Transcript Ethical Issues Emphasized in Trauma Work

Ethical Issues Unique to
Intervention with Victims of
Trauma
“Understanding & Responding to Violence & Trauma”
Inaugural REACH Conference
May 20, 2014 (9:00 – 10:30 am)
John A. Mills, Ph.D., ABPP
Goals for the Session
• At the end of the time, participants
should be able to
– Describe the ethical issues that are most
likely to be magnified in working with
victims of trauma.
– Apply ethical issues to practical dilemmas
faced while conducting interventions
a little about the presenter . . . .
[email protected]
training, experience, current position
orientation to the work
conflicts of interest ? ?
Ethical Acculturation
Gottlieb et al (2008)
– Focus on well-being and minimizing risk rather than
rules
– Part of a way of being – “Who should I be?”
– Best practices rather than avoiding discipline
What’s the plan, Jan?
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Describe an approach to ethics
Outline fundamental ethical principles
Define trauma
Examine some areas of ethics that are more
salient in working with victim
• Not conceptually linear
Some words
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therapist, practitioner, person who intervenes?
Client, victim,survivor, patient?
Trauma, abuse?
Law, Ethic, Principle
• no need to repeat epidemiology, but important to
remember that a 2003 estimate from the National
Center for Injury Prevention and Control (NCIPC)
indicated that more than 25 million US women have
experienced interpersonal violence during their
lifetime
• Significant public health problem with long-term
and short-term negative health consequences
• Estimated to cost 5.8 billion per year
Trauma?
• Assault on body, feelings, thoughts – most
broadly construed.
• Combination of the toxicity of the
stressor, individual vulnerability of the
victim, the quality of the posttraumatic
environment for healing
• Treatment must go beyond “health care”
Fundamental Ethical Principles
• Autonomy – fostering the right to control one’s life
• Nonmalefescence – avoiding actions that might cause
harm
• Beneficence - working for the good of the individual and
society by promoting health and well-being
• Justice– treating individuals equitably and fostering
fairness and equality
• Fidelity – honoring commitments, keeping promises,
fulfilling one’s responsibilities of trust in professional
relationships
• (Veracity) – being truthful
Autonomy
• Principle: fostering the right to control one’s life
(not the same as promoting a stance with respect
to a specific social group or position)
• Applications/Examples:
– Careful and sensitive informed consent process
– Assisting clients to evaluate the implications of their
decisions in the context of their personal goals
Nonmalefescence
• Principle: avoiding actions that might cause
harm
• Applications/Examples:
– Refraining from conducting activities that exceed
one’s competence
Beneficence • Principle: working for the good of the individual
and society by promoting health and well-being
• Applications/Examples:
– Selecting interventions that are best suited to the
challenges at hand
Justice–
• Principle: treating individuals equitably and
fostering fairness and equality
• Applications/Examples: assisting person seek
service independent of their ability to pay
Fidelity
• Principle: honoring commitments, keeping
promises, fulfilling one’s responsibilities of trust
in professional relationships
• Applications/Examples:
– Investigating a question that you said that you would
learn about
– Listening, really
Veracity
• Principle: Being truthful
• Applications/Examples:
– Honest depiction of your credentials
Basic Moral Principles Applied
General Moral Principle
Ethical standard/implementation
Respect for autonomy
thorough informed consent procedure
respect for unique cultural position for
trauma
Beneficence
selecting techniques
Nonmalefescnce
respect need for pace of change
Fidelity: keeping promises
Privacy
Development of Ethical code
• codes of ethics emerged strongly after World
War II in association with the rapid increase in
services for war veterans
• American psychological Association adopted a
code of 1952, Canada followed shortly
thereafter
• ACA - 2014
• Legislation & Case law
Two Major Codes
APA Code
ACA Code
1. resolving ethical issues
I. Resolving Ethical Issues
2. competence
A. The Counseling Relationship
3. human relations
D. Relationships with other professionals
4. privacy and confidentiality
B Confidentiality & Privacy
5. advertising and other public
statements
H. Distance Counseling, Technology, and
social media
6. record-keeping and fees
C. Professional Responsibility
7. education and training
F. Supervision, Training & Teaching
8. research and publication
G. Research & Publication
9. assessment
E. Evalation, Assessment & Interpretation
10. therapy
What are the major areas of emphasis?
