Ethics Assignment 2: Decision Making Process Monique Janssen Pat Veleno University of Calgary February 24, 2009

Janssen & Veleno

Step 1. Identification of the Individuals and Groups Potentially Affected by the Decision

The grandmother and the 11-year-old boy will be most affected by the decision of the psychological team; however, the fact that a psychiatric assessment necessitates a trip of 100 miles makes it probable that we are working in a small community and the reputation of the members of the psychological team and other helping professions in the community would also be affected. There is also concern about losing the trust of the community and leaving the residents feeling suspicious towards future psychologists or other counselors that come to the village to try to help. So, in this way, the discipline of psychology is affected by my actions by way of public trust within the local town, and more specifically, within the aboriginal culture. Step 2. Identification of Ethically Relevant Issues and Practices, Including the Interests, Rights, and any Relevant Characteristics of the Individuals and Groups Involved and of the System or Circumstances in which the Ethical Problem Arose Principles/ Values Principle I: Respect for the Dignity of Persons Value: General Respect I.1 Demonstrate appropriate respect for the knowledge, insight, experience, and areas of expertise of others Regardless of our final decision, the psychological team must convey respect for the grandmother, the boy, the aboriginal culture, and any other professionals involved in our contacts regarding this issue. My Thoughts

Value: Informed Consent I.16 Seek as full and active participation as possible from others in decisions that affect them, respecting and integrating as much as possible their opinions and wishes I.17 Recognize that informed consent is the result of a process of reaching an agreement to work collaboratively, rather than of simply having a consent form signed. It would be worthwhile to consult the grandmother and the boy regarding their perceptions and opinions about the presence of the voices, intrusiveness, the necessity to address them, and how best to intervene. By actively involving the boy and the grandmother in the planning process, the psychological team is much more likely to achieve buy-in (i.e., agreement to psychiatric assessment), with the plan of action, and all parties will be truly providing their informed consent. Efforts should be made to provide the boy with choices and options if he is reluctant to cooperate initially. This is a culture that highly values the role of extended family and we need to respect this and allow for time to consult with other members of the community, including spiritual leaders and/or aboriginal case workers, etc., to facilitate the grandmothers decision-making process regarding the best interests of her grandson, including whether to send him to the facility for assessment. We need to ensure that the boy and the grandmother are fully informed of all their therapeutic options and possible outcomes before consenting and assenting to any treatment. If the presence of the voices poses a significant and imminent risk of harm or danger to the boy or others, i.e., crisis, then informed consent is not immediately necessary, and appropriate actions is required, but informed consent should be sought as soon as

I.18 Respect the expressed wishes of persons to involve others (e.g., family members, community members) in their decision making regarding informed consent. This would include respect for written and clearly expressed unwritten advance directives.

I.19 Obtain informed consent form all independent and partially dependent persons for any psychological services provided to them except in circumstances of urgent need (e.g., disaster or other crisis). In urgent circumstances, psychologists would proceed with the assent of such persons, but fully informed consent would be obtained as soon as possible

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possible, i.e., once the crisis has been managed and risk has been minimized. I.23 Provide, in obtaining informed consent, as much information as reasonable or prudent persons would want to know before making a decision or consenting to the activity. The psychologist would relay this information in language that the persons understand (including providing translation into another language, if necessary) and would take whatever reasonable steps are needed to ensure that the information was, in fact, understood I.26 Clarify the nature of multiple relationships to all concerned parties before obtaining consent, if providing services to or conducting research at the request or for the use of third parties. This would include, but not be limited to: the purpose of the service or research; the reasonably anticipated use that will be made of information collected; and the limits on confidentiality. Third parties may include schools, courts, government agencies, insurance companies, police, and special funding bodies. Value: Freedom of Consent I.27 Take all reasonable steps to ensure that consent is not given under conditions of coercion, undue pressure, or undue reward.

The psychological team could seek to have trusted members of the aboriginal culture involved in the process of communicating pertinent information with the grandmother, including translator services, if necessary, to relay information about the process of psychiatric assessment. If required, we can seek to include representatives in the process, and may even suggest a guided tour of the facility in order to facilitate a thorough understanding of what to expect from admission and assessment. We must ensure to convey the message that all information pertaining to the boys psychological assessment and treatment would be shared with the referral source, i.e., school, prior to obtaining consent to consult with the psychiatric assessment team.

