Confidentiality after a client’s death

Here’s an interesting case scenario that was presented in an ethics textbook as an example of an ethical dilemma. You’ll find rather quickly that it has a simple legal resolution:

You are employed at a community mental health center and delivered services to a client. The client has been killed in an altercation at a local tavern. A reporter for your town’s newspaper seeks you out for information about your client because there have been rumors that your client had a history of violence and had been abusive to his wife and children. The reported wants to know if this is true because, if it is, it may have some relevance in assessing the guilt of the person who killed your client. Should you cooperate with the reporter?

Of course not! The law of confidentiality requires that a client’s confidences be maintained even after the client dies in the interest of protecting the client and his family. This simple case dilemma, like many of those presented on this blog, presents a legal problem that can be resolved by applying the duty to keep a client’s confidences unless a legal exception (the client threatens violence to himself or others, for example). Please read this website’s discussion about confidentiality for more information about confidentiality.

Comments on this scenario are invited!

The duty to report sexual abuse

I recently came across an astounding scenario in a standard ethics textbook. I use the term “astounding” because it presents an example of a clear, legal problem that is in reality not an ethical dilemma at all! I’m going to paraphrase the dilemma as follows:

You are a mental health professional conducting research concerning family relationships involving at least one minor child. As part of the research design you interview each family member personally. You also interview the family as a unit. During one such interview, with Mary, a nine-year-old, she tells you that her fifteen-year-old sister, Clara, has sex with her stepfather, Igor. What would you do?

The answer is clearly driven by the law. Most states impose a duty on members of the public to report suspected child abuse, including sexual abuse. Even if it were not a state-imposed requirement, the legal duty to practice reasonably competently as a mental health professional–as discussed in this website– demands reporting of the incident.

Comments are invited!

Does “counseling out” students from university programs violate their constitutional rights?

Please consider the following fictional scenario: Dr. Dolores Hickey teaches psychology at a public university in Amherst, Massachusetts. At a monthly faculty meeting with her colleagues, she �staffs� students, meaning that she identifies those who appear to be having major academic issues, personal problems interfering with their educational progress, or other difficulties. Dolores, a licensed clinical psychologist, has much experience in the diagnosis and treatment of mental disorders and brings this knowledge to her classroom interactions with students. Her classes tend to be �hands-on,� with students encouraged to achieve self-awareness by sharing personal issues with the class. She regards this classroom exercise as an important aspect of the use of reflective insight in psychology, a task encouraged by some professional educators. At the most recent student staffing, Dolores discusses Wanda Moreno, a second-year master�s student and the daughter of Puerto Rican immigrants to the U.S. Wanda, according to Dolores� description, is a �C� student and has looked �overwhelmed� in class for the last four weeks. She sits silently, never participating in class discussions, and, additionally, she looks �withdrawn and depressed.� Although her class papers have been submitted on time, they are sparsely written and lack self-disclosure, a specific requirement described in the course syllabus. Wanda has declined all of Dolores�s requests for a meeting to discuss these observations, and Dolores now seriously questions Wanda�s emotional maturity and appropriateness for psychology practice. She seeks her colleagues� advice on whether Wanda should be �counseled out,� a process by which university faculty and administrators deliver a strong, personal recommendation to a student to withdraw voluntarily from their degree program. This scenario represents a classic and unfortunate example of a threatened interference with fundamental constitutional rights by a state actor under color of law. The fundamental rights involved here concern Wanda�s personal privacy and self-expression, both liberty-related privileges recognized under the First and Fourteenth Amendments. Wanda�s personality, her manner of personal expression, and her attitude toward Dolores are her own business until such time as the state actors�university faculty members and administrators�can present a compelling reason for interfering with them. A compelling reason here would need to be grounded in the university�s important public responsibilities, which include the training of competent psychologists and the maintenance of an orderly and safe classroom environment in which to perform that task. In the absence of any showing that Wanda�s behavior either violates the university�s academic standards or interferes with classroom decorum or the rights of other students and faculty members, no compelling reason exists to address Wanda�s behavior. Even assuming that Wanda�s behavior suggests clinical issues�a conclusion that is as yet highly suspect�the evaluation that Dolores appears to be offering is not reasonably related to her role as a psychology educator. Rather, it threatens to use the power differential between professor and student to impose clinical assessment and �treatment� on an involuntary client. In this respect, the scenario raises clear informed consent issues. In constitutional terms, Wanda has a liberty-related right to remain free from arbitrary counseling. This case example can be understood alternatively as an equal protection dilemma. The school�s counseling out of Wanda�the state action performed by Dolores and her colleagues�can be regarded as a classification based on Wanda�s fundamental right to privacy and self-expression, as discussed earlier. The foregoing constitutional review of Wanda�s case is not intended to suggest that a student�s communication can never be interfered with or classified by a public university. The grading of examinations and papers is one such example of a classification. In contrast to the categorization attempted by Dolores in this case example, however, grading is reasonably related to the university�s essential purpose, and uses uniform standards that keep students more or less on an equal footing. Students� performance in field practicum and clinical training placements may also require faculty evaluations that grade students on the basis of their communications with clients and co-workers. Here again, however, such evaluations must be narrowly tailored to serve the limited purpose of evaluating student competence objectively in specific tasks. The use of due process and equal protection analysis was described earlier as a means of promoting diversity. The present case example offers a compelling demonstration of this point. In cross-cultural professional relationships, diverse communication styles may sometimes be inappropriately labeled as a failure�often by a minority student�to conform to expectations. By strongly discouraging this type of labeling, the duty to treat clients with due process and equal protection offers specific protections to all recipients of government services, including students. Moreover, recognizing the applicability of due process and equal protection can help to discourage the use of speech based classifications as a proxy for more odious categorizations, such as those based on race and ethnicity. The present case example also raises interesting procedural due process concerns. In the scenario, Wanda plainly has a property right associated with her education. It cannot be regarded as fundamental, because no constitutional protections�either federal or state�have yet recognized the right to an advanced professional education. Wanda�s property right is protected, however, by procedural due process. In her situation, the counseling out process may be used�either intentionally or not�as an informal, less confrontational form of gatekeeping, i.e., the process of determining the eligibility of entrants into the behavioral health professions. When it is practiced in the manner described in the present case example, it serves to eliminate the procedural rights that a public university student should have, including notice of the reasons justifying formal disciplinary action and an opportunity for a hearing. The faculty�s �request� to a student that she withdraw from classes under the circumstances presented is not much different from a police officer�s �request� to enter the home of a person having a loud party. Both requests take advantage of a position of authority, and both may be intended to accomplish a specific end without formal process. Wanda�s dilemma offers vital guidance to decision makers considering the impact of constitutional protections on practice problems. As the case example suggests, mastery of the principles underlying due process and equal protection offers decision makers practical assistance in the consideration of critical, cross-cultural practice dilemmas. Moreover, Wanda�s case demonstrates that a client�s right to life, liberty, and property has concrete implications in all elements of behavioral health practice.

