihoods of attending religious services, being a member of a congregation, or engaging in prayer.
The risk is that this lower level of conventional religiousness among psy- chologists may result in biasing blind spots that lead them to erroneously dis- regard significant religious issues in clinical practice. Unfortunately, there is evidence that just this sort of neglect is occurring. Russell and Yarhouse (2006) found that over two thirds of a sample of training directors at American Psychological Association (APA) internships never foresaw offering training in religious and spiritual issues at their sites. Brawer, Handal, Fabricatore, Roberts, and Wajda-Johnston (2002) surveyed training directors of APA- accredited doctoral training programs and found that only 17% reported sys- tematic coverage of religion and spirituality in their programs. There is little evidence that such findings cause much concern outside of the niche of psychologists who specialize in the clinical psychology of religion. Imagine if such lassitude in the profession were the case for any of the other named diversity domains highlighted for particular attention in the APA (2010) Ethics Code (hereafter referred to as the Code). Ethical Biases Discussion Essay
Yet the situation may be even more problematic than just a climate of indifference. There is evidence that psychologists may be more likely than the general population to be hostile and prejudicial to conventional religion. Delaney, Miller, and Bisono (2007) noted that “it appears to be a relatively fre- quent experience among psychologists to have lost belief in God and disaffili- ated from institutional religion” (p. 542). They found this experience to be nearly 7 times more frequent in their sample of psychologists than in the gen- eral population. In a study of whether antireligious discrimination may be occurring in admissions to doctoral programs in clinical psychology, Gartner
66 WILLIAM L. HATHAWAY
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(1986) found that a sample of faculty at doctoral programs accredited by the APA were less likely to grant admission or to have positive feelings about appli- cants whose admissions protocols contained a conventional religious identifi- cation than about those whose protocols were otherwise identical except for the absence of such religious identification.
It seems unlikely that a negative or less receptive atmosphere among psy- chologists toward conventional religion would not translate into problematic clinical practice patterns toward this client population or niche. In a random national sample of clinical psychologists, Hathaway et al. (2004) found that most psychologists do not routinely assess for clinically relevant spiritual or reli- gious issues in practice. They also noted that a sizeable portion of their sample did not feel that religion is more than a slightly important adaptive domain for such focus.
Although there is no systematic research on the prevalence of apparent antireligious biases and/or overt discrimination toward conventionally religious clients by psychologists, numerous anecdotes have been recounted by clini- cal psychologists (Cummings, O’Donohue, & Cummings, 2009). A doctoral psychology intern at a respected internship informed me about being instructed by his supervisor to diagnose a client with a delusional disorder because the client expressed belief in intelligent design as opposed to evolution. The client reportedly did not display any other indications of thought disorder, psychotic process, or life impairment related to her beliefs. The intern expressed concern about giving this diagnosis, but the supervisor insisted and explained that the intelligent design belief itself was sufficient to warrant the diagnosis. Ethical Biases Discussion Essay
Let us assume that naturalism is true and all of the varieties of beliefs self- identified as intelligent design are false. This would hardly justify a mental health professional diagnosing a believer in intelligent design with a delusional disorder. It has become common in the polemics surrounding the new atheism to declare either theistic or atheistic belief to be a delusion (Dawkins, 2006; Hart, 2009). In terms of pure logic, either atheism or theism is true, but not both, so one of the two groups believes something that is false. Yet having a false belief is not the same thing as having a delusional belief, in a technical psy- chological sense. Delusional beliefs involve a disordered thought process and not just acceptance of beliefs that turn out to be factually incorrect (Clarke, 2001). Giving such a diagnosis in the absence of a genuine psychotic process runs a significant risk of iatrogenic consequences for the client, such as bearing the stigma of receiving an unwarranted diagnosis of a serious psychiatric con- dition, potentially having career and life options adversely affected, or being the recipient of unnecessary treatments. Thus, this practice may constitute a violation of the cardinal ethical concern of doing no harm.