• Informed consent
• Dual Roles/Boundaries
– Therapy-advocacy
– Virtual relationship
• Competence
– Trauma scholarship
– Trauma intervention
• Media
• Ethical conflicts
Essential elements of informed consent
• Diagnosis
• Purpose of proposed treatment / procedure
• Possible risks and benefits of proposed
treatment / procedure
• Possible alternatives to proposed treatment /
procedure
• Possible risks of not receiving treatment /
procedure
Dual roles/boundaries
• Avoided or impact minimized
• Activities consistent with roles (therapist v.
advocate; therapist v mediator)
• Individual v family intervention
• Social relationships
• ACA & Virtual relationships
Boundaries - Framework
• Holding environment
– Shark cage; Mona Lisa
– Vulnerability of client – distinct from fragility
– Plan with client and for client
• Interaction with Informed Consent
Truthfulness
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Professional qualifications
Results of assessment
Risk/benefits
Communication with others
Truthfulness v Completeness
Competence
• Know law and ethics about trauma and where to
learn more and consult
• Implications of training, experience, supervision
• Use of novel techniques
• Freedom from denial about trauma
epidemiology & phenomenology (e.g. recovery
trajectory)
• Interaction with other professionals
areas of additional competence
• individual client experience ( assessment)
– Conceptualization
– Diagnosis
– Cultural issues (we’ll get to that)
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Treatment methods
Suitability of methods for individual Client
Quality of participation in supervision/collaboration
self-awareness
pertinent laws and ethics
risk of re-traumatization
vicarious traumatization of the therapist
Competence & Seasoned Practitioners
• Heard it all
• Not noticing depth or breadth of impact –
retraumatization via abandonment
• Active continuing attention to the issue through
career
Competence & Termination
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Maintenance of therapeutic relationship
Proactive consideration of ending
Clients may terminate prematurely
Significant reflection phase
Vulnerability to abridge the process
Therapist Risk of Vicarious Trauma
• VT happens when therapist perspectives and
beliefs become altered by repeated and
prolonged involvement with Trauma of others
• May interact with therapist’s own trauma
experiences.
• Significance of Boundaries
• Symptoms possible in all systems
Media
• Responsibility for public statements
• Any media
• Appropriateness of public claims – precision,
privacy
• Appropriate specification of professional
relationship
Trauma and Informed Consent
• IC associated with risk of retraumatization –
client AND practitioner factors
• True informed consent?
Informed Consent –
• important to be clear about the treatment
experience
• nearly impossible for the client to have adequate
perspective on the enterprise
– Honesty about the difficulty of therapy
– Careful description of goals and methods
– Limitations of therapy
• more complicated when LAR is giving consent
Informed consent – readiness for work
• plant readiness to begin processing trauma
• Status of coping skills-effectiveness, flexibility,
resources, no additional processes (e.g. practical)
• Wants to do the work
• Not engaging in acting out that impairs coping
(substances, violence, etc.)
• Not lethal
• History of treatment experiences
• Tolerance of regression
Evolution of Consent
• consent has to be a dynamic process
– Evolution of client emerging experiences
– Change in client circumstances
– Response to interventions
• any other change from the assessment of
readiness to work
Culture
• cultural imperatives
• Connection between ethnicity and ability to discuss personal
experiences, particularly traumatic ones
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Choice
Control
Empathy
Respect
• ethnicity and perception of trauma - connection to coping
and coping environment
• Do do not assume that openness fits the context, and the
reality of this must influence goals and processes
• Gender as a particularly significant dimension of difference
Can Soft universalism work for you in
diversity?
• Clarify values through respectful dialogue-work
to see it through their eyes• better to clarify at the beginning
• can be difficult
• Is there flexibility
• where does trauma fit
• Need for consultation
• Personal reaction
Beauchamp and Childress (2001) process for
when moral principles conflict
• the option that one chooses should:
– uphold the most salient moral principle ( if there is
reason to act on one as opposed to the other)
– have a realistic chance of success
– used if no morally preferable options available
– infringe the offended normatively as possible extent
( consistent with primary aims)
– minimize the negative effects on the offended moral
principle
Ethical Decision- Making (Knapp)
• Identify salient moral principles – all of them
• Could any/do any conflict?