Informed consent and reasonable competence in faith based therapy: an example of an unacceptable mental health practice approach

Here’s an example of an excellent question concerning a case example from the world of practice that was posted on a social work listserv. A response is posted below it. Other comments would be appreciated. “Social Workers are expected to use evidence to support our practice. What if the agency with which we are employed bases intervention practices on belief and dismisses the evidence that disputes the agency intervention practices? An example would be a mental health agency that has as a focus ‘rehabilitation’ of homosexuals based on the belief that homosexuals are barbarians that must be disciplined, educated, etc. What are the ethics of this for a social worker employed as a counselor with the agency?” Response: This is a great example of a dilemma that is plainly addressed by using a cross-disciplinary, law based decision making framework, such as the one promoted on this website! The practice of “reparative” therapy simply is not in conformance with reasonable competence and informed consent-related principles, which are both basic legal doctrines. As I’ve already said, I think a law based analysis is in order. The law of informed consent requires all agencies — including faith based inititatives — to explain the risks and benefits of all available services and/or treatment approaches — to their clients; this includes alternative approaches that the agency does not advocate, and also includes a full discussion of the risks of the services the agency does offer. If you’re thinking that this means a lot of agencies out there are in violation of the law of informed consent by not including full disclosure, I agree with you! I think that in the case of faith based approaches, the intervention can only be lawfully used if it is safely within the realm of a reasonably competent practice — in other words, if prudent mental health standards would consider it to be safely applied and the client can therefore reasonably and voluntarily agree to receive it. Even then, the risks and benefits of the procedure must be fully explained. Even with full disclosure, if the intervention is so inherently dangerous that the it violates basic principles of prudent mental health practice, the practice is not reasonably competent.

Do ethical codes have an urban bias?

Consider the following vignette: A licensed, certified professional counselor, Robert Wu, observes an elderly client, Harry Driscoll, in a local coffee shop in Smith River, California, a small, rural town in which both the counselor and the client live and work. Harry invites Robert to have a cup of coffee with him at a local coffee shop, which serves as the �watering hole� for the town�s population. What should Robert do? Following the decision making framework presented on this website, Robert recognizes no law that specifically forbids this type of socializing. Persuaded that a review of applicable ethical standards would supplement his legal analysis, Robert uncovers NBCC Code Sections A8, A9, and B9, which warn licensees to avoid dual relationships that may harm or impair professional judgment. Whether there is actually such a risk in this scenario may depend in some measure on the cultural and regional traditions of the people in Smith River, where Robert and Harry both live and work. Therefore, in this scenario Robert would be wise to consider the application of these ethical standards in the cultural context of the community. If the type of social encounter Robert and Harry are sharing is the norm, as it might be in many small towns, than the risk of harm or exploitation would seem to be low or non-existent. In fact, refusing to engage in a reasonably innocuous social encounter would appear to do little to interfere with the clinical relationship Robert and Harry have experienced, and might actually do more to harm the positive results obtained during the pair�s counseling sessions. It is interesting to note that a version of this practice scenario seems frequently to appear in ethics treatises, often with an author�s suggested resolution supporting the notion that professionals and clients should strictly keep their social distance in the interest of avoiding the creation of a dual relationship and blurring the professional boundary. This conclusion seems to be based on an overly rigid, formal, and urban slant that some treatises appear to adopt. The discerning professional more appropriately should engage in the type of analysis applied in this vignette, which explores the possibility that professional choices must be based on, among other things, a consideration of regional and social context. In this scenario, the fact that Robert could find no direct law impacting his decision to have a brief social encounter with Harry probably provides an important clue that one ought not to assume that any such encounter necessarily violates the best interests of the client; the absence of law here signals the need for contextual analysis rather than a search for consistency among hazy ethical standards.