Although negative or undervaluing biases toward conventional religion appear to be a common risk among psychologists, problems can also arise from
ETHICAL GUIDELINES 67
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proreligious biases. The American Psychiatric Association (1989) adopted guidelines warning against a psychotherapist imposing his or her religious val- ues or beliefs on clients. The ethical principle of nonmalfeasance (i.e., doing no harm) implies that psychologists should not attempt experimental proce- dures in lieu of standard proven psychotherapies without clear warrant and informed consent. I have encountered some psychologists who are personally religious abandoning standard approaches to common clinical problems for which well-supported treatments exist in favor of stand-alone explicitly reli- gious interventions. The stand-alone approaches eschew any other form of assistance apart from the religious or spiritual practice. Typically, these reli- gious caregivers have justified the stand-alone spiritual approaches in terms of their own religious beliefs about what is right for the person. Sometimes these spiritual-only-approach psychotherapists are licensed mental health professionals and other times they are not.
Some of their care recipients report benefits from such stand-alone spiritual-only approaches, but others do not. Their clients are not typically given any scientific data about likely responses to the approach (e.g., success rates, rates of nonresponders, adverse risks), although testimonials of success are frequently shared with the clients. Some persons in our community sought assistance from nonreligious caregivers after dropping out from these stand- alone spiritual-only treatments. The stand-alone dropouts indicated that they were not typically informed by the spiritual-only-approach provider about standard treatments for their concerns or about the experimental nature of the approach. In cases in which this care was being provided by a nonmental health professional, this is perhaps not surprising, but some of these cases involved licensed mental health professionals. Ethical Biases Discussion Essay
The stand-alone dropouts typically reported that their presenting issues had not improved. In fact, they sometimes now had added guilt and shame over not getting better from the stand-alone spiritual approach. When the lack of positive treatment response is attributed to God being unable or unwilling to help, it may deepen recipients’ faith conflicts and emotional pain.
Now, I am not suggesting that such anecdotes prove the stand-alone spir- itual treatments to be ineffective or noxious. Every treatment, even ones with good empirical support, has nonresponders and dropouts. Furthermore, there is a growing body of evidence that spiritually focused and accommodative approaches that combine spiritual interventions with standard psychotherapeu- tic techniques and relational skills are benign and helpful to clients (Tan & Johnson, 2005; Worthington & Sandage, 2002). My concern has more to do with ethical issues raised by the way the licensed caregivers engaging in the stand-alone spiritual approaches practiced (Gonsiorek et al., 2009).
These stories call attention to the need for psychologists to adequately consider the range of relevant ethical principles, standards, and other consid-
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erations that should guide our practice with regard to religious and spiritual issues (Knapp & VandeCreek, 2006). Hathaway and Ripley (2009) pointed out that such guidance can be found by reflecting on relevant ethical codes, pol- icy statements, practice guidelines, legal precedents, exemplar guidance, and evidence-based practice considerations. Let us now reflect on their relevance for the explicit use of spiritually oriented interventions by psychologists.
SPIRITUALLY ORIENTED INTERVENTIONS
A growing literature on spiritually oriented interventions provides detailed descriptions of how to conduct such interventions competently and ethically (Plante, 2009; Richards & Bergin, 2005; Schlosser & Safran, 2009). There is no standard language used to identify this group of interventions. Plante (2009) described them as spiritual practices or tools. Richards and Bergin (2005) referred to them as either theistic or spiritual interventions (p. 281). Schlosser and Safran (2009) called them spiritual interventions and techniques (p. 199). There is considerable overlap among the spiritually oriented interven- tions enumerated by these authors (see Table 3.1). Although some of these would likely be readily thought of as spiritual by most individuals (e.g., the use of prayer), others may be less obvious examples to some of a specifically “spiri- tual” intervention (e.g., meaning making or relaxation).
Among psychotherapists who seek to incorporate an explicitly spiritual aspect to treatment, Schlosser and Safran (2009) also distinguished between two general approaches: “spiritually accommodative approaches typically com- bined a manualized treatment with practices and beliefs from a particular world religion, whereas spiritually oriented approaches are typically less standardized and more inclusive” (p. 200). It should be noted that none of the psychologists whose work is cited in Table 3.1 is proposing a stand-alone use of spiritual and religious interventions or techniques regardless of whether they are used in a spiritually accommodative or spiritually oriented manner.
