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Therapy in a Rural Community


Donald Strom has been a licensed clinical psychologist in Newark, New Jersey for the past 15 years. Fascinated with Hawai'ian culture, Donald has accepted a position with a family service agency in Lana'i, Hawai'i, a rural island community whose dominant Native Hawai'ian population has been experiencing a socioeconomic transition from a traditional farming community to an increasingly tourist- and casino-driven society. Reports have suggested that this transition has had a critical impact on community mental health, with the result being an erosion of family stability and cohesion. An additional effect has been a fairly rapid shift in values and cultural beliefs as a result of the in-migration of non-native groups. As a result, families appear to be dissolving in greater numbers, there are more identified problems in marital relationships, and there has been a measurable increase in child abuse and neglect rates.

Donald has chosen to practice in Lana'i partly on the basis of his review of national professional journals, some of which have suggested that rural community mental health agencies have a spotty record nationally in the design and implementation of outpatient services for individuals and families in crisis. Donald fervently believes that his practice will cater to the needs of such persons. His mode of therapy, honed over the course of his professional career, emphasizes the use of individual counseling and psychodynamic techniques that promote self-awareness, personal growth, and enhancement of self-esteem. Donald is aware of his newness to the community, and he believes that what he lacks in regional experience is more than made up for by his filling a critical gap in mental health services. His attitude is inspired by the APA Code’s Principle D (“Justice”), which suggests that psychologists have a duty to make known to underserved communities the benefits of psychological services, including therapeutic knowledge and skills.

 Donald enthusiastically embraces other ethical standards and professional values of clinical psychology, specifically with regard to the need to promote client well-being and self-determination (APA Code Principle E, “Respect for People’s Rights and Dignity,” and Principle A, “Beneficence and Nonmaleficence”), and he believes that his practice methods are consistent with these standards. He is also aware, however, that the APA Code advises psychologists to receive the training and experience, necessary to ensure the cultural competence of their services (Ethical Standard 2.01a, b, and c, “Boundaries of Competence”). Donald hopes to acquire this cultural competence as he engages in practice, but also believes that, in light of the demand for services, he has much to offer right away as an experienced therapist.

 Shortly after the opening of his office in Lana'i, Donald meets Mrs. Kanahele, a 62-year-old retired schoolteacher, who complains of sadness and “nerves,” symptoms she attributes to her husband’s alcoholism and her “family history” of depression. In addition, she is upset about her teenage grandson, who lives with her and her husband and has become increasingly angry and “out of control” in recent weeks. Mrs. Kanahele desperately wants help to deal with her situation. What decisions should Donald make about his intervention?

 This case example suggests that Donald, despite his best intentions, simply may not yet be in a position to practice reasonably competently. Clearly he has adopted a practice methodology during his years in Newark that he has applied successfully for some time. However, despite his superficial acknowledgment of the APA Code’s areas of guidance, Donald now seems prepared to apply his practice technique in a new and culturally distinct community. Moreover, he may be ready to do so without a significant understanding of regional norms and the cultural viability of his technique—a mistake that would seem to be directly at odds with the standard of care mandated by the duty to practice reasonably competently. Donald frames his position largely on the basis of his years of experience and a basic confidence in the value of his own professional experience. As noted, Donald means well; he has sought ethical guidance from the APA Code of Ethics and examined the standards previously outlined. Indeed, Donald may even feel conflicted when he attempts to apply the blizzard of ethical directives outlined above. As a result, he may offer his psychotherapeutic services to Mrs. Kanahele with the expectation that the exchange between client and therapist will serve as a cultural learning experience for both. Unfortunately, Mrs. Kanahele probably has no personal need to be sought after as merely an educational opportunity for her therapist.

 In this case, the legal duty to practice reasonably competently directs specifically that Donald assume the responsibility to practice as a fully informed clinical psychological would in Lana'i, Hawai'i. This principle outlines a number of burdens that Donald has to meet before implementing a practice strategy, and Donald must understand that these legally defined burdens supersede the broad ethical considerations outlined above. First, in order to competently assess Mrs. Kanahele and determine the appropriateness of a practice intervention, Donald must be familiar with his client’s family background, cultural worldview, and the nature and quality of her relationships with her family and community. Second, Donald has the obligation to be familiar with literature and research outlining practice strategies appropriate for populations living in rural Hawai'i. In performing this research, Donald is likely to learn that socioeconomic change in this area has a direct relationship to family and marital dissolution and may be a critical predictor of client well-being. Moreover, Donald is likely to learn that individual psychotherapy—Donald’s practice modality throughout his career—is likely to be less successful with regional populations than family counseling, a practice approach that Donald may be uncomfortable with and unprepared to provide. Nonetheless, the literature indicates that a psychodynamic approach, the treatment modality Donald has been most familiar with, may simply be wrong for this client. Rather, the importance of incorporating traditional Hawai'ian culture into mental health programs is underscored here. Unlike the western, psychodynamic structure of the human psyche, traditional Hawai'ian custom views wellness as dependent upon personal mana (spirit), and regards illness as a loss of mana resulting from a lack of pono (balance or harmony). Therefore, the Hawai'ian perspective emphasizes that when one become ill, treatment must be applied to restore balance with emotional cleansing—Ho 'opono pono (to correct or set things right, in order to remove mental obstacles to healing). This model is supplemented by the suggestion that in view of the link between socioeconomic change and community mental health, psychotherapists must work to combine social advocacy with clinical expertise to ensure a continuity of care.

 If Donald applies the duty to practice reasonably competently first in his evaluation of practice choices, he must be prepared to offer culturally and regionally appropriate practice techniques at the commencement of therapy. Even if a pressing need for services exists, regardless of whether Donald’s intentions are ethical and sincere, reasonably competent practice suggests that a practitioner who has not yet acquired the ability to provide appropriate services should not offer any; nor should he provide a client with services from which she is not reasonably likely to benefit. With this in mind, Donald must seek alternatives to his initial plan of action consistent both with the reasonable competence standard and the ethical guidelines cited earlier. This may even mean declining to treat Mrs. Kanahele and instead referring her for services that include culturally competent family based therapy.

 Is the practice choice suggested by this discussion overly harsh? Should no avenue be left open for Donald to acquire the skills necessary for him to grow competent in his use of culturally competent treatment strategies? How does the reasonable competence standard help Mrs. Kanahele immediately? The answer to all these questions depends on whether the professional believes Mrs. Kanahele is better off being exposed to individual psychotherapy—even if it is not ideal for her needs—than to have no assistance at all. In this scenario, the duty to practice reasonably competently promotes the principle that the professional should “first do no harm.” This canon is one of many that find more protection in the law than in ethical codes. (Were Donald to review more thoroughly the APA Code, he would in fact uncover a provision addressing this issue, Ethical Standard 3.04, “Avoiding Harm”; its place alongside competing standards, however, together with its broad scope, makes it difficult to identify and apply as a first step in this scenario.)