Transcript Ethical Challenges in Serving Diverse Population

Gerald P. Koocher, Ph.D.
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Using a mindfulness perspective, participants will reflect on their own
ability to recognize client differences that may trigger a stereotypic
response in themselves.
Participants will identify significant variations in clinical populations that
will require them to adjust their practice approach from an ethical
perspective, including (for example) differences in age, race/ethnicity,
gender preference, linguistic ability, and physical disabilities.
Using case examples, participants will discuss and share strategies for
ethically appropriate steps when confronted with diverse clients for
whom they lack specialized competence or training to serve.
Participants will frame strategies to recognize both subtle and obvious
client differences that might warrant special ethical considerations and
adapt their practices appropriately.
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(a) Psychologists provide
services, teach, and
conduct research with
populations and in areas
only within the
boundaries of their
competence, based on
their education, training,
supervised experience,
consultation, study, or
professional experience.
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(b) Where scientific or professional knowledge
in the discipline of psychology establishes that
an understanding of factors associated with
age, gender, gender identity, race, ethnicity,
culture, national origin, religion, sexual
orientation, disability, language, or
socioeconomic status is essential for effective
implementation of their services or research,
psychologists have or obtain the training,
experience, consultation, or supervision
necessary to ensure the competence of their
services, or they make appropriate referrals,
except as provided in Standard 2.02, Providing
Services in Emergencies.
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The term “compassionate use” or
“compassionate exemption” means that a
patient is allowed to receive a drug even
though he/she does not meet the eligibility
criteria of a clinical trial in which the drug is
being studied.
The decision to provide a drug in this manner
is made on a case-by-case basis and there
must be a reasonable expectation the drug
will prolong life or improve a person’s quality
of life.
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2.01 (d) When psychologists are asked to provide
services to individuals for whom appropriate
mental health services are not available and for
which psychologists have not obtained the
competence necessary, psychologists with closely
related prior training or experience may provide
such services in order to ensure that services are
not denied if they make a reasonable effort to
obtain the competence required by using
relevant research, training, consultation, or
study.
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In emergencies, when psychologists provide
services to individuals for whom other mental
health services are not available and for
which psychologists have not obtained the
necessary training, psychologists may provide
such services in order to ensure that services
are not denied. The services are discontinued
as soon as the emergency has ended or
appropriate services are available.
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When interpreting assessment results, including
automated interpretations, psychologists take
into account the purpose of the assessment as
well as the various test factors, test-taking
abilities, and other characteristics of the person
being assessed, such as situational, personal,
linguistic, and cultural differences, that might
affect psychologists' judgments or reduce the
accuracy of their interpretations. They indicate
any significant limitations of their interpretations.
(See also Standards 2.01b and c, Boundaries of
Competence, and 3.01, Unfair Discrimination.)
1. Recognize that cultural differences are subjective, complex, and
dynamic.
2. Understand that forming a good therapeutic alliance requires
addressing the most salient cultural differences first.
3. Addressing similarities can form a good prelude to discussion of
cultural differences.
4. Recognize that the client’s level of distress and presenting
problem will influence appropriate timing for discussion of cultural
differences in psychotherapy.
5. Consider cultural differences as assets that can advance the
therapeutic process.
6. Understanding the patient's cultural history and racial identity
development is critical to assessing how best to conceptualize
presenting problems and achieve treatment goals.
7. The meanings and salience of cultural differences are influenced
by ongoing issues within the psychotherapeutic relationship.
8. The psychotherapeutic relationship exists embedded within the
broader cultural context that in turn affects the relationship.
9. The therapist's cultural competence will have an impact on the
way differences are addressed.
10. Dialogues about cultural differences can have an effect on the
patient's cultural context.
Where do our
biases come from?
Name
Description
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Anchoring effect
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Base rate neglect
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Confirmation bias
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Failure to adjust sufficiently
from initial anchor points,
even when the points are
arbitrary.
Overlooking background
frequencies in favor of
salient anecdotal evidence
(e.g., “All my clients are
liberal Democrats, so…”).
Seeking out opinions and
facts that support our own
beliefs and hypotheses
(e.g., “I’m sure I’m right, I
just need to find the
proof”).
Name
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False consensus bias
Fortune teller effect (or
Barnum effect)
Description
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Inclination to assume
your beliefs are more
widely held than they
actually are (e.g., “Family
therapists pretty much
agree on this”).
Tendency of people to
accept
general
descriptions as uniquely
relevant to them (e.g.,
“You think about sex
from time to time”).
Name
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Groupthink
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Homogeneity bias
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Lake Wobegon effect
Description
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Pressure to irrationally agree
with others in strong teambased cultures (e.g., “I better
keep my odd ideas to myself
because the rest of the team
thinks the sky is green”).