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Topic71professionalboundary.pdf
117
INFORMED CONSENT
7
The overarching ethical principle of showing respect for patients’ autonomous ability to make their own decisions is reflected in the American Psychological Association (APA, 2010) Ethics Code through standards that require psychologists to provide information to, and secure consent from, consumers of psychological services (e.g., Standard 3.10). The doctrine of informed consent stems most directly from General Principle E: Respect for People’s Rights and Dignity, which urges psychologists to respect the self- determination of others. Ethical Biases Discussion Essay
Respect for patient decision making has influenced the wording and content of other standards in the APA Ethics Code. For example, advertising should be guided by transparency and accuracy so that prospective patients can make informed choices as to whether to seek services from a particular psychologist. In addition, respect for patient autonomy guides the selection of treatment goals. In this chapter, we review difficult ethical problems for which
http://dx.doi.org/10.1037/14670-008 Ethical Dilemmas in Psychotherapy: Positive Approaches to Decision Making, by S. J. Knapp, M. C. Gottlieb, and M. M. Handelsman Copyright © 2015 by the American Psychological Association. All rights reserved.
118 ethical dilemmas in psychotherapy
respect for patient autonomy is especially important. Other issues dealing with respect for patient autonomy are considered in Chapter 9.
WHAT TO PUT IN ADVERTISEMENTS
In Standard 5.01b, the APA Ethics Code identifies certain activities that are unethical in advertising:
Psychologists do not make false, deceptive, or fraudulent statements con- cerning (1) their training, experience, or competence; (2) their academic degrees; (3) their credentials; (4) their institutional or association affilia- tions; (5) their services; (6) the scientific or clinical basis for, or results or degree of success of their services; (7) their fees; or (8) their publications or research findings.
Other than additional restrictions on testimonials (Standard 5.05), the APA Ethics Code says little else about advertising. From the standpoint of positive ethics, psychologists want to do more than just refrain from violating 5.01, 5.05, and other relevant standards. Instead, they want their advertisements to help patients make informed decisions about services. Nonetheless, and especially given the ubiquity and “freedom” of the Internet, separation strate- gies may include the idea that advertising is an ethics-free zone if additional prohibitions are not mentioned in the APA Ethics Code. At that point, eco- nomic self-interest, business frames for advertising, or other factors unrelated to psychology ethics determine their course of action. Ethical Biases Discussion Essay
Positive ethics, of course, provides additional guidance in the form of over- arching ethical principles, virtues, and values. For example, would it be ethical for a psychologist to advertise himself as “The Sportsman’s Psychologist,” with a picture of himself holding a gun and wearing a hunting outfit? Would it be ethi- cal for a psychologist to indicate on her website that her hobbies are hiking and playing tennis? Some questions to ask include, Are these advertisements consis- tent with professional values, such as respecting patients’ autonomous decision making by giving patients accurate and useful information to help them decide whether to seek services from a particular psychologist? Are the messages mis- leading in some way? Looking at advertising from the perspective of trying to help prospective patients, it may be appropriate for a psychologist with expertise in sports psychology to note, for example, that she was a collegiate tennis cham- pion; such information may be relevant to the decisions of prospective patients. It may be appropriate for a psychologist with an interest in treating religious patients to note that he or she is an ordained member of the clergy.
Reasonable psychologists may disagree on whether certain disclosures can be linked to overarching ethical principles. One psychologist noted that
informed consent 119
he had lived in the city all his life. Although some readers may view this as an unnecessary self-disclosure, he considered it an indication that he was aware of the community’s values and local resources. He also judged that the information was unlikely to cause harm (nonmaleficence).
Other forms of self-disclosure in advertising appear more problematic. One psychologist worked part time as a singer and, on her professional website, included a link to samples of her recordings. This practice raises the issue of whether psychologists should place unrelated secondary occupations on their professional website. Although it may not be an explicit violation of the APA Ethics Code to include such information, doing so enhances the opportunity for potentially contraindicated boundary crossings and multiple relationships. A preferred integration strategy would be “boundary bolstering” (Anderson & Handelsman, 2010, p. 83), such as the one adopted by a colleague of ours who buys and sells classic guitars. He maintains two separate websites: one for his practice and one for his business. Neither site gives any hint of the other.
