Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy

Thursday, July 5, 2012

Court Upholds Counseling Program's Requirement That Students Accept Gay Clients

By Peter Schmidt
Chronicle of Higher Education
Originally published June 26, 2012

Jennifer Keeton
A federal district court has thrown out a civil-rights lawsuit challenging the Augusta State University school-counseling program's dismissal of a student who said her Christian beliefs preclude her from affirmatively counseling homosexual students.

Judge J. Randal Hall of the U.S. District Court in Augusta, Ga., dismissed the lawsuit last week, rejecting its claims that the graduate counseling program had violated the student's rights under the U.S. Constitution by demanding that she demonstrate a willingness to counsel homosexual students in a nonjudgmental manner.

In upholding the counseling program's decision to kick out the student, Jennifer Keeton, for refusing to complete a remediation plan intended to change her position, Judge Hall said the plan was based on a "a legitimate pedagogical interest in cultivating a professional demeanor" and concern that Ms. Keeton "might prove unreceptive to certain issues and openly judge her clients."

Ms. Keeton was motivated by her religious beliefs, but those she sued were not, Judge Hall concluded in rejecting her claims that professors and administrators at Augusta State, and officials of the University System of Georgia, had violated her rights under the Constitution's First Amendment and Equal Protection Clause.

Rejecting the idea that the case represented "a public contest of values," Judge Hall said the facts it had presented "amount to no more than this: a student enrolled in a professional graduate program was required to complete a course of remediation after being cited for purported professional deficiencies by educators in her chosen field of study; she refused to do so and was dismissed from the program."

The entire story is here.

Thanks to Ken Pope for this story.

Christian Group Backs Away from Ex-Gay Therapy

By Patrick Condon
The Associated Press
Originally published June 26, 2012

Alan Chambers
The president of the country's best-known Christian ministry dedicated to helping people repress same-sex attraction through prayer is trying to distance the group from the idea that gay people's sexual orientation can be permanently changed or "cured."

That's a significant shift for Exodus International, the 36-year-old Orlando-based group that boasts 260 member ministries around the U.S. and world. For decades, it has offered to help conflicted Christians rid themselves of unwanted homosexual inclinations through counseling and prayer, infuriating gay rights activists in the process.

This week, 600 Exodus ministers and followers are gathering for the group's annual conference, held this year in a Minneapolis suburb. The group's president, Alan Chambers, told The Associated Press on Tuesday that the conference would highlight his efforts to dissociate the group from the controversial practice usually called ex-gay, reparative or conversion therapy.

The entire story is here.

Wednesday, July 4, 2012

Parity for Patriots: The mental health needs or military personnel, veterans and their families

The National Alliance on Mental Illness released a report entitled Parity for Patriots: The Mental Health Needs of Military Personnel, Veterans and their Families.  Here is a section of the report that is particularly important.

"The U.S. Department of Defense must move more forcibly to end discrimination associated with invisible wounds of war. Reducing the stigma of mental illness will enhance opportunities to deliver prompt, effective treatment to military service members and families who live with PTSD, depression and other mental health conditions. Examples of immediate steps that can be taken to eliminate stigma and barriers to seeking help include:

  • Military leader accountability for stigma and suicide: Military leaders throughout the chain of command should be required to focus on preventable psychological injuries and deaths, which should be part of their efficiency reporting process. Suicides are preventable just as are the heat and cold injuries of service members for which leaders are routinely relieved of command.
  • Purple Heart for psychological wounds: Posttraumatic stress and other mental health injuries, that are the result of hostile action, including terrorism, should be eligible for award of the Purple Heart with the same level of appreciation and recognition as those awarded to warriors with visible wounds.

The Veterans Health Administration must increase service capacity by expanding provider networks to include community mental health agencies and private practitioners. The VHA should monitor the degree to which contract providers accept veterans and families as clients and should adjust networks to make care available when and where it is needed. Ongoing training in military-informed mental health treatment should be a basic requirement for contract providers. Improved distance delivery through technology should be implemented to remove the travel burden from veterans and improve the use of professional care giver time."