We must be careful to convey information in a manner that does not prompt the grandmother and the boy to feel as though they have no other choices. We must not force our opinions upon them, or otherwise mislead or trick them into heeding our advice. We provide all pertinent clinical information to them in an empathic, but neutral fashion and allow them to decide outcomes freely. Suggesting a psychiatric assessment may lead to a desire to discontinue psychological treatment. Furthermore, we must be sensitive to cultural influences that may inhibit the communication of a desire to discontinue services. We must make sure to convey the message that it is ok (but unadvisable) to discontinue services, upon their request.

I.30 Respect the right of persons to discontinue participation or service at any time, and be responsive to non-verbal indications of a desire to discontinue if a person has difficulty with verbally communicating such a desire (e.g., young children, verbally disabled persons) or, due to culture, is unlikely to communicate such a desire orally. Value: Protection for Vulnerable Persons I.34 Carry out informed consent processes with those persons who are legally responsible or appointment to give informed consent on behalf of persons not competent to consent on their own behalf, seeking to ensure respect for any previously expressed preferences of persons not competent to consent. Value: Confidentiality I.44 Clarify what measures will be taken to protect confidentiality, and what responsibilities family, group,

Since the boy is not of the age of majority, the legal guardian must provide consent to treatment. Is this the grandmother? If not, we must seek to include parents and/or persons legally responsible for the boy in this process. Although it is unlikely that he would be considered a mature minor, we must seek to include his viewpoints and problem solve creatively to encourage willful participation.

Should it be deemed necessary for grandma and the boy to become involved in family therapy to address unhealthy

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and community members have for the protection of each others confidentiality, when engaged in services to or research with individuals, families, groups, or communities. I.45 Share confidential information with others only with the informed consent of those involved, or in a manner that the persons involved cannot be identified, expect as required or justified by law, or in circumstances of actual or possible serious physical harm or death Principle II: Responsible Caring Values Statement [Psychologists] engage only in those activities in which they have competence or for which they are receiving supervision, and they perform their activities as competently as possible. Value: General caring II.1 Protect and promote the welfare of clients, research participants, employees, supervisees, students, trainees, colleagues, and others. II.3 Accept responsibility for the consequences of their actions.

codependence/boundaries issues, the psychological team must clarify the responsibility that each has in protecting the confidentiality of each other. If a community liaison is involved he/she is also bound to protect the confidentiality of the clients. We need to make sure that we obtain consent to consult with psychiatric team and that all conversations are done in private. Also, the consenter needs to know that information will be shared with the referral source (the school) with informed consent.

The psychological team members are not competent to assess psychiatric symptoms and are not under supervision to do this.

We would not be protecting the welfare of the client if we proceed with treatment while allowing psychiatric symptoms to go unchecked. We have to accept responsibility for the way this situation turns out- if the Grandmother says no to psychiatric assessment than we have to do our best to treat the boy or to refer to a counselor who is better equipped to address the issues at hand, i.e., an aboriginal counselor or one who has experience working with the aboriginal population.

Value: Competence and self-knowledge II.8 Take immediate steps to obtain consultation or to refer a client to a colleague or other appropriate professional, whichever is more likely to result in providing the client with competent service, if it becomes apparent that a clients problems are beyond their competence II.10 Evaluate how their own experiences, attitudes, culture, beliefs, values, social context, individual differences, specific training, and stresses influence their interactions with others, and integrate their awareness into all efforts to benefit and not harm others From this principle there appears to be a need to refer because the psychological team is unqualified to assess the psychiatric symptoms. Furthermore, referral to a colleague with experience in aboriginal issues, or with a sound knowledge base of the aboriginal culture may be appropriate. Based on our educational, cultural and religious beliefs, we have biases that strongly lead us to examine biomedical origins to the presence of voices. We also believe in the sanctity of the family structure it would cause dissonance for us to break up the grandmother with her grandson. Additionally, we think that it is the duty of the family leader to do all that is necessary to ensure the wellbeing of the child; however, this culture may be more mistrustful of psychiatric treatment or feel that the child can be better treated within the aboriginal community.

Value: Risk/benefit analysis

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II.14 Be sufficiently sensitive to and knowledgeable about individuals, group, community, and cultural differences and vulnerabilities to discern what will benefit and not harm persons involved in their activities.