Psychologists using separation strategies may disclose information as they would to friends or social acquaintances in which mutual self-disclosure is a norm. But some behaviors that are acceptable or even desirable in social relationships may be contraindicated in professional ones in which self- disclosure needs to be selective and focused on patients’ needs. A psycholo- gist whose professional website contains a link to her singing web page also may be using a marginalization strategy to the extent that she would be happy with the sale of a couple tunes, even if it ran the risk of decreasing the effec- tiveness of her clinical services.
Ethical fading (Bazerman & Tenbrunsel, 2011), that is, when the ethical dimensions of a situation become overshadowed by practical, monetary, or other nonethical concerns, can occur in decisions about advertising. If psy- chologists think about advertising only in terms of how to maximize referrals (a business frame), then the ethical implications of advertising (an ethical frame) may fade away in the decision-making process. Psychologists can reduce the risk of ethical fading by keeping ethical principles in mind from the beginning of their deliberations. Ethical Biases Discussion Essay
RESPECTING PATIENT DECISIONS CONCERNING TREATMENT GOALS
Beginning at the outset of treatment, psychologists need to have informed consent discussions to ensure that patients understand a variety of relevant information, including “the nature and course of therapy, fees, involvement of third parties, and limits of confidentiality” (Standard 10.01, Informed Consent to Therapy). Psychologists who value respect for patient
120 ethical dilemmas in psychotherapy
autonomy and practice positive ethics will want to involve patients—at the start of the relationship and at points throughout the course of treatment—in as many treatment decisions as is clinically indicated.
Agreeing on Treatment Goals With Children and Adolescents
Standard 3.10b of the APA Ethics Code requires psychologists to “seek the . . . assent” of those who cannot legally consent to treatment. In Chapter 2, we discussed the need to balance respect for the autonomy of the child or adolescent receiving treatment as a matter of beneficence (the welfare of the child) with respect for the autonomy of the parents who must authorize treat- ment. Often, disagreement about goals can involve highly sensitive informa- tion. This example expands on that theme:
Sexual Orientation Issues With an Adolescent An adolescent presented for treatment with symptoms of depression.
The psychologist decided to see the boy in individual therapy, and over time it became clear that he was struggling with feelings of attraction to individuals of the same sex. The parents, who were conservative Chris- tians, would likely view same-sex attraction as a moral failing and would expect the psychologist to work to rid their son of these feelings. The psychologist was gay affirmative and would not agree to do so. Ethical Biases Discussion Essay
Should the psychologist continue to see the boy and accept payment from the parents, even though she is working on issues different from what the parents expected and is accepting behaviors or feelings that the parents would likely find offensive? Beneficence would suggest that the psychologist should con- tinue to treat the boy with a therapeutic stance that allows him to express his sexual feelings freely. Also, respect for patient autonomy would suggest that the adolescent has the right to choose the topics he wishes to explore. However, consider the potential for conflict of interest: Seeing the adolescent would be in the psychologist’s self-interest in that the patient would continue in treatment, and seeing him would mean additional income. Because the psychologist is gay affirmative, seeing the boy will advance the public accep- tance of the therapist’s views and agenda on sexual orientation. On the other hand, meeting the boy’s needs most likely conflicts with the parents’ goals and interests; if so, they may refuse to pay for further therapy and may terminate treatment, even though it may not be in their son’s best interest.
In this case, many psychologists would agree that the importance of having the adolescent explore his sexual feelings trumps respect for the par- ents’ rights (beneficence trumps respect for autonomy). This alternative could be viable if the psychologist’s informed consent process included the provision that he could give the parents accurate but incomplete information
informed consent 121
concerning the nature of their son’s treatment. For example, the adolescent and the psychologist could agree on what to tell the parents about the nature of therapy and the manner in which the parents are told (e.g., a phone call between the psychologist and parents or a face-to-face meeting that included the psychologist, boy, and parents). The psychologist could, for example, accurately describe general symptoms, such as anxiety and depression, as reasons for continued sessions. Out of concern for the anticipated effect on the parents and the boy, the psychologist could discuss with him whether to reveal that there are other sensitive topics that he chooses not to share. If specifically asked what they are, the psychologist, based on his consultation with the teen, can decide whether to reveal more information, and if so, how much.