Mental health research and legal decision making

Consider the following fictional scenario:

Patricio Ortega, an adjunct research professor at a university school of psychology, is undertaking scientific study to survey the presence of anxiety spectrum disorders within a population of elderly persons representing various demographic groups in a multicultural community in Miami, Florida. As part of the study, Patricio will conduct interviews with community members and distribute several assessment instruments commonly used by mental health professionals to identify anxiety disorders. Following completion of the research, treatment is to be offered as necessary to study participants at the university’s mental health clinic. Consistent with federal policy, Patricio has prepared an informed consent form in English and Spanish that outlines the benefits and risks that are expected from the research. He has obtained informed consent forms from a self-identified population of 75 Cuban-American immigrant participants (of whom 35 are monolingual Spanish speakers), 20 Non-Hispanic Whites, and 5 Native Americans.

Undertaking human subjects research is a potential minefield for mental health professionals not entirely familiar with the boundaries of informed consent. As already noted, federal policy has been developed to extend informed consent protections to human research participants, and it requires the establishment by research institutions, such as universities and medical facilities, of institutional review boards (IRBs) to monitor the satisfaction of informed consent. It is important for the researcher to know and apply the rules of informed consent discussed here in addition to relying on the IRB process to confirm the researcher’s compliance with these principles. The reason is that understanding the broad dictates of informed consent generally provides better, overall guidance for the researcher than do the confusing and sometimes contradictory internal standards adopted by state and private institutions for the review of research proposals. Often, this review is undertaken by an insular group—the IRB membership—lacking the time to give research proposals significantly more than a minimal examination for compliance with the federal regulations cited above. Indeed, psychological testing proposed at even renowned research institutions is occasionally prone to insufficient review.

One of the most prolific dangers connected with institutional research concerns the failure to fully advise already mentally ill participants of the risks posed by the research. For example, in some research the testing of mentally ill subjects may exacerbate symptoms; in other instances the questioning of those who have had mental disorders in the past may promote a relapse of the earlier symptoms. Moreover, an inadequate research design, including the use of instruments whose cross-cultural application has not been demonstrated, may lead to the over- or under-reporting of mental health symptoms by subjects who simply do not understand the questions being posed. If clinical services are then offered to test study participants, some may ultimately agree to an unnecessary intervention. In other words, the satisfaction of informed consent depends upon a culturally competent research design.

What do these issues reveal about how Patricio should undertake his research study? In this case example, Patricio must have his research proposal evaluated by the university’s IRB to assess the anticipated risks of the research, the expected benefits, and the quality of the informed consent that has been sought. However, even if the IRB approves Patricio’s research design he still must take reasonable steps to verify the cultural and regional appropriateness of his methodology. Additionally, he should implement such procedures as are necessary to ensure that the risks and benefits of participation are truly understood. This may present a significant problem when subjects are frail or vulnerable, where language or literacy barriers exist, or when cross-cultural communication may influence the expectations of the participants. At the very least, Patricio must be mindful of the presence of anxiety, PTSD, and related disorders among immigrant populations and understand that his research format must account for the risk of retraumatizing participants. This is especially true in the light of evidence suggesting the experience of cognitive and memory difficulties that may be present in PTSD sufferers.

In this scenario, in order to ensure that study participants actually understand the risks and benefits presented by the research, Patricio and his staff must be willing to dialog with study participants before, during, and after the undertaking of the research. This multistep process promotes issue clarification and absolute support of the participants during the stress of the testing. Should Patricio and his staff choose instead to rely simply on the dissemination of an informed consent document at the commencement of the testing, this will almost certainly violate both the letter and spirit of informed consent, especially when the form may be nearly unintelligible to participants who are elderly and lack significant formal education. Even if participants cannot understand the form, the avoidance of verguenza and deshonra (shame and dishonor, respectively) may well lead those reading the form to claim understanding even when they do not understand it. For these reasons, Patricio should consider the use of trained, multilingual clinical assistants who are available to provide ongoing support and psychological reinforcement to study participants and who can facilitate the discussion of questions that study participants may have throughout the undertaking of the research.

Patricio must also be prepared to ensure the voluntariness of his participants’ involvement. Where Patricio has advised prospective study participants that he is prepared to offer clinical aftercare services to them, both their voluntary consent to the research and the integrity of their responses to test questions are questionable; stated simply, the possibility of aftercare may unduly influence participants to take part in the study.

An additional informed consent problem is caused if study participants ultimately accept Patricio’s offer to provide clinical services to them; specifically, the link between the research and the services raises a question as to whether the services have actually been sought voluntarily rather than driven solely by participation in the research. Furthermore, Patricio’s own involvement in the research may limit his ability to obtain informed consent for his clinical work with participants. The reason is that his willingness to provide treatment is at least partly grounded in his professional interest in the research study, including the scholarly publications and potential financial remuneration that may result. The effect is to create a conflict of interest that may influence the treatment stance he takes with his future clients; at the very least, it threatens the independence and reliability of the clinical services and therefore compromises his clients’ best interests. This type of conflict is a risk that all research participants—and prospective clients—need to understand.