We must educate ourselves about the aboriginal community and culture so as to recognize potential problems associated with separating the grandmother and her grandson, the potential loss of faith and trust in the profession prompted by suggesting temporary placement of the grandson in an institutional setting, and the origin of the voices.

Value: Maximize benefit II.18 Provide services that are coordinated over time and with other service providers, in order to avoid duplication or working at cross-purposes. II.20 Make themselves aware of the knowledge and skills of other disciplines (e.g., law, medicine, business administration) and advise the use of such knowledge and skills, where relevant to the benefit of others. II.21 Strive to provide and/or obtain the best possible service for those needing and seeking psychological service. This may include, but is not limited to: selecting interventions that are relevant to the needs and characteristics of the client and that have reasonable theoretical or empirically-supported efficacy in light of those needs and characterizes; consulting with, or including in service delivery, persons relevant to the culture or belief systems of those served; advocating on behalf of the client; and, recommending professionals other than psychologists when appropriate Value: Minimize harm II.30 Be acutely aware of the need for discretion in the recording and communication of information, in order that the information not be misinterpreted or misused to the detriment of others. This includes, but is not limited to: not recording information that could lead to misinterpretation and misuse; avoiding conjecture; clearly labeling opinion; and, communicating information in language that can be understood clearly by the recipient of the information II.31 Give reasonable assistance to secure needed psychological services or activities, if personally unable to meet requires for needed psychological services or activities II.33 Maintain appropriate contact, support, and responsibility for caring until a colleague or other professional begins service, if referring a client to a colleague or other professional Value: Extended responsibility We need to ensure that all communication we have with the psychiatric assessment team makes clear our opinions about the voices and how this differentiates from what the boy has reported about the voices. Also, we make sure we discuss the particulars of the culture if relevant. Lastly, in sharing this information with the referral source, we make sure that this information is not generalized or misused, i.e., by suggesting that all aboriginal people hear voices and/or are susceptible to mental illness, etc. We need to do our best to help the family get to the city to access the psychiatric assessment, and make sure to refer to a counselor with experience with aboriginal issues or who has an aboriginal background, and has experience with similar clinical problems. We need to begin/ continue counseling until the trip can be arranged, and secure needed support services, as necessary, to assist the grandmother and grandson and ensure safety until such time as psychiatric services can be initiated. We need to be prepared to work with the psychiatric assessment team to meet the best interests of the boy. As psychologists, we are aware that some of the boys issues, i.e., the voices, may be beyond our scope of practice and expertise. As such, we suggest a referral for psychiatric assessment by a qualified medical practitioner, i.e., psychiatrist. We need to do whatever we can to ensure this client gets what he needs to be treated successfully. If the trip is too costly than perhaps we have to contact the government about sending someone to our community to do an assessment or try to find other ways for the family to get to the city. We may seek to include cultural leaders or respected community figures in the process to facilitate a trusting relationship between grandmother and professionals involved, or seek to make arrangements to involve grandmother in the assessment process, with increased access to her grandson. Referral to psychiatric services is made to address issues beyond our scope of practice and competency.

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II.49 Encourage others, in a manner consistent with this Code, to care responsibly

We may need to encourage the psychiatric assessment facility to help the family access their centre, while encouraging them to provide services by an appropriate professional, i.e., with similar cultural background, or with experience in similar clinical issues.