The psychologist also could consider how the parents may have inter- preted the informed consent information. For example, even though the psychologist informed the parents that he would not share certain sensitive information, neither he nor the parents could have anticipated that this issue would arise and that the parents may consider this much more than just another “sensitive topic.” If so, and the parents learned of their son’s sexual concerns and that they had not been informed of them, they may react with feelings of betrayal, regardless of how thorough the informed consent process may have been. Ethical Biases Discussion Essay
The psychologist would do well to consider how his emotions and other nonrational factors may influence his deliberations. He may ask himself, Am I stereotyping the parents and their religious beliefs? If so, is there a risk of confirmation bias on my part? Am I placing too much importance on my patient’s sexuality—relative to other issues—because of my own political beliefs and personal experiences with discrimination? How might my own experience with issues of sexual preference, and my experience with religious patients, be short-circuiting my assessment of the relevant ethical principles and alternatives? Do I fear loss or embarrassment, and are these feelings lead- ing me to misjudge the risk associated with the alternatives I am consider- ing? What System 2 questions might I be missing by focusing on System 1 concerns?
We know one psychologist with a long background of promoting fair- ness for sexual minorities who consciously monitors his thoughts on the value of coming out when he deals with patients who are questioning their sexual orientation. Although he sees the social value that occurs when gay men pub- licly discuss their sexual orientation, he is aware that his primary obligation as a psychologist is to help patients make their own decisions. The failure to take such a position could be considered intrusive advocacy (Pope & Brown, 1996), wherein the political agenda of the psychologist trumps the patient’s autonomous decision making.
122 ethical dilemmas in psychotherapy
Agreeing on Treatment Goals With Adult Patients
Most of the time, psychologists can agree on treatment goals with their adult patients. However, respect for patient autonomy may conflict with other values. Consider the following example involving a seriously depressed patient:
The Unwilling Prostitute A psychologist worked with a 21-year-old college student who was
involuntarily involved in prostitution; she initially got involved volun- tarily, but soon found herself trapped in a coercive relationship. Her par- ents knew that their daughter was upset, and they paid for therapy, but they did not know the reason for her distress. The patient believed that she would be beaten or maimed by her pimp if she were to stop, and she appeared highly traumatized. Ethical Biases Discussion Essay
The psychologist wanted to uphold beneficence by alleviating the symptoms of depression and helping the patient extricate herself from her situation. However, the patient saw herself as hopelessly trapped, and if the psychologist fully respected patient autonomy, she would not have challenged the patient’s acquiescence to her circumstances. However, the psychologist judged that the situation was not in the patient’s best interest and that she could not make an informed or autonomous decision while in such a compromised state. Consequently, she proceeded with treatment of depression and trauma, but also gently insisted that a social worker with experience in helping women involved in prostitution join them for a session of therapy to discuss ways in which the patient could extricate herself from “the life.”
Because of the potential for harm to the patient, the psychologist acted paternalistically; that is, she trumped what the patient believed to be in her best interest, even though it meant raising an option that the patient did not want to consider at the time. Although, in general, the psychologist respected her patient’s autonomy, she concluded that in this situation beneficence dic- tated trumping autonomy to protect her patient from a situation in which she seemed unable to act on her own behalf. Some may consider this weak or soft paternalism (Feinberg, 1986) because the patient’s ability to make decisions about the focus of treatment was partially compromised, and thus the infringe- ment on autonomy was minimal, and the intervention served to increase the patient’s ability to make independent decisions. Ethical Biases Discussion Essay
On the other hand, the psychologist could have done nothing to address the issue of prostitution and not invited the social worker to become involved. That option may represent an assimilation strategy, albeit an overly simplistic one: “I’m here to serve the goals of the patient. She’s legally competent,
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Topic7InformedConsentConfidentialityandDiagnosingEthicalGuidelines.pdf
Volume 35¡Number ll]anuary 2OI3lPages 15-28
Informed Consent, Confidentiality, and Diagnosing: Ethical Guidelines for Counselor Practice
Victoria E. Kress
Rachel M. HofTman
Nicole Adamson
Karen Eriksen
Informed consent and confidentiaKty are discussed in the context of counselors’ use of the DSM
diagnostic system. Considerations that can facilitate counselor diagnostic decision-making
related to informed consent and confidentiality are identified in a case application. Suggestions
that can enhance ethical diagnostic practices are provided.