For the foregoing reasons, Patricio best obeys the principles of informed consent if he refrains from offering any clinical services to research participants and instead seeks an alternative means of providing this care. Additionally, his conflict of interest should be explained to all participants in the research study at the commencement of the research. As a safe approach that honors the letter and spirit of informed consent, Patricio may wish to dissociate himself entirely from the aftercare program, leaving the provision of clinical services to a therapist not directly involved in the research.

Sexual relationships with mental health clients

Some social alliances are so inherently destructive to the professional relationship that they are defined as malpractice, as in the case with sexual associations between psychotherapists and their clients. In some states, this kind of behavior is criminalized. Sexual relationships between other health and human service professionals, e.g., social workers, physicians, nurses, and attorneys, are somewhat more complicated to analyze because the purposes of these professional relationships are not as immediately and irreparably harmed by inappropriate sexual behavior as the psychotherapeutic bond is. Nevertheless, if one performs a thorough conflict of interest analysis, any sexual relationship with a client would appear to compromise the professional’s ability to deliver services objectively and be so inherently coercive as to substantially interfere with the client’s ability to consent voluntarily to the professional relationship. This is the position adopted by the NASW, APA, and NBCC Codes. Social workers, for example, are admonished in the NASW Code’s Ethical Standard 1.09a, “under no circumstances to engage in sexual activities or sexual contact with current clients, whether…consensual (or not).” Similarly, the APA Code (Ethical Standard 10.05) warns psychologists not to engage in “sexual intimacies” with current clients. Finally, counselors are advised flatly in the NBCC Code (Section A10) that “sexual intimacy” with clients, together with physical and romantic intimacy, is unethical. These clear standards may be the most binding and enforceable in all three ethical codes, a fact reflected in data suggesting that sexual misconduct accounts for the most instances nationally of disciplinary actions by licensing boards against behavioral health professionals. The treatment of sexual misconduct through license revocation proceedings alone has an important flaw: A mental health professional who has lost a license through sexual misconduct without further consequences can conceivably continue to practice as a therapist in some states simply by using a practice designation that is not regulated by law, i.e., by calling oneself a “psychotherapist” or “lay therapist.”

Providing services to clients with whom a past sexual liaison has taken place has the strong potential for undermining the professional relationship. The legal conflict of interest analysis suggested here should lead the decision maker to conclude that this kind of situation blurs professional boundaries, threatens exploitation of the client, and compromises the ability of the provider to offer reasonably competent behavioral health services. For this reason, ethical codes take a strong stand against the provision of clinical psychotherapy services to partners of a past sexual relationship (see, e.g., the NASW Code’s Ethical Standard 1.09d and the APA Code’s Ethical Standard 10.07), but only in the case of psychologists does the APA Code plainly require that the provision of psychotherapy services to such individuals is absolutely ruled out. No such prohibition is imposed against counselors in the NBCC Code, nor does it seem to apply to social workers not engaged in psychotherapy. Considering the fact that counselors and social workers frequently engage in such diverse fields as school based counseling, agency administration, program development, community organizing, and other human services not involving direct clinical interaction, this interesting omission leaves the behavioral health professional without specific ethical guidance covering this practice situation. Here again, the decision maker is urged in such contexts to complete the conflict of interest analysis outlined in this section.

Engaging in sexual liaisons with former clients also raises significant conflict of interest questions. In this circumstance, the professional relationship technically has terminated before the commencement of the sexual association. Here, however, there exists a profound risk to the former client that the lingering impact of the prior professional relationship may be used coercively as a means to manipulate the person into the sexual affiliation. This danger is especially acute when psychotherapy has been provided. In such cases, the intense professional relationship that existed during the formal treatment phase has a permanent effect on the continuing mental health of the client. Therefore, the progress the client has made may be jeopardized if the relationship with the past therapist becomes inappropriately personal. Viewed in this light, a psychotherapist should regard any professional relationship and the duties imposed by it as extending beyond the formal termination date of services.

The present conflict of interest discussion might reasonably lead a decision maker who has provided clinical services to a client to conclude that involvement in a sexual relationship with the former client violates the duty to practice reasonably competently because it can be expected to have an impact on the client’s continuing health. This is the position of many state legislatures, which have criminalized sexual relationships between psychotherapists and former clients where the professional services have only been terminated for a relatively short time (as an example, one year in New Mexico) (N.M. Stat. Ann. §30-9-10(A)(5), 2008)). Even when such conduct is not criminal, it still may be so inherently harmful to the former client as to constitute malpractice. This danger may or may not be present in the case of sexual relationships between other human service professionals, such as social workers and counselors providing solely informational (i.e., non-clinical) services, and their former clients.

Ethical codes in the mental health disciplines (see, e.g., the NASW Code’s Ethical Standard 1.09b, the NBCC Code’s Section A10, and the APA Code’s Ethical Standard 10.08) suggest that sexual relationships with former clients are to be avoided, and these codes place the burden on professionals seeking to engage in such relationships to demonstrate the absence of exploitation. In the case of counselors and psychologists, according to the NBCC and APA Codes, respectively, this burden includes the passage of at least two years since the termination of services.