Principle III: Integrity in Relationships Value: Accuracy/honesty III.8 Acknowledge the limitations of their own and their colleagues knowledge, methods, findings, interventions, and views Value: Objectivity/lack of bias III.10 Evaluate how their personal experiences, attitudes, values, social context, individual differences, stresses, and specific training influence their activities and thinking, integrating this awareness into all attempts to be objective and unbiased in their research, service, and other activities. III.11 Take care to communicate as completely and objectively as possible, and to clearly differentiate facts, opinions, theories, hypotheses, and ideas, when communicating knowledge, findings, and views Value: Straightforwardness/openness III.14 Be clear and straightforward about all information needed to establish informed consent or any other valid written or unwritten agreement (for example: fees including any limitations imposed by third-party payers; relevant business policies and practices; mutual concerns; mutual responsibilities; ethical responsibilities of psychologists; purpose and nature of the relationship, including research participation; alternatives; likely experiences; possible conflicts; possible outcomes; and, expectations for processing, using, and sharing any information generated). Value: Reliance on the discipline III.38 Seek consultation from colleagues and / or appropriate groups and committees, and give due regard to their advice in arriving at a responsible decision, if faced with difficult situations If the family cannot make the trip, or perhaps even before sending them, we should consult with a psychiatrist with knowledge of the aboriginal culture and get his/her opinion about whether this case needs to be evaluated by him/her; and consultation with an aboriginal spiritual leader should be sought to talk about religious beliefs associated with the presence of voices. The clients must be informed about how any information gathered will be used. For example, if the boy was referred for services by the school, then psychological information gleaned will be shared with the school, pending consent, to aid treatment. Further, how the school will use this information, (i.e., to provide appropriate support services within the classroom setting, or to influence school/classroom placement, etc. to promote academic and learning success) will be fully explained. We must be open-minded about the possibility of the role of religion and spirituality in this case. Our personal beliefs, opinions and values cannot influence clinical decision-making. We must admit the limitations associated with western medicine and our collective ignorance of the role of spirituality, institutional biases, etc.

Our oral/written reports and findings will be clearly conveyed, in the absence of ambiguous, judgmental and/or biased language. Facts and suggestions regarding clinical findings will be comprehensive.

Principle IV: Responsibility to Society Value: Beneficial activities

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IV.4 Participate in and contribute to continuing education and the professional and scientific growth of self and colleagues

We will endeavor to educate ourselves on aboriginal cultures, and issues related to the delivery of service to this population, including spiritual and religious beliefs and the formulation of trust within the professional relationship. We will also endeavor to share this information with other individuals who provide psychological or other services to this culture, as appropriate.

Value: Respect for society IV.15 Acquire an adequate knowledge of the culture, social structure, and customs of a community before beginning any major work there. IV.16 Convey respect for and abide by prevailing community mores, social customs, and cultural expectations in their scientific and professional activities, provided that this does not contravene any of the ethical principles of this Code. Value: Development of society IV.29 Speak out and/or act, in a manner consistent with the four principles of this Code, if the policies, practices, laws, or regulations of the social structure within which they work seriously ignore or contradict any of the principles of this Code We may need to bring to the attention of the public/government the accessibility issues for this population of people and try to bring about change to increase accessibility. Do we have an adequate knowledge of this culture to understand whether these voices are part of the religion or part of a psychiatric disorder, and how to proceed? We must be careful to respect and adhere to cultural rules of behaviour to avoid offending and/or jeopardizing the therapeutic relationship, provided that we remain true to our Code of Ethics.

Step 3. Consideration of How Personal Biases, Stresses, or Self-interest Might Influence the Development of or Choice Between Courses of Action The biases of the psychological team stem from growing up and living in a large, urban area of Ontario, which may contribute to some misunderstandings or misinterpretations of the culture and religion and therefore we may incorrectly interpret the meaningfulness of the voices. Furthermore, being socialized in a traditional westernized culture, with a Christian background, it is the inherent belief of the psychological team that children should not be alone, and the family structure should ideally be kept intact, so splitting up the boy and his grandmother may cause some dissonance. Additionally, although it is the intention of the psychological team to help the boy and his grandmother, there may be some self-interest, pride, ego, etc. in achieving successful outcomes regarding this difficult situation. Alternately, there is also self-interest served in having someone else, who is more experienced with aboriginal culture and issues assess this boy as it takes the burden of responsibility off of the psychological team.

Step 4. Development of Alternative Courses of Action Alternative 1.

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The first step would be to contact a psychiatrist at the urban center and speak in general terms about the situation and seek consultation regarding the psychiatrists opinion about the appropriateness of referring the boy. If the psychiatrist believes that a psychiatric referral is not necessary, then the psychological team can resume counseling and contact the psychiatrist if further concerns arise.