The Gouncil for the Accreditation of Gounseling and Related Educational Programs (GAGREP, 2009) requires that all trainees be instructed in ethical principles (GAGREP, Section II.G.I.j). The GAGREP standards also require that clinical mental health counselors and addictions counselors be trained in the use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, hereafter DSM; American Psychiatric Association [APA], 2000; GAGREP Standards for Glinical Mental Health Gounseling Section K. 1 and Standards for Addiction Gounseling Section K.I). With regard to the intersection of ethics and diagnosis and in relation to informed consent, the American Gounseling Association (AGA) Gode of Ethics (2005) states “Gounselors take steps to ensure that clients understand the implications of diagnosis” (A.2.b.). The American Mental Health Gounselors Association (AMHGA) Gode of Ethics (2010) asserts that “Informed consent is ongoing and needs to be reassessed throughout the counseling relationship” (B.2.d.).
The DSM contains 297 diagnoses (APA, 2000), which will be explored with generally equal breadth and depth in the next DSM iteration (APA, 2011). It may therefore be difficult for counselors to fully understand the myriad eth- ical considerations that need to be addressed when applying DSM diagnoses (Eriksen & Kress, 2005). Galley (2009) stated that because they are elusive
Victoria £. Kress is affiliated with Youngstown State University: Rachel Hoffman with Meridian Services, Youngstown, OH; Nicole Adamson with the University of Narth Carolina at Greensboro, and Karen Eriksen with the Eriksen Institute. Delray Beach, Florida. Correspondence about this article should be addressed to Victoria E. Kress, Beeghly Hall, Department of Counseling and Special Education, youngstown State University, Youngstown, OH 44555. E-mail: victoriaekress@gmail.com.
Journal of Mental Health Counseling
aspects of counselors’ personal and professional behavior, ethics must be explicitly addressed if they are to be fully integrated into professional practices. Explicit discussions of DSM ethics-related issues are thus important if coun- selors are to be deliberate and ethical in their practice (Galley, 2009). Ethical Biases Discussion Essay
There is a need for context-specific applications of ethics related to informed consent, confidentiality, and the DSM (Eriksen & Kress, 2005; Kress, Hoffman, & Eriksen, 2010). A lack of professional exchange about this topic could give the impression that it is not of importance. Gonversely, more detailed discussions should facilitate ethical practices related to the DSM, con- fidentiality, and informed consent (Galley, 2009). Although professional codes of ethics focus on appropriate use of the DSM (AGA, E.5.a.-E.5.d.; AMHGA, D.1.-D.3.) and GAGREP requires counselor training in its use, the literature offers minimal guidance on how to. use the DSM ethically. Only a few articles have touched specifically on the topic of client-informed consent and confi- dentiality as related to the DSM (e.g., Bassman, 2005; Kress et a l , 2010; Walker, Logan, Glark, & Leukefeld, 2005).
Ghent diagnosis has risks, and clients are often not fully apprised of them. This lack of transparency compromises the counseling values of beneficence and nonmaleficenee (because client well-being may be jeopardized), and autonomy (because the client is not given all the information needed for an informed deeision). Galley (2009) suggested that counselors consider complex ethics issues comprehensively, explicitly identifying problems and relating them to the principles of beneficence, nonmaleficenee, justice, and fidelity. Galley suggested there is value in examining all ethical codes that apply to a particular dilemma and identifying how the standards are being executed.
According to Galley (2009), if upon consideration a counselor is unable to conclude that ethical codes are being upheld, it is necessary to explore the issue in greater depth. Galley suggested consulting resources to help identify desirable ethical standards and how they can be applied to a given ethical dilemma. This article disseminates a new way of demonstrating that ethical codes are upheld when diagnosing clients.