• Identify options & evaluate the primacy of one
moral principle over the other
• If necessary, minimize the negative effects from
infringing on the offended ethical principle
Intensity and Ethical Decision-Making
• Adapted from Lincoln and Holmes (2010)
– Moral Awareness
– Moral judgment
– Moral intention
• at each step, there are two types of questions
– directly related to the step
– Consideration of situational factors
Lincoln & Holmes:
Moral Awareness
Moral awareness questions
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Is anything wrong here?
Is a person, community, or ideal at risk to lose dignity, respect, or liberty?
Might a moral principle be violated?
Are competing values at work? Individual versus community? Justice versus Mercy?
Truth versus loyalty? Short-term versus long-term?
5. Do I find myself at odds with a standard to which people that I respect adhere?
Situational Questions
1. Would my peers detect a moral dilemma in this situation? < Who are peers?>
2. How would their opinions influence my moral awareness? < Social consensus>
3. is there a standard of care that can be determined?
Lincoln & Holmes: Moral judgment
questions
moral judgment questions
1. is the probable decision fair or unfair?
2.Is the probable decision just or unjust?
3.Was the decision morally right or morally wrong?
4.With the decision be acceptable to my family and friends?
5.With a probable decision be in line with the culture and
traditions of trauma intervention
6.Does the decision violated promise or code that is
important in the intervention community
Lincoln & Holmes: situational questions
related to Moral judgment
1. is the probable decision fair or unfair?
2. Is there a standard of care?
3. what would my professional peers think about the potential
consequences? How would their opinions affect my moral
judgment? (Social consensus)
4. What is the extent of the harm or benefit that occur from
the decision?
5. How does the magnitude of the possible consequences
influence my moral judgment? (Magnitude of consequence)
6. What is the likelihood that the possible outcomes and the
harm or benefit from those outcomes will occur in the
situation? How does this probability affect my moral
judgment? (Probability of effect)
Lincoln & Holmes: Moral Intention
Questions
• what do I think I should do? Must what do I
think I should do?
• Do I intend to act in my decision?
• What is my intention?
Moral Intention Questions
• What would my peers think about the potential
consequences? How would their opinions affect
my moral intention? (Social consensus)
• What is the likelihood that the possible
outcomes and the harm or benefit from those
outcomes will occur in the situation? How does
this probability affect my moral judgment?
(Probability of effect)
moral action questions
• do/will I follow through in my intention?
• What may prevent me from acting on my
intention?
• What may aid me in following through my
intention?
• Would my peers act on their decision?
• How does their potential election influence my
behavior? (Social consensus)
Disobey the law?
• if I disobey the law, how can I limit my disobedience to
the minimum necessary to fulfill my higher goal?
• Seek consultation to ensure that the law requires what
you believe it requires. – ignorance is not a defense
• Make sure that you understand the relevant ethics
• Can you follow the law and uphold values
• How should I act to support the events the most relevant
virtue?
• Documentation
Selected References
• Becker-Blease, K.A. & Freyd, J. J. (2006). Research participants telling the
truth about their lives: The ethics of asking and not asking about abuse.
American Psychologist, 61, 218-226.
• Beauchamp, T., & Childress, J. (2009). Principles of biomedical ethics. (5th ed.)
New York: Oxford University Press.
• Goldsmith, R. E., Barlow, M.R. & Freyd, J.J. (2004). Knowing and not
knowing about Trauma: Implications for therapy, Psychotherapy: Theory, Research,
Practice, Training, 41 (4), 448-463.
• Knapp, S., Gottlieb, M., Berman, J., Handelsman, M.M. (2007). When Laws
and Ethics Collide: What should psychologists do? Professional Psychology:
Research and Practice, 38, 54-59
• Lincoln, S. H. & Holmes, E. K. 2010). The Psychology of Making Ethical
Decisions: What Affects the Decision? Psychological Services, 7, 57-64
• Younggren, J. (2007). Competence as a process of self-appraisal. Professional
Psychology: Research and Practice, 38, 515-516.