A High Risk Situation: The Suicidal Client

Gary Schoener

From our experience, psychologists and students frequently look for excellent resources for dealing with suicidal patients.  Working with suicidal patients can become time intensive and emotionally draining.  Psychologists need to become educated and remain current with their training.  Consulting with other psychologists when dealing with at-risk patients is always recommended.



Gary Schoener, noted ethics educator, permitted our committee to post this resource when dealing with suicidal patients.

Suicide Handout

Should you blow the whistle?

What to do when you suspect your adviser or research supervisor of ethical misconduct.

By Cassandra Willyard

The Monitor on Psychology

After graduating with a master’s in counseling, “Jackie Frank” (not her real name) decided to get some research experience before applying to a PhD program. She took a position at a small medical center where a researcher had a grant to study post-traumatic stress disorder and substance abuse. As part of the job, Frank interviewed study volunteers to assess the severity of their condition — and that’s when she noticed something fishy was going on.

“Our supervisor framed leading questions and expected you to do that as well,” Frank says. The researchers, she believes, were trying to manipulate the study results “to make a bolder, statistically significant statement.”

Frank later noticed that some of data had been changed. “At that point, I knew we didn’t have the same ethical values,” she says.

Frank debated whether to “suck it up,” but ultimately decided to leave before her funding ran out. In her exit interview, she brought up her concerns and handed in a formal letter detailing her observations. Not long after, she heard that the lead researcher was under investigation for possible misconduct.

Nearly every graduate student faces ethical uncertainties, says Melissa Anderson, PhD, a professor of higher education at the University of Minnesota in Minneapolis who studies research integrity. But these quandaries become even more complicated when you suspect that your superior is involved in ethical misconduct.

“Graduate students, like all other researchers, are working at the frontier of knowledge,” she says. “And with every new thing, there’s the potential for new ethical complications.” The line between “cleaning up” and “cherry picking” data can be fuzzy, for example. And students may not be privy to all the nuances of a study’s protocol.

Even if ethical misconduct is clear, whistle-blowing may not always be the best option for you, says Michael Zigmond, PhD, a neurology professor at the University of Pittsburgh and associate director of an ethics workshop for graduate students. If you’re a fourth-year student and your adviser adds the head of the department to your paper even though he didn’t do any work, bringing it to the authorities’ attention may not be worth the potential damage to your career. On the other hand, if you’re working for a professor in another department and you witness sketchy research practices, quitting quietly and sharing your concerns in an exit interview — as Frank did — might be a good way to go.

Here’s some tried-and-true advice on how to navigate these and other ethical quagmires:

• Review the evidence. Avoid jumping to conclusions, Anderson says. You may not know the whole story. Reflect on your communications with the person you suspect of wrongdoing. What led you to suspect something isn’t quite right? Is there evidence to support what your gut is telling you?

If you don’t know what constitutes misconduct, consult your university’s guidelines or the U.S. Office of Research Integrity’s handbook on responsible conduct of research. Every university that receives federal research funding is obligated to adopt the federal definition of scientific misconduct — fabrication, falsification or plagiarism — and some institutions may have even stricter definitions.

Then write notes about any ethical violations you suspect, suggests Anderson. Be sure to jot down the details of every conversation: What was said, who was present, where it occurred, and the date and time. Save your emails, both the ones you send and the ones you receive. Keeping track of what you see can help you form a conclusion and provides invaluable documentation if you decide to report the situation. “Good recordkeeping throughout a research collaboration is important in any case,” she says. “But it becomes really important when something bad is going on.”

The rest of the story is here.

What to Do With a Drunken Patient?

Samuel Knapp, EdD, ABPP

Director of Professional Affairs

How should psychologists respond if they have a patient who has been drinking and who intends to drive home after a therapy appointment? After reasonable efforts to dissuade the patient from driving have failed, does the psychologist have an obligation to warn the police about the potential danger? Alternatively, does confidentiality prevent the psychologist from doing so?