Because the literature provides no guidance, it is important to explore the multiple ethical dimensions of diagnosing, informed consent, and confiden- tiality (Galley, 2009). Thus we discuss confidentiality and informed consent as related to counselors’ use of the DSM, offer specific suggestions for optimizing ethically-sensitive diagnosis, and describe a case study application.
INFORMED CONSENT CONSIDERATIONS AND DIAGNOSIS
Diagnosis is often not discussed as part of the informed consent process (Gampbell, 2000; Eriksen & Kress, 2005; Fisher, 2002; Kress et a l , 2010). At a minimum, clients should be informed that they may receive a diagnosis and. Ethical Biases Discussion Essay
16
Informed Consent, Confidentiality
once given a diagnosis, they should be told what it is (Kress et al., 2010). A diagnosis allows for reimbursement by third-parfy payers (i.e., health
insurance companies or agency grant funders; Braun & Gox, 2005). Insurance companies require a medical diagnosis for reimbursements. Further, in organi- zations that obtain government or other funding to treat specific diagnoses (e.g., addictions), only clients diagnosed with those problems may receive ser- vices. Thus, DSM diagnoses give clients opportunities to attain needed ser- vices, which is particularly important given the high costs of treatment. From a psychological perspecfive, another potential strength is that some clients find relief and validafion in having a label to describe their difficult experiences (Goodwin, 2009; Marzanski, Jainer, & Avery, 2002; Mitchell, 2007). Moreover, diagnosis can be used to guide counselor interventions and treat- ment plans. Ideally, counselors use diagnoses to select treatments that have proved to be successful.
The well-documented risks of diagnosis (e.g., Eriksen & Kress, 2005, 2006; Ivey & Ivey, 1998, 1999; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008) should also be conveyed to clients. Ghents with mental health diagnoses may be stigmatized at school or work and viewed and treated negafively (Eriksen & Kress, 2006). They may come to think of themselves as “less than” or perhaps as permanently “ill” with little possibilify of becoming or seeing themselves as “well.” Those diagnosed may take on the identify of a “sick” person and find it difficult to separate themselves from the label (Eriksen & Kress, 2005).
Glients who are not aware that not all DSM diagnoses are reimbursable may agree to incur the risks of receiving a diagnosis but not receive the finan- cial benefit (Braun & Gox, 2005). Although the Paul Wellstone and Pete Domenici Mental Health Parify and Addiction Equify Act of 2008 (the Federal Mental Health Parify Act; U.S. Department of Health and Human Services, 2008) prohibits providing discrepant benefits for mental health and substance abuse treatment, third-parfy payers are not required to reimburse for mental disorders that are not biologically based (U.S. Department of Health and Human Services, 2008). In other words, treatment for those mental illnesses (i.e., many illnesses other than schizophrenia, schizoaffecfive disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, and panic disorder) is considered supplemental, and insurance companies have discrefion about whether to reimburse (U.S. Department of Health and Human Services, 2008). Also, under the Parify Act, employers can choose which non-biologically-based mental health and sub- stance use diagnoses they will reimburse—there is no coverage mandate. Glients should be informed that though a diagnosis may be required for third- parfy reimbursement for services, some diagnoses may not be eligible.
The counselor’s challenge is to find a balance between adequately explaining the potential harms associated with diagnosis and the benefits (see
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Hinkle, 1999, for a broader discussion of these issues; Kress et a l , 2010). Because even trained counselors may struggle to do this, it is especially impor- tant to gain an objective view to help clients get an impartial picture of DSM advantages and disadvantages. Ethical Biases Discussion Essay
Veracity is also highly valued in the health professions (Hill, 2003). Veracity is the commitment of a professional to be open and honest with a client, despite the discomfort that might occur. Because the well-being of the client is at the heart of the relationship, it is imperative that the counselor be truthful and realistic. In the short term, it might seem more beneficent to give clients information that will encourage them to receive the services they seem to need, but for some clients the long-term consequences of diagnosis may out- weigh the treatment benefits. Thus, fully informing clients of the potenfial risks as well as benefits of diagnosis allows counselors to uphold the traditional coun- seling values of beneficence, nonmaleficence, and autonomy (Galley, 2009).