One could certainly conclude reasonably that the ethical codes’ treatment of sexual relationships with former clients is too unrestricted. One could argue additionally that the legal standard in place—the duty to practice reasonably competently—probably would never condone the involvement of psychotherapists in sexual relationships with past clients, no matter what the therapist’s specific discipline is, or the length of passage of time between the professional relationship and sexual association; the danger of harm to the former client is too strong and obvious. With this point considered, is it ever possible for the professional to overcome the presumption that sexual relationships with former clients is inherently harmful? Consider the case of a social worker or counselor serving as a hospital patient advocate. The patient advocate’s services during the client’s one-day hospital visit consist of communicating the client’s grievance concerning the hospital’s food to the administrative staff. Ten years pass, and the advocate has been reintroduced to the former client at a social event; she and the client now choose to pursue an intimate sexual relationship. Whether the relationship should be avoided depends in large measure on the advocate’s assessment of the potential harm to the former client. Applying the test suggested above, the advocate might reasonably conclude that the prior professional relationship terminated at the time of the hospital discharge, and that the professional relationship that previously existed has no continuing impact on the client’s present well-being. Indeed, applying the reasonable competence and informed consent principles to this analysis, both would seem to be somewhat more forgiving of sexual relationships initiated some time after the termination of non-psychotherapeutic services.

Mental health legal problem: the telethon

Please share your thoughts on the following fictional scenario:

In response to Hurricane Katrina’s devastating impact on the Gulf Coast in 2005, a private consortium of citizens, community organizers, and celebrities in Branson, Missouri embarked on a fundraising initiative for storm victims. As part of this enterprise, they created an agency, the Branson Heart Club, which opened a bank account under the name “Katrina Fund.” In addition to collecting and distributing funds, the Branson Heart Club has attempted through several agency-sponsored social events to raise public awareness about the plight of survivors of the disaster. In the immediate aftermath of Hurricane Katrina, the agency distributed the funds it collected to a variety of programs for hurricane survivors, including food banks, homeless shelters, and even programs for the victims of family violence, a problem that has spiraled in the wake of the Katrina disaster.

In the months and years following the Hurricane, the Heart Club and its staff members have dedicated themselves tirelessly to collecting funds through the acceptance of individual and corporate contributions as well as small grants from several private foundations. This fundraising has been carried out despite the fact that, at the time of its creation, the Heart Club’s organizers lacked formal fundraising experience. Nevertheless, the agency has attempted to carry on its work with the additional benefit of having the donated services of a small group of committed volunteers. Now, three and one half years after the catastrophe, the Heart Club finds that its small group of devoted backers lacks the time and energy to continue its earnest commitment to ongoing fundraising activities. It now seems evident that an organized, full-time fundraising effort is simply beyond the means of the relatively modest number of Branson locals who first organized it.

At the same time, as they realize that Katrina’s impact promises to cause long-term, newly emerging social problems, the organizers of the Heart Club are interested in ensuring that their efforts to provide for victims continue. Knowing that they can no longer individually commit themselves to ongoing fundraising, they are determined to seek assistance from other experienced fundraisers who, the organizers believe, can create the infrastructure and organize the participants necessary to keep the Heart Club’s efforts ongoing. Toward this end, the organizers have engaged the assistance of a regional telemarketing organization experienced with large-scale charitable collection activities. Through the efforts of the telemarketer, and with the donated support of a network of area television stations, the Heart Club has planned a three-hour telethon whose proceeds are to be earmarked for the agency’s relief efforts. Consistent with charitable telemarketing practices, a small percentage of the funds collected are to go to administrative costs and the telemarketer’s fees.

Disagreement among the Heart Club’s organizers has occurred as to exactly how much of the funds collected from the telethon should be applied specifically to the needs of fund victims and deposited in the Katrina Fund. Several of the organizers are concerned that the immediate needs of Katrina survivors have been addressed by the federal government and private sources in the years following the disaster, and that it is therefore wrong to collect money for this specific purpose when doing so will only divert necessary attention away from other important regional purposes, such as combating poverty, hunger, and homelessness throughout the southern U.S. The group also believes that a solitary emphasis on aiding Katrina victims is no longer timely, and, in addition, serves only to distract potential contributors from these other vital purposes. Indeed, other charitable organizations have reported that, in the first years following Katrina, a decrease in contributions has occurred, presumably as a result of the attention that has been focused on Katrina and its consequences. The idea that the long-term needs of hurricane victims have been satisfied is both naïve and plainly disputed by research. Indeed, the long-term mental health impact of the disaster is just now becoming evident, and the ongoing problems of victims—including homelessness and family decay due to relocation—are likely to continue indefinitely.

In light of the present scenario, the Branson Heart Club’s organizers must make important decisions concerning their agency’s mission, their responsibilities to the clients targeted by that mission, and their duty, if any, to prospective recipients of funding resulting from the telethon. The decision making framework provides a tool for analysis of the Heart Club’s dilemma. If organizers conduct a thorough legal inventory, they will likely note the applicability of the duties to practice reasonably competently, to seek informed consent, and to identify the agency’s primary clients.

In the present case example, reasonably competent practice provides the general standard by which the agency must conduct its fundraising. This includes management of the fiduciary responsibility connected with solicitation of funds from the public. The Heart Club’s organizers have taken an appropriate first step in fulfilling this obligation by affiliating with an experienced fundraising organization that can compensate for the organizers’ lack of expertise in this area. Fundraising is a discrete responsibility requiring competent methodology, attention to detail, and fiscal responsibility both to donors and recipients of donations.