Please remember our military service personnel on this holiday.

The Fiduciary Heart of Ethics


By Ed Zuckerman, PhD


We have all heard the word “fiduciary”bandied about during the ongoing mortgage and banking crisis and probably thought it meant something about money. Not true.

In your first day in professional school, when they talked about the helping relationship, you were probably told something like, always put your client’s needs ahead of your own. As soon as you nodded to that you became a fiduciary.

The fiduciary duty then is an obligation to act in the best interests of another party. In any relationship it is imposed upon the stronger (more knowledgeable, richer, smarter, whatever) as a duty to the weaker. Stealing candy from a baby is a breach of this duty and so is insider trading–using non-public information gained because of one’s special position to buy stock for a gain not available to the public. In one sense being a good parent is fulfilling a fiduciary obligation to a child - doing what is in the child’s best long-term interest instead of what is convenient for the parent. 

However, stockbrokers only have to offer what is suitable - likely to be beneficial -  to the client. They do not have to offer what might be in the clients best interest or what is less profitable for the broker. Similarly, and closer to therapy relationships, a lawyer cannot represent both plaintiff and defendant in a dispute - the lawyer cannot act for two principals and be loyal to both.

A “fiduciary is, in law, a person who is obliged to discharge faithfully a responsibility of trust toward another. Among the common fiduciary relationships are guardian to ward, parent to child, lawyer to client, corporate director to corporation, trustee to trust, and business partner to business partner.” 
The Columbia Electronic Encyclopedia Copyright © 2004.

And psychologist to client. A cornerstone of counseling is the moral principle of trust, the client’s belief that the clinician will be honest and tell the whole truth, will not conceal any important relevant information, and will maintain the confidentiality of what is entrusted to the clinician. Underlying all of these is the principle of fiduciary responsibility - to not take advantage of the client for the benefit of the clinician. Although it may not always be apparent, concealing some facts, inadequate documentation, or breaching confidentiality would only be done for some advantage to the clinician. The promise of non-exploitation provides the safety to reveal and explore thoughts, feelings, history, plans or anything else which would have to be concealed out of fear of the consequences to the client.

“In a fiduciary relation one person justifiably reposes confidence, good faith, reliance and trust in another whose aid, advice or protection is sought in some matter. In such a relation good conscience requires one to act at all times for the sole benefit and interests of another, with loyalty to those interests.” Wikipedia, accessed December 17, 2009.

Respect and autonomy

While such efforts are legally and ethically imposed they also can be empowering of the client and clinically useful in the therapy.

The fiduciary principle expands the principles of respect and trustworthiness in specific and helpfully guiding ways. It recognizes the multiple differences between the parties and extends that knowledge into ethical rules. The fiduciary duty requires one to explore, identify and recognize differences. It requires one to weigh and to adapt to these differences; to respect and dignify them. 

With respect for the other comes trust by the other in our loyalty to them. The enactment of such trust can be seen in at least  two relevant and related ethical responsibilities placed on clinicians: 
to ensure fully informed consent about all aspects of the therapeutic relationship both initially and as the relationship evolves and is extended, and 
to make every necessary effort to ensure and protect the privacy of the patient’s information.  

Multiple relationships

We have an ethical obligation to avoid harmful multiple relationships. But why? 

First, because each role has obligations and expectations and these may be in conflict. Multiple roles require choices of actions and the therapist might choose to meet his or her needs or wants before the needs of the client or just be seen by the client as putting his or her needs first. Simply put, a fiduciary may not and does not have a conflict of interests. 

A second element is that by foregoing any relationship other than client to therapist we absolutely prevent even accidental breaches of confidentiality. If we are not members of the client’s work setting or deal with relatives of the client we cannot even accidentally reveal information vouchsafed to us with the expectation of confidentiality (that we will not share it with another).