Some counselors, feeling uncomfortable discussing diagnostic informa- tion with clients, may avoid full disclosure (Hill, 2003), and when counselors fully explain the risks of diagnosis, clients might choose not to receive services. The value of veracity suggests that counselors should nevertheless discuss uncomfortable topics like diagnosis because that will promote long-term ben- efits for counselors and clients (Hill, 2003).
Martin, Garske, and Davis (2000) found that an open and honest exchange is a key predictor of therapeutic success regardless of many other fac- tors, such as the difficulties associated with diagnosis. Glients should have the opportunity to freely determine whether they will agree to receive a diagnosis. Gounselors might provide the following information to present an objective view of the diagnostic process: (a) whether the client’s third-party payer or a prospective and desired program will require a diagnosis; (b) the most common problems associated with a diagnosis; (c) the benefits of a diagnosis; and (d) what the options are should the client choose not to receive a diagnosis or not to have a third-party payer involved. As most counseling employers require a diagnosis by the end of the first session, discussions related to diagnosis need to be part of informed consent discussions early in that meeting.
CONFIDENTIALITY CONSIDERATIONS
Ethical practice requires that counseling professionals provide informa- tion about diagnosis and confidentiality as part of the informed consent process. Gonfidentiality-related information helps to ensure that client agree- ment to participate in counseling is adequately informed (AGA, 2005; AMHGA, 2010; Kaplan et al., 2009; Ponton, 2009). Thoughtfully and thor- oughly conveying that information to clients assures clients that counselors will keep them apprised of important information while keeping the counseling
Informed Consent, Confidentiality
experience confidential. Glients have a right to discuss and understand the risks and benefits of counseling before agreeing to participate.
The AGA (2005) and AMHGA (2010) Godes of Ethics state that clients have the right to confidentiality and to have its limitations explained. There are risks involved with the unanticipated—sometimes inadvertent—release of diagnostic information, and clients have a right to know of them. Ethical Biases Discussion Essay
Grover (2005) commented that “consent may not be truly informed in that the full implications of having the diagnosis and of having it communi- cated to others may not be adequately understood by the client at the time he or she proffers consent” (p. 78). For example, a client who signs a release on a job application that allows an employer to check into counseling history may be harmed, and the employer may not employ people with certain diagnoses (e.g., the military; Gouture & Penn, 2003). Parents of young clients may sign releases for mental health professionals to communicate with schools (U.S. Department of Health and Human Services, 2010), perhaps making a diagno- sis part of the ehild’s permanent school record, which can result in stigmatiza- tion as long as the client is a student.
Mental health records and diagnoses may also be used against clients dur- ing legal battles and in court hearings (Dentón, 1989; Kress et a l , 2010; Scott, 2000; Woody, 2000); the result can range from stigmatization and embarrass- ment to a loss in a legal batfle. Diagnoses become a permanent part of client mental health records, which offen must be released in civil or criminal cases (Luepker, 2003; Scott, 2000; Woody, 2000). Although privileged communica- tion is a responsibility of counseling professionals, the law does not always sup- port such ethical considerations (Fisher, 2003). Gounseling information- including diagnoses —may have to be disclosed in court and might lead to a client not being awarded custody of a child (Glosoff, Herlihy, & Spence, 2000). Although it is routinely mentioned during the initial informed consent conver- sation that a judge’s written order can overrule confldentiality, clients may not foresee the impact this could have on them.
Gonfidentiality is further complicated in group or family counseling, where diagnostic information may be shared; the legal system offen does not acknowledge privileged communication in such situations (Woody, 2000).
There are also risks in releasing diagnostic codes to insurance companies (Ackley, 1997; Gampbell, 2000) that clients need to be made aware of (Braun & Gox, 2005). A client’s diagnosis becomes a permanent part of the insurance record affer one reimbursed service using the ascribed diagnosis is billed (Privacy Rights Glearinghouse, 2011). This information can then be classified as a preexisting condition that can be accessed by future employers and insur- ers. Depending on state laws and how long ago the client was diagnosed (U.S. Department of Labor, 2009), clients may lose job or insurance opportunities based upon past mental health diagnoses. Ethical Biases Discussion Essay