From whom must informed consent be sought in this situation? The answer depends on the organizers’ creation of a professional relationship with one or more primary clients. The most critical professional relationship in this scenario is the one that the Heart Club has sought to create with the survivors of Hurricane Katrina. After all, at the time of the Heart Club’s creation, money to be collected ostensibly was to be directed to their benefit, and that point has been plainly revealed to the public. It is important to remember that the duty to identify a primary client is as important a legal responsibility in community organizing as it is in clinical mental health practice. This point suggests that the Heart Club should not engage in funding efforts without the voluntary support of the families and the seeking of informed consent from them. The Heart Club’s duties to seek the voluntary support of survivors and gain their informed consent may be more difficult to accomplish than in one-on-one therapeutic relationships, but they can be satisfied just the same. This requires the concerted effort of the Heart Club to reveal fully its fundraising strategy and to obtain clear permission from the families to collect funds and to contribute these funds to programs that have been organized on their behalf. This can be accomplished, at least in spirit, through the holding of public meetings with families themselves or with the leaders of hurricane victim associations that have come into existence since the disaster occurred. The use of mass media may be instrumental in fostering communication between the Heart Club and its beneficiaries, given the scope of the fundraising effort undertaken by this agency.

Without first identifying the families’ immediate needs regarding support services, the collection of funds arguably was not carried out with adequate attention paid to this point. Moreover, at the initiation of the fundraising effort, organizers had no experience in fundraising, nor did they seek out the assistance of persons with this expertise. Given these facts, it is fair to conclude that the Heart Club’s efforts for the first three and one half years of its existence were not carried out with due regard for the legal responsibilities mentioned here. However, the agency’s current determination to regroup and organize its future fundraising strategy with the assistance of a firm experienced in this area provide it with the opportunity to satisfy its duties regarding the identification of its primary clients and the solicitation of informed consent.

If Hurricane Katrina victims are the Heart Club’s primary clients, then what association exists between the agency and the donating public? Although not strictly in the nature of a professional relationship, as that term has been used in this book, it is nonetheless a fiduciary association, akin to the contractual bond that exists between a service provider and a third-party payor or insurance company. Viewed in this light, the Heart Club has a responsibility to use fair solicitation techniques that include openness and clarity in identifying the purposes to which donated funds are to be applied.

In acknowledging hurricane victims as the Heart Club’s primary clients, organizers should carefully consider whether broadening the agency’s mission to include other needy persons and groups is a wise decision. Clearly the agency’s efforts have historically targeted solely hurricane victims, and it is certain that its ability to raise funds through the years has been heightened by its public association with the Katrina tragedy and its aftermath.

In completing the legal inventory, Heart Club organizers should evaluate the impact of federal and state policies governing trade practices and funds solicitation. This evaluation is likely to support the result mandated by informed consent and competent practice standards: Money solicited for Katrina survivors must be earmarked expressly for those persons and programs that directly support them.

A supplemental review of ethical, regional, and cultural factors enriches the legal inventory in this case scenario. It reveals that persons touched by human tragedy are sometimes motivated to help alleviate its effects regardless of the cost. Therefore, it is not unusual in such circumstances to find individuals of modest means pledging donations out of a sense of emotional attachment to victims. This phenomenon is heightened by the use of mass media to solicit donations. Therefore, the use of a telethon to seek donations must be planned sufficiently competently to ensure that the information shared with the public is accurate and that prospective donors are not exhorted to donate money to an extent inconsistent with their own family budgets. In this regard, telethon viewers are particularly vulnerable. Indeed, they are particularly vulnerable to any T.V. fundraiser in which a newsworthy event is used to inspire donations by the public. In less populated areas, people tend to rely particularly upon the media to obtain news and public information, and also to choose charities they wish to support. These considerations make it clear that the fundraisers in the present example have a special responsibility to their community to be honest and fair in their efforts.

Finally, pragmatic considerations compel the conclusion that fund solicitation planned for a particular purpose—in this case to aid hurricane survivors—must be dedicated to that purpose. It is patently unreasonable for organizers to plan a telethon to aid Katrina victims and even consider diverting funds from the telethon to other purposes. Although it is true that there is a multitude of social problems experienced by persons in the South and elsewhere, this fact alone cannot justify the diversion of funds and the resulting violation of immediate professional duties owed to primary clients—in this case, hurricane survivors. To do otherwise would be to mislead the public. In practical terms mismanagement of the telethon and the diversion of monies from its intended recipients compromise the Heart Club’s public credibility, and may hamper its future ability to raise funds.

The ethical and legal problems created by this scenario, inspired as they are by a recent national event, are intended to alert the professional decision maker to the utility of a law based framework in the resolution of mental health dilemmas and legal problems both small and large. The scenario stands as a model for the maintenance of a community focus in all daily practice decisions. With respect to each important choice made by every mental health professional, this approach surely is the most effective way to champion both the client’s best interests and the community’s shared values.

