Complexities of Culture: Opportunities and Ethical ... · # Anderson & Guyton, 2013 (small N study,...

10/1/15

Falender, Bahadur, Zamudio 1

!"

Complexities of Culture: Opportunities and Ethical Challenges

Members of the LACPA Ethics Committee Carol Falender, PhD, Committee Chair

Mudita Bahadur, PhD Anthony Zamudio, PhD

A Multicultural Frame

!"# The generic ecosystemic parameters,

! Migration/acculturation ! Ecological context, !  Family organization ! Family life cycle ! Apply to diverse cultural groups, incorporating cultural

diversity and social justice lenses. Within a postmodern position of not-knowing and curiosity

! Cultural humility

Multidimensional Ecological Comparative Approach ( MECA) (Falicov in Falender, Shafranske, & Falicov, 2014)

10/1/15


!"#  Shared worldviews, meanings, adaptive behaviors, derived from

simultaneous membership and participation in multiple contexts !  language; rural, urban or suburban setting; race, ethnicity, and

socioeconomic status; age, gender, sexual orientation, gender identity religion, spirituality, disability, nationality; employment, education and occupation, political ideology, stage of migration/acculturation, partaking of similar historical moments and ideologies (Falender, Shafranske, & Falicov, 2014)

# Or exclusion from #  Each person has a series of collective identities--groups of belonging,

participation, and identification that comprise ecological niche #  Each individual’s ecological niche shares "cultural borderlands" or

zones of overlap of similarity and difference with others

Ecological Niches and Borderlands

!"# Cultural aspects of presenting problem(s) in this frame # Holistic assessment of family—contexts to which they

belong, resources, strengths, constraints and cultural dilemmas ! However, knowing the context is NOT knowing the family

# Do ask, don’t assume # Exploring health, religious resources that may be helpful-

how those work adopting a “not-knowing” approach…curiosity and respect

MECA

!"# Consider a session in which you share one or more

identities with the client (e.g., religion, age, sexual orientation, gender)

# Consider a session in which you share no identities with the client.

# Discuss each with a colleague—how it affects you, the client, attitudes, relationships

Vignettes

10/1/15


!"# Principle E # 2.01(a) (b) Boundaries of Competence # 3.05 Multiple Relationships # 7.04 Student Disclosure of Personal Information

Ethical Aspects

Mudita Bahadur, PhD

!"# An African American family, consisting of a mother

and teenage son, seek a full assessment. The teen presents with a history of hyperactivity, difficulty paying attention in class, lying, minor stealing from school, and disruptive behavior in class. Teen recently switched schools due to these behavioral difficulties at previous school.

# The assessment case was to be completed by a Caucasian female intern

# What cultural issues need to be considered when proceeding with the case?

Ethics, Diversity, and Psychological Assessments

10/1/15


!"# Selection of assessment battery. What ethical codes

need to be considered? # 9.03 Consent # 9.02 Use of Assessments Larry P v Riles case (1971) banned use of IQ tests by school districts in California for African American children for placement in EMR classes. # 9.01 Multi-setting Assessment # 9.06 Interpreting Assessment Results

The Assessment process

!"# Mother calls Assessor, upset, angry. Requests

a “third party” present at feedback session. # Mother resistant/refusing to hear results # What ethical standards are raised here?

Bringing it Home

!"#  Determine that the matter is an ethical one. #  Consult available ethical guidelines that might apply to

provide a possible mechanism for resolution. #  Consider all sources that might influence the kind of decision

you will make. #  Locate and consult with a trusted colleague #  Evaluate the rights, responsibilities, and vulnerability of all

affected parties #  Generate alternative decisions#  Enumerate the consequences of making each decision. #  Make the decision. #  Implement the decision.

#  (Koocher & Keith-Spiegel, 1998, 12-15)

Ethical Decision Making Models

10/1/15


!"# Principle E – Respect for People’s Rights and Dignity # 9.10 Explaining Assessment Results in a manner that

would be understandable and clinically useful # 2.01 Boundaries of competence # 2.04 Bases for Scientific and Professional Judgments # 9.04 Release of Test Data

Ethics codes reviewed

Carol Falender, PhD

!"# Should a therapist friend a client? # Follow a client on Twitter? # Do a Google search on a client? # Access the client’s Facebook page after the session if the

therapist felt uneasy he/she had inadequately assessed for suicidality?

# Access a client’s blog?

Potential Issues

10/1/15


!"# Things psychologists and social workers reveal on Facebook

! Relationship status !  Email address !  Profile photo ! Religious affiliation !  Political affiliation

#  Anderson & Guyton, 2013 (small N study, 3 states)

Internet

!"# Albert was treating a family, a couple with an adolescent

daughter. After one family session the daughter emailed Albert and asked that he be a Facebook friend to “help her out” with school problems. He agreed, checked and secured his privacy settings, and reviewed his postings. He responded to her every several days, coaching her on social situations. After several weeks, having not revealed this to the family, he decided to do so, and they were angry and upset. Ethical issues?