Among our responses can be a withdrawal from one role or the seeking of informed consent to allow limited role overlap. For example, we can inform about the ways a friendship would conflict with therapy and ask for consent to forego the friendship’s benefits. If we fail to resolve he conflicted interests we will breach our fiduciary duty and thus be open to both accusations of ethical failure and the possibilities of malpractice suits. 

In our work, preserving privacy, respecting differences, and supporting autonomy are aspects of our fiduciary duty. Carrying out this duty consistently and thoroughly - professionally - enables us to deserve the trust of those who seek our help.

Appreciation to Sam Knapp for his helpful comments.
December 17, 2009 and June 26, 2012.

Tuesday, July 3, 2012

Teacher: Sex with students was "casual" and "warm"

A teacher admits having sex with students but says he's "surprised they remember." An expert says that this is typical.

By Tracy Clark-Flory
Salon.com
Originally published June 25, 2012

More startling than the fact that he gave an interview to the media, or even that he admitted to having had sex with his underage students, was that Tek Young Lin described the many-decades-old incidents as “warm” and “casual.”

In Sunday’s New York Times, the former teacher at the elite Manhattan private school Horace Mann, which is now the focus of widespread allegations of abuse, said, “The only thing I can assure you of was that everything I did was in warmth and affection and not a power play.” Of his three former high school students who spoke with the Times about the incidents — two of whom say the sexual contact began at 14 or 15, one of whom said it began at 17 — Lin said, “I’m surprised they remember. It was all so casual and warm.”
James Cantor, a psychologist and editor in chief of the research journal Sexual Abuse, tells me this sort of rationalization is common among adults who pursue sex with minors.

The entire story is here.

Thanks to Gary Schoener for this story.

Monday, July 2, 2012

Sandusky Verdict: Will Reporting Rates For Sex Abuse Improve?

A strong set of beliefs prevents reporting, but seeing the system visibly work will encourage others to come forward

by Christopher J. Ferguson
Time Magazine - Ideas
Originally published June 25, 2012

Jerry Sandusky
With the verdict in the Jerry Sandusky trial behind us, it’s worth reconsidering one of the most troubling aspects of this case: Why do many people, including professionals such as psychologists and pediatricians, fail to report child sexual abuse? It is well-known that authorities at Penn State, including head football coach Joe Paterno, did not report what they had learned to legal authorities. The incident witnessed by Mike McQueary was passed up the chain at Penn State, but no one took that crucial step of informing law enforcement officials. This failure allowed Sandusky to remain free to continue to abuse children.

It is easy to convince ourselves that we would act more decisively if we were in the same situation, and many people indeed do. But even medical and mental health professionals with a legal duty to report abuse fail to do so.

The entire story is here.

Thanks to Gary Schoener for this story.

------------------------------------

On a national ethics educators listserv, the following exchange took place about this article.

Sam Knapp:

This article reflects popular attitudes about mandated reporting.

However, reporting rates are highly influenced by rates of substantiation after reports of abuse are made. Pennsylvania has the lowest rate of substantiated child abuse in the country (one-seventh the national average) and a rate of substantiating child abuse, which is 14% (compared to 23% nationwide). And if you look across the country you find that the states that have low rates of child abuse reports tend to have low rates of substantiating those reports and states that have high rates of child abuse reports tend to have high rates of substantiating those reports. What happens is an informal process of education where mandated reporters learn, over time, that certain reports are not going to be founded (or even investigated), so they discontinue making those reports.

Some states have proposed legislation that would make the failure to file a mandated a report a felony (in most states it is a misdemeanor). My concern is that the fear of a felony will cause mandated reporters to adopt a very low threshold for making reports resulting in an investigation of a large number of cases where the likelihood of child abuse being founded is extremely low.

I know that we as a profession can do better at educating our own on child abuse and child abuse reporting laws. My point is that reporting rates are very much influenced by the response of the child protective system to those reports.

Gary Schoener responded:

I agree Sam that reporting is not the issue in terms of mandated reporters -- at least not the lone issue.