Reasonable Competence in Social Work Practice

Consider the following fictional social work dilemma and please share your thoughts concerning its outcome: Jade Melman, a recent graduate of a master�s level program in social work, is anxious to put her newly acquired clinical skills to the test. As part of her graduate program, Jade has completed basic course work in clinical social work practice, psychopharmacology, human behavior in the social environment, and group work. Now licensed in New York as a master social worker, but lacking any advanced training or certification as a clinical social worker, she accepts a position as a psychotherapist at a community mental health center in a rural town in upstate New York within a county that is large geographically but fairly sparsely populated. The mental health center has been desperate to hire a therapist for some time in order to adequately address the service needs of the community. Jade will be practicing under the supervision of the licensed psychologist who oversees outpatient services at the center. Having reviewed the law in New York governing social work practice, Jade knows generally that clinical social workers certified within that specialty have the legal authority to diagnose and treat mental illness. She is uncertain, however, about the specific practice expectations associated with her area of specialization. The duty to practice reasonably competently suggests several responsibilities that Jade and her supervisor have with respect to Jade�s rendering of clinical services. First, Jade arguably does not meet the threshold amount of post-educational field experience necessary to practice clinical social work competently, at least in the absence of ongoing supervision. If she proceeds to see clients without informing them of her training limitations, lack of field experience, and the fact that she must practice under close clinical supervision, then clients are likely to assume Jade has a level of qualification reasonably expected from a trained, experienced clinical social worker. In light of the duty to practice reasonably competently, what options do Jade and her supervisor have with respect to any representations they convey to clients about Jade�s qualifications? Moreover, exactly what should be the extent of Jade�s participation in the delivery of client services? For one thing, Jade can assist in the provision of services to her supervisor�s clients, a most reasonable arrangement in terms of providing needed services to clients while allowing Jade to receive training necessary for an apprentice clinical social worker. Put differently, Jade should refrain from treating clients independently of her supervisor�i.e., accepting her own clients�until her training regimen has been satisfied. This arrangement reflects the manner in which a reasonable therapist practicing in a rural, service-deprived community should offer care: Both Jade�s supervisor and Jade can ensure the competence of the services offered and provide needed treatment in an underserved area. At the same time, this arrangement must be explained to clients at the commencement of services so that they have a realistic appreciation of the professional duties owed respectively to them by Jade and her supervisor and can intelligently consent to receive services. What exactly should be explained to clients? First, it should be made clear that services will be provided to each client under the direct supervision of Jade�s supervisor; second, the extent of Jade�s credentials, along with their limitations, should be explained to clients; third, the supervisor�s credentials should be discussed with clients; finally, clients should be advised as to the nature of the supervisory relationship between Jade and her supervisor. If this explanation is provided, then clients will have a more reasonable and fully informed understanding of the services they are receiving and the preparedness of the professionals providing them. In this scenario, offering a clear explanation serves to identify the professional relationships between the client and each provider and the responsibilities to be assumed by Jade and her supervisor. In the manner just described, Jade can enjoy a professional relationship with her supervisor�s clients, but from a legal perspective her duty to practice reasonably competently requires that she practice at least initially under supervision and that she acknowledge and convey her limited training to prospective clients. This approach should be employed at least until such time as Jade has attained the practice experience sufficient to allow her to offer care with the reasonable competence expected of mental health providers in the community. What additionally responsibilities does Jade�s supervisor have? Most importantly, with Jade�s limited practice experience explained to clients, the supervisor must be prepared to assume primary authority for the responsible provision of clinical care to each client. Consistent with this responsibility, the supervisor must provide services that match those reasonably expected from a provider with advanced clinical training. If this is to be accomplished, during the period allotted for Jade�s training the supervisor must ensure that Jade�s treatment of each client conforms to the skill level expected of a clinician with Jade�s education and degree of training. This responsibility makes the provision of appropriate supervision to Jade a vital duty. Given the large geographical size of this rural community, the limited number of available services, and the multiple responsibilities of Jade�s supervisor, it may well be reasonable for the supervisor to extend considerable latitude to Jade in the performance of her job functions, including intake and assessment of clients and direct clinical dialog with them, provided that Jade�s supervisor does not cede responsibility for the essential therapeutic environment until such time as Jade is reasonably competent to manage it independently. The professional apprenticeship not only serves the needs of Jade and her supervisor, but also is a fairly typical way in which clinicians can achieve advanced training while honoring the duty to provide reasonably competent mental health care. It is an essential process in the field preparation of virtually all clinical mental health providers.

Suspected Neglect in Lumberton

Please share your thoughts on the following fictional scenario:

 Gussie Shirley is a 43-year-old single mother living in Lumberton, Robeson County, North Carolina, a diverse community of Anglo, African American, Native American, and Hispanic people. Lumberton, a city of about 20,000, has been beset over the last few years by the closing of multiple local industries, resulting in an unemployment rate among the highest in the U.S. for cities of its size. Not unexpectedly, Robeson County has one of the highest poverty rates in the U.S. Gussie, a Lumbee Indian, has recently suffered a badly broken leg. After treatment at a regional health clinic, an infection has set in. Following a brief hospital stay, Gussie has been released to her home with a discharge plan calling for a series of 10 nurse visits. Gussie is confined to bed rest and required to take a regimen of antibiotics.