Vignette 1

!"# Hannah had just begun to see a family with three children under

the age of 15 and was not gaining any traction with the oldest in sessions. She was on the internet and discovered his Facebook site was unsecured so she looked at his friends, his postings, and was shocked to see he was writing about her and how he hated sessions. She was upset and unsure how to proceed.

Vignette 2

10/1/15


1. Why do I want to conduct this search? (Motivation, Rationale) 2. Would my search advance or compromise the treatment? Harm my client or our relationship? Potentially benefit client? 3. Should I obtain informed consent from the client? If not, why not? 4. Should I share the results of the search with the client? How will I use the information? How will I deal with undisclosed duty to warn if it arises? 5. Should I document the findings of the search in the clinical/ medical record? 6. How do I monitor my motivations and the ongoing risk/benefit profile regarding searching?

-Modified from Clinton, Silverman, & Brendel, 2010, pp. 105–107

Ethics Questions for Internet Searching

!"# 4. Confidentiality # 3.10 Informed Consent # 3.04 Avoiding Harm # 3.05 Multiple Relationships # 3.06 Conflict of interest # 10.02 Therapy involving couples or families

Ethical Considerations

!"# A Beneficence and Nonmaleficence # B Fidelity and Responsibility # C Integrity # D Justice # E Respect for People’s Rights and Dignity

How could these inform a response to the vignettes?

Reflect Attending to Principles:

Positive Ethics

10/1/15


Anthony Zamudio, Ph.D. Associate Professor of Clinical Family Medicine

Director, Behavioral Science USC-Family Medicine Residency Program

at California Hospital 1400 S. Grand Avenue, Suite 703

Los Angeles, California 90015 (213)741-1106

[email protected]

!"

Why Psychology in Primary Care?

#  Primary care settings become de facto mental health system !  80% of PC visits involve

some mental health disorder

!  Only 50% will visit a mental health professional

#  Provide a venue for screening, assessment and treatment for ethnic minority populations

!"

Primary Care Behavioral Health

#  Identify, confirm, or refine psychiatric diagnoses #  Clarify salient points of the patient’s history

!  Example: Prior suicide attempts #  But, we have shorter & less frequent sessions

!  30 to 45 initial evaluation !  15 – 30 minutes follow-up visits !  3-4 to 4-6 sessions !  Referrals to mental health settings

#  Integrated Behavioral Health is NOT: !  “Doing the same things, just faster”

# Requires a different mind set & techniques

10/1/15


Different Mindset

# Rather than ask: “Can I see this patient?”

# Reframe the question: “What services can I ethically provide to this patient to maximize benefits and avoid harm?”

Ivey & Doenges, 2013

!"Case #1

# Adult Mexican female: headache, muscle ache, poor appetite, poor & excessive sleep.

# cc: Multiple medical visits with no physical findings # Symptoms began after her mother’s death # In reference to her symptoms, she tells you:

!  “A lo mejor me agarro el susto” # A clinic staff members translates:

!  “The fright probably got me” # She shares without her physician’s knowledge using

multiple herbal remedies.

Names and demographic background information on all cases have been changed for confidentiality purposes

!"Question Case 1

# How would you explain her symptoms? ! To the patient? ! To referring physician?

# What recommendations would you give? # What are the ethical challenges?

10/1/15


!"Cultural Beliefs

# Caution when translating & working with cultural beliefs:

# Translation of patient’s statement: !  “The fright (emotions) probably got me.”

# May imply: !  “Maybe I caught fright (an illness; aka Susto)”

!"

DSM-V: Cultural Concepts of Distress

SUSTO: # A frightening event that causes the soul to leave the

body and results in unhappiness and sickness # Symptoms may appear from days to years # In extreme cases may result in death

!"Susto: Symptoms

# Typical Symptoms: ! Appetite disturbances ! Poor sleep !  Sadness ! Lack of motivation ! Low self-worth or dirtiness !  Interpersonal sensitivity

# Somatic Symptoms ! Muscle aches & pains ! Cold in extremities ! Pallor ! Headache !  Stomach ache ! Diarrhea

10/1/15


!"

Susto: Perception & Recommendations

# Ritual healings are focused on calling the soul back to the body and cleansing the person to restore bodily and spiritual balance

# Medical providers’ attention to the body (i.e. heart & blood functioning): ! Provide physical examinations ! Regular medical follow-ups

!"

Primary Care Behavioral Health Common Ethical Issues APA Codes # Informed Consent (3.10 & 10.01) # Confidentiality (4.01 & 10.02) # Therapy Involving Couples or Families (10.02)

!"

Informed Consent

# Make sure patient understands mental health services involve: ! Assessment, mental health diagnoses, & treatment ! Billing ! Communication includes other medical providers

# Informed consent is not always a one-time event but on-going process especially in primary care.

10/1/15


!"

Informed Consent

Debate vs

Universal consent form ! Consent form is

addressed @ time of patient registration

! One written consent form that encompasses all providers #  e.g. Physicians,

physician assistants, physical therapists, dieticians, psychologists, etc.

Separate consent form ! Addressed verbally by

psychologist @ time of first patient meeting

! A separate written consent form may or may not be presented.