If the psychiatrist believes that a referral is appropriate, then we need to speak to the grandmother and explain our concerns and convey the opinion that an assessment is necessary. At this time the psychological team would seek to provide the grandmother with an opportunity to discuss her feelings about the situation, concerns, timeframe for making the journey, and obtain her informed consent to share information with the psychiatrist in order to expedite the process with which the psychiatrist can initiate his/her services. Informed consent would need to be granted to share pertinent information with the referral source as well. At this point the grandmother may be agreeable and willing to take the grandson to the city, which is a positive outcome. It is also possible that the grandmother shows resistance through a mistrust of the treatment the boy will receive, an inability to get to the city, or a desire to have the boy treated in his own community. It is important to express our point of view without being overly forceful and making her mistrustful of the psychological team while respecting her right to make decisions about her grandsons care. We also have to be prepared to do our best to counsel the boy without going out of our own bounds of confidence if she decides only to seek care in the community. This may further necessitate a referral to a counselor with experience in aboriginal issues/culture.

Alternative 2. A second option is to include the services or assistance of a trusted aboriginal liaison, such as a spiritual leader, case manager, or trusted acquaintance to facilitate the psychological team in speaking to the grandmother about her interpretations of the voices the boy hears and understanding her concerns, while exploring any other possible signs of psychiatric disturbance. We would invite the boy, grandmother and her trusted advisors to assist in the formulation of a plan of action, in partnership with the psychological team, possibly including taking a tour of the facility and meeting the treating psychiatrist beforehand in order to allay any fears or anxieties that the grandmother or grandson may have. We would recommend a referral to an aboriginal psychiatrist, if possible, since the investigation of psychiatric issues is beyond our scope of practice. Otherwise, efforts would be made to refer to a psychiatrist who has experience with aboriginal cultures, in order to ensure that a proper assessment was conducted. At this point, the psychological team would offer to support the grandmother in breaking through any barriers to accessing the service such as helping her make the appointment, arranging transportation, and involving grandmother in the assessment process wherever possible, etc. Furthermore, if necessary, the psychological team would make arrangements to have grandmother accompany the boy on the trip while seeking to make accommodations to allow her to engage in extended visits with her grandson on a regular basis throughout his time there. Pending the completion of the assessment, the psychological team would offer to provide services to both the grandson and grandmother regarding their respective issues, after having researched further information and acquired a knowledge base about aboriginal culture and beliefs, etc. At this time, we would clearly explain our expectation that relevant psychological information pertaining to the boy would be shared with the referral source, i.e., school, for the purposes of academic placement and/or support services, pending the provision of informed consent.

Alternative 3. A third option is to refer the client to a counselor/psychologist with previous experience with the aboriginal culture and/or aboriginal issues. This may be difficult to achieve, so arrangements would have to be made to bridge

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services until such time as an appropriate counselor could be found. This would mean that we would communicate our limited scope of understanding of the aboriginal culture to the grandmother and grandson, while making efforts to become educated on the culture in the interim. Our intervention would take on a limited scope, and we would invite the assistance of an approved community liaison, pending the grandmothers consent, to facilitate the process of providing psychological services, as appropriate. Further to this, we would seek to pursue government funded community support services to provide one-to-one care to the boy on a temporary basis, to address his loneliness issues and provide supervision and leisure opportunities until such time as formal, more intensive intervention begins with a better-suited psychologist.

Step 5. Analysis of Likely Short-term, Ongoing and Long-term Risks and Benefits of Each Course of Action on the Individual(s)/group(s) Involved or Likely to be Affected (e.g., Client, Client's Family or Employees, Employing Institution, Students, Research Participant, Colleagues, the Discipline, Society, Self) Possible Positive Consequences Alternative 1 Psychiatrist indicates there are no concerns and we can continue counseling Possible Negative Consequences Grandmother feels that the professionals are ganging up on her and decides to remove her grandson from all services and may speak negatively of the situation to others in the community making them less likely to seek services in the future Grandmother is unable to access service in the city and we need to find a way to try to help her- we may not be able to get her to the city (if money is an issue) and then we have a new problem to solve

Psychiatrist wants to evaluate the boy and grandmother agrees to this and is able to take him to the city

Grandmother feels that the mental health system is looking out for her grandson and is thankful for our initiative in speaking to a more qualified professional Alternative 2 By including cultural liaisons, grandmother feels empowered and trusting of us because her expertise and beliefs are being considered and respected, while we allay her fears about temporary institutional placement by making special accommodations for her and involving her intimately in the process We learn more about the aboriginal culture by actively encouraging grandmother and her chosen liaisons to speak about their beliefs and traditions We may have to suggest further psychiatric assessment despite the fact that the grandmother (and the community liaison) may not agree with our decision, and grandmother (and the liaison) may become a disruptive force in the assessment process or fail to provide consent to treatment We explain away symptoms as cultural differences and miss an important opportunity to help the child