This dilemma arises intermittently for practicing psychologists. Of course, psychologists have a legal duty to report impaired drivers to the Pennsylvania Department of Transportation (Baturin, Knapp, & Tepper, 2003). However, this requirement does not help resolve the immediate safety issue. Nuances in the interpretation of this mandated reporting law are covered in the article cited above on that topic on the PPA website.

In dealing with the immediate problem of a drunken patient who wants to drive home, much of the decision-making of the psychologist will account for situational factors. The extent of the patient's impairment from alcohol may be difficult to determine. This may be similar to evaluating pornography, in that it can be hard to define, but easy to recognize. In many cases, individual psychologists may observe the same patient and differ in their interpretation of their degree of impairment. I know of no rule of thumb or quick evaluation tool for psychologists to rely upon. However, in many other cases, everyone would agree that staggering, slurred speech, affect, and other behaviors would indicate that this person is too drunk to drive.

Psychologists should try to dissuade an impaired patient from driving, and consider options such as getting a taxi for the patient, calling a relative or friend to drive the patient, or other alternatives. Another option might be to inform them that you will call the police if they drive away from your office drunk. Furthermore, this behavior needs to be a part of the calculation in a decision to notify the Department of Motor Vehicles concerning their competency to drive.

The true dilemma arises when a patient you determine to be too drunk to drive insists upon driving anyway. What are the ethical or legal obligations that you have? Are you legally liable if the patient harms others?

In discussions with different psychologists on this exact question, I have learned that several psychologists have called the police on a drunken patient who insisted upon driving home from a therapy session, and no complaints were filed against them. Others have worked with patients who were too cognitively impaired with neuropsychological problems and have similarly notified the police.

There is not, to my knowledge, any court case in Pennsylvania that deals specifically with the legal liability of psychologists in these situations. However, the regulations of the State Board of Psychology permit such disclosures “when there is clear and imminent danger to an individual or to society, and then only to appropriate professional workers or public authorities” (49 Pa. Code §41.61, Principle 5 (b) (1)). I think this can be interpreted to justify notifying the police when a patient is too drunk to drive. In addition, when there is ambiguity in laws or regulations, psychologists should interpret them in light of overarching ethical principles that, in this case, would mean notifying the police if we thought a driver was dangerous to the public. Safety trumps privacy and we do need to live with ourselves. Of course, drug and alcohol facilities in Pennsylvania are governed by special federal and state regulations that have a stricter level of confidentiality.

Reference

Baturin, R., Knapp, S., & Tepper, A. (2003, November). Legal and practical issues related to the treatment of impaired drivers. Pennsylvania Psychologist, 5-6.

Strong Beliefs About Vaccines Work Both Ways

By Kristina Fiore, Staff Writer, MedPage Today

Sometimes, Dr. Andrew Lieber has to tell his patients' parents that it just isn't working out.

When parents refuse to vaccinate their children in spite of his efforts to convince them of the benefits of immunity, he reluctantly cuts the cord.

"By four months, if I can't help you come to terms with the scientific fact that vaccines are helpful, then I've done about all I can do to educate you," Lieber, a pediatrician with Rose Pediatrics in Denver, told MedPage Today.

At that point, he'll tell them to find another doctor -- something he has to do "a couple times a year."

"I feel like I have a bigger responsibility to all the other kids walking through my waiting room," Lieber said.

Pediatricians appear to be increasingly taking this hard-line approach as parents make greater efforts to screen doctors for one whose vaccination philosophy matches their own.

According to a 2001 American Academy of Pediatrics survey, 23% of physicians reported that they "always" or "sometimes" tell parents they can no longer be the child's pediatrician if they won't get the proper shots.

The Academy doesn't have more recent survey data, but physicians say that they see plenty of their colleagues joining the ranks.

Lieber will sometimes work with parents to adjust the vaccination schedule -- "I'm willing to separate some vaccines by two weeks, whatever I can do to increase vaccination rates is good" -- but if an interviewer comes along wanting to cross all vaccines off the list, Lieber says No.

Few physicians question the ethics of this practice, especially in light of recent outbreaks such as pertussis in California and in certain communities within Brooklyn.

Indeed, the American Academy of Pediatrics has deemed it ethical to dismiss patients who refuse to get their children vaccinated, and offers a clinical guideline as well as an online toolkit on how to handle the pertinent issues.