!"Confidentiality

# Communal room ! Curtains separate patient beds ! Visitors @ roommate or patient’s bedside

# Patient care interruptions during session !  e.g. Blood pressure & sugar level checks, medication,

procedures. ! Physician, specialists, & staff drop-ins,

Religious Belief Systems

10/1/15


!"

Case #2: Eclipse of the Son

# Pregnant Latina female medical visit is scheduled during a period of a solar eclipse.

# Mother-in-law demands that she cancel her appointment to avoid birth defect or wear a safety pin and red ribbon to protect her grandchild

# Husband pleads that she wear safety pin/red ribbon. # The patient refuses the demands and pleads, but

feels guilty

!"Case 2 (con’t)

# During your first meeting with this patient you realize: ! Her mother-in-law and husband are also your

patients: #  You treat her mother-in-law for depression #  You treat her husband for stress and anxiety

# What are the ethical challenges?

!"Whole Family Care

# Primary care provides family based medical services to multiple members of the same family !  Same clinic !  Same provider

10/1/15


!"

Context of an Outpatient FHC

# A clinic can average of 1,200 patients per month # 24-health care providers

#  Physicians, physician assistants, physical therapist, dietician, social worker, case manager

# As the sole behaviorist, you may average 30-50 patient contacts per week

!"

Multiple Relationships: Minefield

# Referring medical provider often offer behaviorist only a brief review of patient

# Medical providers’ high volume of patients may not be aware of complex multiple relationships

# Conducting the social history is often when you may discover a multiple relationship

!"

Factors Influencing the Presentation of Ethically Challenging Relationships in Primary Care versus Specialty Mental Health

Whole Family Common Care Delivery Team Based

Care Model Longitudinal Whole Person Pt Volume High

Specialty Mental Health Uncommon

Autonomous

Episodic

Low

Dimension Primary Care

10/1/15


!"References

Ahmann, E. (2013). ADHD Among African-Americans. Psych Central. (http://psychcentral.com/lib/adhd-among-african-americans/00017250)

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

American Psychological Association. (2012). Ethical Principles of Psychologists and code of conduct. Retrieved from

www.apa.org/ethics/code. Blount, A. (1998). Integrated Primary Care: the future of medical and mental

health collaboration. New York: W.W. Norton & Company, Inc. Blount, A., et al. (2007). The economics of behavioral health services in medical

settings: A summary of the evidence. Professional Psychology: Research and Practice, 38, 290-297.

!"

References

Callahan, E. J., Bertakis, K. D., Azari, R., Robbins, J., Helms, L. J., Miller, J. (1996). The influence of depression on physician-patient interaction in primary care, Family Medicine, 28, 346-351.

Clinton, B. K., Silverman, B., & Brendel, D. (2010). Patient-targeted Googling: The ethics of searching online for patient information. Harvard Review of Psychiatry, 18, 103–112. doi:10.3109/10673221003683861

Falicov, C. J. (2014). Psychotherapy and supervision as cultural encounters: The MECA framework. In C. A. Falender, E. P. Shafranske, & C. J. Falicov (Eds.), Multiculturalism and diversity in clinical supervision: A Competency-based Approach. (pp. 29-58).. Washington, DC: American Psychological Association.

Falicov, C.J. (2007) Working with Transnational Immigrants: Expanding Meanings of Family, Community and Culture. Family Process, 46,2,157-172

Hodgson, J., Mendenhall, T., & Lamson, A. (2013). Patient and provider relationships: consent, confidentiality, and managing mistakes in integrated primary care settings. Families, Systems, & Health, 31, 28-40.

Holden, et al. (2014). Toward culturally centered integrative care for addressing mental health disparities among ethnic minorities. Psychological Services, 11, 357-368

10/1/15


!"References

Ivey, L.C. & Doenges, T. (2013). Resolving the dilemma of multiple relationships for primary care behavioral health providers. Professional Psychology: Research and Practice, 44, 218-224.

Reiter, J. & Runyan, C. (2013). The ethics of complex relationships in primary care behavioral health. Families, Systems, & Health, 31, 20-27.

Vogel, M.E., Kirkpatrick, H.A., Collings, A. S., Cederna-Meko,C.L., & Grey, M.J. (2012). Integrated Care: Maturing the relationship between psychology and primary care. Professional Psychology: Research and Practice, 43, 271-280.

!"Resources

# CalMHSA: Integrative Behavioral Health Project ! www.ibhp.org !  A virtual library for those contemplating, planning, or

operating treatment programs in integrate behavioral and medical services

# Sierra Family Medical Clinic: you tube ! The SFMC provide a series of provider-patient

encounters using Integrative Behavioral Health (IBH)

!"Primary Care Resources

# Trauma Resiliency Model ! http://traumaresourceinstitute.com ! Teach skills to working with traumatic stress reactions

# University Massachusetts Medical Center: ! www.integratedprimarycare.com !  Information & tools for the integration of behavioral

health and primary care

Complexities of Culture: Opportunities and Ethical ... · # Anderson & Guyton, 2013 (small N study,...

Documents

Transcript of Complexities of Culture: Opportunities and Ethical ... · # Anderson & Guyton, 2013 (small N study,...