What was troubling about the Sandusky case was not the non-reporting as much as the inaction by the adults -- especially officials.  I have seen cases where at least there is internal disciplinary action, referral for therapy, etc.  In fact, some of the high visibility Catholic cases actually did involve taking action -- it's just that the action was ineffective.

One common problem was the failure of professionals who were sent pedophiles for treatment to know what they were doing, or to propose a return to work without any surveillance.  You may not remember, but in Boston there was a big pissing match between the Archdiocese and the Institute for Living.  The Archdiocese did not ask if the guy should be put back, and the Inst. for Living allegedly made no such warning or recommendation about safety.

Likewise, that Minnesota statute I mentioned was directed at people like us, asking that we be accountable in cases where someone has been caught and is being fired or resigning.  We have not eliminated silence agreements completely, I am sure, but they are very rare indeed here.

I certainly agree that reporting to child protection can be very ineffective, and the same can be true for reporting to the police. 

Sunday, July 1, 2012

Suicide in young men

The Lancet, Volume 379, Issue 9834, Pages 2383 - 2392, 23 June 2012
doi:10.1016/S0140-6736(12)60731-4
By A. Pitman, K. Krysinska, D. Osborn, and M. King.

Summary

Suicide is second to only accidental death as the leading cause of mortality in young men across the world. Although suicide rates for young men have fallen in some high-income and middle-income countries since the 1990s, wider mortality measures indicate that rates remain high in specific regions, ethnic groups, and socioeconomic groups within those nations where rates have fallen, and that young men account for a substantial proportion of the economic cost of suicide. High-lethality methods of suicide are preferred by young men: hanging and firearms in high-income countries, pesticide poisoning in the Indian subcontinent, and charcoal-burning in east Asia. Risk factors for young men include psychiatric illness, substance misuse, lower socioeconomic status, rural residence, and single marital status. Population-level factors include unemployment, social deprivation, and media reporting of suicide. Few interventions to reduce suicides in young men have been assessed. Efforts to change help-seeking behaviour and to restrict access to frequently used methods hold the most promise.


Means restriction for suicide prevention

The Lancet, Volume 379, Issue 9834, Pages 2393 - 2399, 23 June 2012
doi:10.1016/S0140-6736(12)60521-2
By Yip, et. al

Summary

Limitation of access to lethal methods used for suicide—so-called means restriction—is an important population strategy for suicide prevention. Many empirical studies have shown that such means restriction is effective. Although some individuals might seek other methods, many do not; when they do, the means chosen are less lethal and are associated with fewer deaths than when more dangerous ones are available. We examine how the spread of information about suicide methods through formal and informal media potentially affects the choices that people make when attempting to kill themselves. We also discuss the challenges associated with implementation of means restriction and whether numbers of deaths by suicide are reduced.



Self-harm and suicide in adolescents

The Lancet, Volume 379, Issue 9834, Pages 2373 - 2382, 23 June 2012
by K. Hawton, K. Saunders, and R. O'Connor
Originally published June 23, 2012

Summary

Self-harm and suicide are major public health problems in adolescents, with rates of self-harm being high in the teenage years and suicide being the second most common cause of death in young people worldwide. Important contributors to self-harm and suicide include genetic vulnerability and psychiatric, psychological, familial, social, and cultural factors. The effects of media and contagion are also important, with the internet having an important contemporary role. Prevention of self-harm and suicide needs both universal measures aimed at young people in general and targeted initiatives focused on high-risk groups. There is little evidence of effectiveness of either psychosocial or pharmacological treatment, with particular controversy surrounding the usefulness of antidepressants. Restriction of access to means for suicide is important. Major challenges include the development of greater understanding of the factors that contribute to self-harm and suicide in young people, especially mechanisms underlying contagion and the effect of new media. The identification of successful prevention initiatives aimed at young people and those at especially high risk, and the establishment of effective treatments for those who self-harm, are paramount needs.