Exaggerated conclusions about
large populations based on small
samples (e.g., “My three clients
typify the universe”).
Coined by Garrison Keillor, the
tendency of people o assume
they are “above average.”
Name
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Not my fault bias
Description
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Truthiness
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Wow effect
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If the patient does not improve,
it could not have been me (e.g.,
“They must have not followed my
advice or screwed up some other
way”).
Coined by Comedy Central's
Stephen Colbert, refer-ring to
the human propensity for
determining truth by what we
feel in our gut, independent and
frequently in opposition to
objective reality or scientific
research.
Salient memories override
normative reasoning
The client: a gay , 30 something state police officer with depression
and axis II features, along with many years of chaotic, unstable
relationships, often involving lots of drinking.
Situation: client gets involved with another trooper who sounds
"borderline"....highly emotional, needy, manipulative, history of
lots of crazy drama with both men and women. These two break
up and get back together frequently, always much drama. My
client isn't healthy enough to see where this could go. Is too taken
with beauty and wild sex. Six months later, my client comes in
saying she feels "trapped in my own home." Her girlfriend accuses
her of cheating, or not being reliable, or not loving her enough,
etc. and has made a couple of suicidal "gestures“ (i.e., getting very
drunk and cutting her wrists). Once while my client was sleeping,
and once while my client was out of the house. My client says she
did not call 911 or use ER because of the possible repercussions
to both of them professionally as state police. The girlfriend
continues to be very depressed, insecure, irrational and is pretty
much living at my clients home.
Ethics questions:
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One concern I have (in addition to urging my
person to get out of this relationship) is that I am
hearing about a clearly impaired police officer,
responsible for protecting the public safety. I don't
think my client is the only one at risk. These people
have guns and fast cars and access to so much.
Is there any duty to warn her employers regarding
her mental status ? I know we can't predict
dangerousness too well but this whole situation
made me very nervous.
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I work with a 19 year old female who has a history of sexual
abuse. She was a previous client of mine when she was 14
years old and has returned to therapy on and off over the
years. This most recent return was due to a break up with her
boyfriend, who had lied to her and betrayed her. The client
has a Dx of MDD, and still lives at home with her parents. Her
older brother and father both have substance abuse issues,
mother is not supportive of client.
The client has begun dating a new boyfriend and disclosed the
name, workplace and other identifying information of her new
boyfriend to me. I immediately recognized the boyfriend as
the client of a colleague with whom I share an office and with
whom I participate in peer supervision. As a result, I know that
my client’s boyfriend is actually a biological female living as a
male and at the very beginning stages of transitioning to a
male.
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My client also told me that during high school,
rumors circulated around the school that her
boyfriend was actually a female. My client
stated that she recently confronted her
boyfriend about those past rumors and was
told that they were untrue.
Obviously, confidentiality prevents me from
disclosing any information to the client, but
ethically, it has felt difficult to know this
information when she speaks to me about him.
I also worry about the ramifications of the
clients running into each other in the waiting
room (though we have tried to prevent this) for
both of their privacy as the therapist whom the
boyfriend sees is a gender specialist and I
worry that my client might figure this out.
Lastly, I wonder what impact if/when my client
learns that her boyfriend is a biological female.
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During her first session with Nan Turner, a
28-year-old African American woman, Darla
Dense, M.D., asked about which part of the urban
ghetto Turner had grown up in. Turner explained
that she grew up in the same suburban
community as Dr. Dense, but the psychiatrist's
could not believe some of the experiences Turner
reported. Dr. Dense’s perceptions of the town
were quite different from Ms. Turner's, and
Dense could not recognize the possibility of such
things happening, so she concluded that Turner
was either misrepresenting her past due to
shame or had poor reality testing abilities.
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Carrie has Crouzon Syndrome, an autosomal dominant
genetic condition sometimes called craniofacial
dysostosis. The condition was detected at birth and she
has had more than 30 surgical procedures; first to prevent
brain swelling in infancy and then to help improve her
airway, dental functioning, and physical appearance.
During childhood people frequently assumed that she had
cognitive delays even though her IQ is well above average.
As a college student she has sought psychotherapy to help
with pervasive self-esteem problems and concerns about
future reproductive issues. She has a boy friend but
seems preoccupied with how she might handle a
pregnancy. The therapist she is assigned to see at the
college counseling center has difficulty making eye contact
with her.
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Marsha Young, a recent business school
graduate, won a job at a prestigious advertising
agency. The office was highly competitive, and
she soon developed anxiety attacks and
insomnia. At times, she felt as though she were
the “token woman” in the organization, and she
feared that her work was being scrutinized far
more critically than that of recently hired males.