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The boys assessment process is shortlived and successful, while allowing extended participation by grandmother. This allows psychological services to begin with the boy and the grandmother in a timely fashion and facilitates a positive attitude toward the members of the psychological team The treatment facility administrators may deny permission to allow grandmother extended accommodations, which would then create animosity and possible negative feelings toward all professionals involved, and the fields of psychology and psychiatry, respectively; and the individual members of the psychological team, specifically The boy is determined to have a serious mental health issue, and is required to have an extended stay in the facility, or is further traumatized by the experience, leading to negative feelings by the aboriginal community in general, including grandmother Alternative 3 The services of a competent counselor with aboriginal experience or with an aboriginal background is secured quickly, thereby allowing grandmother and the boy to receive intervention from a professional with a deep understanding of their cultural beliefs and traditions, while encouraging feelings of trust between the clients and professionals The introduction of direct community support services with the boy has an immediate positive outcome, and greatly reduces the need to seek psychiatric assessment It is difficult to find professionals with experience in aboriginal issues, and the process becomes time consuming, to the possible detriment of the boys and grandmothers mental health. The services of the psychological team is met with resistance

The grandmother and grandson resent the involvement and presence of a stranger in their lives and deem it an intrusive intervention and invasion of their privacy. This deepens the mistrust between the aboriginal community and the helping professions

Step 6. Choices of Course of Action After Conscientious Application of Existing Principles, Values, and Standards We believe that the best course of action is alternative 2 because this process actively involves the grandmother and grandson in the decision-making process, and seeks consultation from individuals across the medical and cultural realms, respectively. Furthermore, we believe this plan of action provides the boy with the greatest chance for success, and facilitates feelings of trust and security within the grandmother and aboriginal community. This action places all professionals involved in a better position to decrease barriers and fosters open and direct communication, thereby increasing the collaborative approach and encouraging successful outcomes. We also believe this plan of action helps create positive perceptions toward the psychological team, specifically, and the field of psychology in general.

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Step 7. Action with a Commitment to Assume Responsibility for the Consequences of the Action Since the psychological team is hesitant to begin providing services without the consult we need to contact grandma and arrange the meeting between her, the boy, the community liaison, and us as soon as possible. The outcome of this consultation about hearing the voices will determine whether or not we refer the boy for psychiatric assessment, but we already feel strongly that he should be referred. If we do make a referral and grandma and the liaison disagree with this referral than we need to be prepared to present supporting evidence for our suggestion and respect the decision that grandma, as guardian, makes.

Step 8. Evaluation of the Results of the Course of Action In evaluating the results of implementing alternative 2 we will need to understand multiple perspectives including the boys, the grandmothers, the liaisons and our own to understand why decisions were made and how we can be better prepared to assess, treat, and communicate in similar situations that may arise in the future.

Step 9. Assumption of Responsibility for the Consequences of Action, Including Correction of Negative Consequences, If Any, or Re-engaging in the Decision-making Process If Ethical Issue Is Not Resolved If grandmother and the liaison become disruptive to the treatment process we need to take responsibility for allowing her to choose a community liaison (who may not understand the importance of psychotherapy) rather than finding a trusted member of the community who values our contribution to the community and could further our understanding of cultural differences. Additionally, if we are absolutely unable to aid our clients in getting to the psychiatric treatment facility or grandmother removes her grandson from all care we need to engage in the ethical problem solving approach again to determine how to best meet the clients needs, with their input in the process.

Step 10. Appropriate Action as Warranted and Feasible, to Prevent Future Occurrences of the Dilemma (e.g., Communication and Problem Solving with Colleagues, Changes in Procedures and Practices We are aware that practicing in an isolated community will present barriers to access and we may need to work on advocating to the government for increased access to these services such as having a psychiatrist visit once every month to do assessments, supervise medications, and consult on treatment plans. Furthermore, we would advocate for increased psychological services and social programs for the elderly as a means of early recognition and prevention of mental health issues in this population within the community. We may also need to expand our education to improve our ability to understand and meet the needs of the community.