"Physicians, like their patients, are moral agents," says Felicia Cohn, PhD, director of bioethics for Kaiser Permanente in Irvine, Calif. "Any physician may refuse an individual for moral reasons or may conscientiously object to providing particular treatments."

David Cronin, MD, a pediatrician with Medical College of Wisconsin in Milwaukee, says it's "entirely appropriate for a physician to refuse elective treatment to any patient. Being a physician does not obligate one to provide care to 'all comers.'"

Yet others say refusing to treat because of vaccine preference is indeed unethical because it punishes the wrong party. Samuel Katz, MD, of Duke University, says it's not right to refuse seeing a child "because it is the parent who is the problem, whereas the child merits medical care."

The entire story can be read here.  You may have to sign up for the free services.

Vignette 4: A Psychologist in Turmoil

You have been treating a fellow licensed psychologist for several months. He presents himself as having a dissociative identity disorder. Although his condition has been deteriorating he continues to maintain a private practice and one of his egos reports that he has been flirting with several of his female patients.

What are possible emotional reactions would you have in this situation?

What would be your best options for this scenario?

To add some additional detail, you live in Pennsylvania where the reporting requirement for impaired professionals does not apply to patients you see in treatment. Therefore, you, the treating psychologist, are not required to report your patient to the licensing board.

Facebook friend request from a patient?

The Lancet, Volume 377, Issue 9772, Pages 1141 - 1142, 2 April 2011

doi:10.1016/S0140-6736(11)60449-2

Sharmila Devi

Widespread use of new technologies such as social networking sites are creating ethical problems for physicians that some doctors' organisations are beginning to address. Sharmila Devi reports.

Social networking sites such as Facebook and the ubiquity of search engines such as Google are creating new medical ethical dilemmas as physicians around the world grapple with how to responsibly include new technologies in their professional lives.

In the USA, birthplace of most of these technological advances, various associations of health-care professionals are starting to issue codes of conduct when dealing with new digital media. Other countries, such as the UK, Canada, and Australia, are also debating what rules should be set. But some doctors believe such codes will have to evolve and adapt as younger generations, used to living an online life from an early age, start to dominate health care and to teach subsequent waves of professionals.

Websites such as Facebook allow individuals to post messages, photos, and videos and share them with an online group of friends. They can also be used to reach out professionally to a wider range of people than was possible with some traditional marketing methods. But used unwisely, such sites can blur the lines between the personal and professional and cause embarrassment.

“Older generations will moralise and say it's unethical and unprofessional [to be friends with clients on sites such as Facebook]”, says Ofer Zur, an Israeli psychologist based in California, USA, who offers online courses in digital medical ethics. “Younger generations have less of a sense of hierarchy and see the internet as an equaliser that opens doors. I am typical of the older generation because I sometimes cringe at the things my daughter posts online.”

Although it would seem obvious for many professionals to maintain as strict a boundary between them and clients in the online world as in the physical world, Zur said online interactions should be looked at on a case-by-case basis. For example, a physician in a small community might find that Facebook simply replicated the flow of information that already took place amid existing close relationships, he says.

Cases where health-care professionals have taken things too far are rare but well publicised. In February, a physician assistant working at a medical centre in New York state was found to have posted photos on Facebook showing him holding a syringe at a man's neck. He said: “When you can't start a line in a junkie's arm…go for the neck”, reported The Journal News, a local newspaper.

Such behaviour is unanimously condemned as inappropriate. More difficult to answer are questions such as whether health-care professionals should be allowed to research a client's background on the search engine Google? Does a blog's informative value outweigh any possible breach of confidentiality? Should medical students post online any personal information about themselves for fear of jeopardising relations with future clients and employers? “Questions about the internet are becoming a common inquiry among our members who want to take advantage of it, especially younger members and students, and the number one concern is confidentiality and how to preserve it”, says Erin Martz, manager of ethics and professional standards at the American Counselling Association. “We actually just received our first ethical complaint that's Facebook-connected and technically-driven. I do think Facebook can be quite dangerous.”