Lambert Urbano is the visiting nurse assigned to the Shirley family’s case. During Lambert’s initial home visit, he surveys the rustic cabin in which Gussie lives with her 10-year-old daughter, Alice. Lambert notices that the Shirleys have no running water, but instead draw their supply from a nearby well. Having no plumbing facilities, they rely on an outhouse and an old tub that they fill with heated water in which to bathe. Several of the cabin’s windows are broken, with glass shards surrounding the outside areas. Hastily prepared cardboard covers are taped to the inside of two windows, protecting the cabin from the elements. The family has a wood stove on which Gussie cooks and which provides heat during the winter months.

Lambert, a recent transplant from Chicago, is not used to the living conditions he witnesses. Observing Alice, Lambert notes that she is very thin, wears a dress she probably has worn for some time, and that her arms and legs are dirty.

During his examination of Gussie, her leg shows no signs of healing. To make matters worse, Lambert receives hesitant and conflicting reports from Gussie regarding her attention to the discharge plan. In particular, Lambert suspects that Gussie might not be taking her prescribed medications. When asked about this, Gussie responds that she “tries to.”

Lambert has concerns about the family’s living conditions and more specifically believes that the environment might be sufficiently unhealthy for Alice as to constitute child neglect. Moreover, he has fears about Gussie’s ability and/or willingness to care for herself. In view of these concerns, Lambert elects to consult with his agency supervisor, Clara Tobarn, a licensed social worker and Lamberton native, regarding the possibility of making a referral to the county’s child protective services unit, a step that would then require a formal investigation of the Shirley family by that agency.

In beginning their legal inventory, Lambert and Clara will probably at once recognize and apply the duties to practice reasonably competently and identify the primary client (please see this website’s discussion of Practice Dilemmas and the legal principles governing mental health practice). In the present scenario, the professional relationship established by Lambert with Gussie exists for the sole purpose of providing home health care and related services. It is not, therefore, Lambert’s duty to diagnose or treat any condition that does not fall within the scope of this professional relationship. The duty to practice reasonably competently, however, also entails the responsibility to recognize and report suspected child abuse and neglect to appropriate authorities. Additionally, it requires the protection of vulnerable adults who may be self-neglectful to the degree that they pose a reasonable threat of harm to themselves.

Legal duties that are specific to Clara include the responsibility to give reasonably competent supervision to Lambert. In the exercise of this duty, Clara must draw upon her understanding of community expectations in Robeson County regarding the daily lifestyles of local people.

Understanding the legal duties applicable to both, Clara and Lambert initially agree that in the present case they are required to report suspected child neglect or adult self-neglect only in the event that there is a reasonable suspicion either harm is occurring. This standard is intended as a precaution to ensure that marginal cases are investigated. Consequently, as a relative newcomer unaccustomed to the lifestyles of some Robeson County residents, Lambert’s initial assessment is that his observations of the Shirleys’ home life are enough to satisfy the reasonable suspicion standard. Lambert thinks this is true with respect to both Gussie and Alice, meaning that he believes Gussie is neglecting both Alice and herself; therefore, he believes that the agency should err on the side of caution and refer the family for investigation. At the least, Lambert believes making the report will provide the family with needed support services.

In consultation with Clara, Lambert shares his opinion but finds that Clara regards the situation to be more ambiguous. If Clara brings her understanding of community lifestyles to her assessment of the Shirley family, she is likely to conclude that the family’s living arrangements are not unusual for Robeson County, which, as noted, ranks among the poorest in North Carolina and the U.S. In consultation with her agency counsel, Clara may well conclude that poverty in itself must never give rise to the presumption of child neglect.

As to the possibility of Gussie’s self-neglect, Clara’s interpretation of the conduct Lambert has described to her should also be based on a consideration of community norms. Specifically, Clara might note that Gussie’s apparent reticence in describing her self-care is as likely the result of fear and suspicion than subterfuge. Moreover, Clara might note, in a community in which homemade, culturally based remedies are a common form of treatment, and antibiotics are not deemed the only acceptable response to infection, Lambert’s hypothesis that neglect is occurring is not necessarily accurate or helpful.

Summarizing the foregoing considerations, a regionally and culturally based interpretation of applicable law argues against a premature referral for suspected neglect in this case. Consistent with reasonably competent practice, further assessment—with the assurance of cultural and regional consistency—should follow in order to clarify some of the medical issues that have identified themselves with respect to Gussie’s self-care. This assessment should include attention to the duty to seek informed consent, which in this scenario requires an open and appropriate discussion of health issues specifically related to the treatment of Gussie’s leg. Although Gussie’s living arrangements may distress Lambert, they are not unusual for this community, and therefore should not fall within the scope of his assessment, at least to the extent that they do not directly affect the healing of Gussie’s leg. Moreover, Lambert cannot allow his initial impression of the family to dictate his future course of services. In this instance, his attention to his primary role as a medical provider with limited, agency-defined duties advances his patient’s best interests.

A review of pragmatic considerations supports the legal and cultural assessments. Specifically, it underscores the consequences of an overly hasty referral for an investigation of neglect. The imposition of a government intervention on a family that is marginal economically but apparently functional in other respects may upset the family’s equilibrium and drive it into social isolation, perhaps hastening the very health problems that the agency wishes to prevent. Indeed, while good intentions here may support the early reporting of suspected neglect, thoughtful consideration of the consequences does not.