She sought a consultation with Jack Chauvinist,
Ph.D. Dr. Chauvinist soon concluded that Ms.
Young suffered from “penis envy” and was afraid
of heterosexual intimacy. He advised her that it
was critical for her to address these matters in
therapy if she ever hoped to be able to be
married and bear a child, thus fulfilling herself as
a woman.
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When Henry Tower, an African American college student over
6-feet tall, went to the University Counseling Center for help in
dealing with difficulties he was experiencing on campus, he was
assigned to Biff Jerko, Psy.D. In an effort to “forge an early
alliance,” Dr. Jerko attempted to greet Mr. Jackson with a “high
five” instead of a more traditional handshake. During the course
of the session, Dr. Jerko continued his “attempt to connect” by
using profanity and slang that he regarded as emulating “ghetto
talk.” Mr. Jackson wanted to talk about the fact that his imposing
stature and dark skin seemed to make people uncomfortable. Dr.
Jerko quickly attempted to reassure Mr. Jackson that he would be
judged only by his character and studies on campus and resisted
exploring the impact of prejudice that may accrue to tall black
males. Neither the hand greeting nor slang use were a part of Mr.
Jackson's background, and both were perceived as alienating.
Adding insult to injury, Dr. Jerko asked Mr. Jackson whether he
planned to try out for the college basketball team. Jackson did
not have the energy or assertiveness to attempt reeducation of
the therapist, and he never returned for another appointment.
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Carlotta Familia, a Latino woman in her early 20s,
was struggling with issues involving her relationship
with her mother when she sought consultation with
Carl Cutter, M.S.W. Ms. Hernandez was the first
college-educated person in her extended family and
was torn between traditional obligations to family and
her newly experienced social mobility. Mr. Cutter
praised her academic achievement and encouraged
her to sever or at least minimize contact with her
family, which continued to reside in a poor inner-city
neighborhood. He did not understand the importance
of balancing family connections with individual
achievement manifested in many Latino cultures. Ms.
Hernandez needed to pursue options of how to stay
connected in an emotionally healthy way. The more
Mr. Cutter pressed her to disconnect, the more
depressed she felt.
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Inda Closet had always felt attracted to other women,
but had dated men from time to time because it was
what her parents and society seemed to expect of
her. Concerned about sexuality, fearful of social
rejection, and wondering about how to explore her
sexual feelings, Ms. Closet built up the courage to
consult a psychotherapist and made an appointment
with Heda Knowsitall, Ph.D. After taking a brief
history Dr. Knowsitall informed Ms. Closet that she
was “definitely heterosexual” because “she had a
history of dating men and, therefore, instinctual
drives toward heterosexuality.” Closet was advised to
enter behavior therapy to “unlearn” her attraction to
women.
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Pam Passer, a very fair-skinned African
American, was concerned about just how “black”
she was, given that she could “pass” as White.
Robert Blinders, L.M.H.C., her therapist,
dismissed such concerns, stating that she should
just see herself “as an American.” Passing for
White might give her greater social and
professional mobility, but the price would be
disconnection from her family and the
community in which she was raised. Mr. Blinders
can not seem to hear the implications of the
disconnections for her, as these were not his
values.
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Helena Sistine, M.D., is a psychiatrist and a
conservative Christian who holds deep traditional
values. She works in the counseling center of a
state university. Carl Quandary came in for an
initial appointment and wanted to discuss the
anxiety he has experienced over several
homosexual contacts he has had during the prior
6 months. Mr. Quandary reports, “I don't know
what I'm supposed to be. I want to try and figure
it out.” Dr. Sistine realizes that her own feelings
of opposition to homosexuality would make it
difficult for her to work with Quandary
objectively, especially if he should decide to
continue having sexual relationships with other
men.
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Yochi Tanaka was the eldest son of a proud Japanese
family, who was sent off to attend college in the United
States at age 17. He had some difficulty adjusting at the
large state university and failed midterm exams in three
subjects. Mr. Tanaka sought help at the college counseling
center and was seen by Hasty Focus, M.A., an intern. Mr.
Focus, became misled by Tanaka's excellent command of
English, Western-style fashion consciousness, and
tendency to nod in seeming assent whenever Focus
offered a suggestion or interpretation. Focus failed to
recognize the subtle, but stressful, acculturation problems
or to detect the growing sense of depression and failure
Tanaka was experiencing. Tanaka was apparently unwilling
to assert his concerns over the interpretations of the
“expert” in an impolite or unseemly fashion. After 5
sessions and 6 weeks, fearing failure on his final exams
and disgrace in the eyes of his family, Tanaka committed
suicide.