The rest of the article is here and can be accessed through psycnet.apa.org/psycinfo with your APA log in.

The Menace Within: The Stanford Prison Experiment

What happened in the basement of the psych building 40 years ago shocked the world. How do the guards, prisoners and researchers in the Stanford Prison Experiment feel about it now?

By Romesh ratnesar

It began with an ad in the classifieds.

Male college students needed for psychological study of prison life. $15 per day for 1-2 weeks. More than 70 people volunteered to take part in the study, to be conducted in a fake prison housed inside Jordan Hall, on Stanford's Main Quad. The leader of the study was 38-year-old psychology professor Philip Zimbardo. He and his fellow researchers selected 24 applicants and randomly assigned each to be a prisoner or a guard.

Zimbardo encouraged the guards to think of themselves as actual guards in a real prison. He made clear that prisoners could not be physically harmed, but said the guards should try to create an atmosphere in which the prisoners felt "powerless."

The study began on Sunday, August 17, 1971. But no one knew what, exactly, they were getting into.

Forty years later, the Stanford Prison Experiment remains among the most notable—and notorious—research projects ever carried out at the University. For six days, half the study's participants endured cruel and dehumanizing abuse at the hands of their peers. At various times, they were taunted, stripped naked, deprived of sleep and forced to use plastic buckets as toilets. Some of them rebelled violently; others became hysterical or withdrew into despair. As the situation descended into chaos, the researchers stood by and watched—until one of their colleagues finally spoke out.

The public's fascination with the SPE and its implications—the notion, as Zimbardo says, "that these ordinary college students could do such terrible things when caught in that situation" —brought Zimbardo international renown. It also provoked criticism from other researchers, who questioned the ethics of subjecting student volunteers to such extreme emotional trauma. The study had been approved by Stanford's Human Subjects Research Committee, and Zimbardo says that "neither they nor we could have imagined" that the guards would treat the prisoners so inhumanely.

In 1973, an investigation by the American Psychological Association concluded that the prison study had satisfied the profession's existing ethical standards. But in subsequent years, those guidelines were revised to prohibit human-subject simulations modeled on the SPE. "No behavioral research that puts people in that kind of setting can ever be done again in America," Zimbardo says.

The Stanford Prison Experiment became the subject of numerous books and documentaries, a feature film and the name of at least one punk band. In the last decade, after the revelations of abuses committed by U.S. military and intelligence personnel at prisons in Iraq and Afghanistan, the SPE provided lessons in how good people placed in adverse conditions can act barbarically.

The experiment is still a source of controversy and contention—even among those who took part in it. Here, in their own words, some of the key players in the drama reflect on their roles and how those six days in August changed their lives.

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The entire article can be here.  The article brings up a host of ethical issues related to research.

Drug Marketing Often Targets Med Students: Analysis

Robert Preidt
Medicine.net

Drug company marketing to those attending medical school is common and can cloud students' ethical judgment, researchers warn.

A team led by Kirsten Austad and Aaron S. Kesselheim at Harvard Medical School in Boston analyzed published studies that included a total of 9,850 students at 76 medical schools in the United States. The investigators found that most of the students had some type of interaction with drug companies and that this contact increased during the clinical years, with up to 90% of clinical students receiving some form of marketing materials from drug makers.

Among the students queried, most believed there was no ethical problem in accepting gifts from drug companies. Their justifications included financial hardship or pointing out that most other medical students accepted such gifts.

Nearly two-thirds of the medical students claimed that drug company promotions, gifts or interactions with sales representatives did not affect their impartiality regarding drug makers and their products.

The study authors said their findings suggest that strategies to educate medical students about interactions with drug makers should directly address widely held misconceptions about the effects of marketing.

In addition, medical schools need to introduce reforms, such as rules limiting contact between students and drug company representatives.

"These changes can help move medical education a step closer to two important goals: the cultivation of strong professional values, as well as the promotion of a respect for scientific principles and critical review of evidence that will later inform clinical decision-making and prescribing practices," the researchers concluded.

The study is published in the May 24 online edition of the journal PLoS Medicine.