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.

More about ethical codes and their urban bias

A review of the major ethical codes in the mental health professions reveals that they do indeed tend to emphasize practice goals all too often from a national, urban perspective, with precious little attention paid to regional variations and cultural issues in practice. For example, the professional counselors’ code of ethics — the NBCC Code, Section A2 — cautions professional counselors that, when they accept employment with an agency or other employer, this acceptance implies agreement with institutional policies and procedures. To highlight the over-rigidity of this provision, note that in the case of a counselor’s employment with a national system of mental health providers, the provision appears to encourage allegiance to professional practices that might not represent the best interests of persons within a particular community. One could certainly argue that clients who live in a rural setting, speak a language other than English, or whose cultural affiliation demands flexibility in the delivery of treatment modalities, the NBCC Code would do well to encourage counselors to impart culturally competent strategies with clients. Unfortunately, the only reference to diversity within the NBCC Code, contained in Section A12, advises counselors rather imprecisely to have “awareness of the impact of stereotyping and unwarranted discrimination.”

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.

More about the weaknesses of ethical codes in mental health decision making

One general weakness of ethical codes is that they often are better at articulating overarching and general, aspirational ideals, i.e., values, than they are at setting standards that prescribe or proscribe particular behavior, i.e., ethics. Thus, the NASW Code broadly espouses the promotion of client well-being (Ethical Standard 1.01), the development of people, communities, and environments (Ethical Standard 6.01), and the advancement of client self-determination (Ethical Standard 1.02), as social work aspirations, but offers only a handful of enforceable standards in the pursuit of these ideals. For example. as already noted, the NASW Code clearly proscribes conduct specifically in the case of social worker-client sexual relationships. Interestingly, in the very portion of the NASW Code in which ethical standards are set forth (Introduction to Ethical Standards), The Code warns readers that only �some of the standards that follow are enforceable guidelines for professional conduct, and some are aspirational.� The Introduction to Ethical Standards goes on to explain that �the extent to which each standard is enforceable is a matter of professional judgment to be exercised by those responsible for reviewing alleged violations of ethical standards.� This extraordinary lack of certainty by NASW itself as to the binding quality of its own �standards� raises serious questions about whether any relied upon in disciplinary proceedings against social workers would be enforceable in subsequent litigation by the subjects of such proceedings. The reason for the cautionary stance by NASW regarding enforceable standards may well be that the framers of the NASW Code have remained somewhat ambivalent about how they envision the Code�s purpose; when drafting the present Code they may have regarded the imposition of stricter standards as an undesirable substitute for allowing flexibility. In the NASW Code, Ethical Standards 1.06 and 3.01, respectively, social workers are cautioned to avoid social relationships and conflicts of interest with clients and colleagues, but only where there is a �risk of harm or exploitation.� The ambiguity inherent in this standard may serve the purpose of ensuring flexibility in its interpretation, but it also unfortunately makes it virtually meaningless in the absence of a situational, regional, cultural, or some other subjective context unique to every practice situation.

Mental health law vs. ethical analysis: which takes precedence in decision making?

When do ethical codes defer to metal health law? Put differently, when, if ever, do ethical codes advise us to follow the law?

Each of the codes of ethics in the mental health professions guides practitioners to follow mental health law when it is relevant to the resolution of a dilemma, although they sometimes do so in an oblique manner. For example, the NASW Code, in Ethical Standard 1.01 (“Commitment to Clients”), advises social workers that “specific legal obligations may on limited occasions supersede the loyalty owed clients.” The APA Code, Ethical Standard 1.02, rather fancifully and vaguely advises psychologists to resolve conflicts with the law by “mak(ing) known their commitment to the Ethics Code and tak(ing) steps to resolve the conflict.” In the same Ethical Standard, psychologists are advised rather inadequately that “if the conflict is irresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing legal authority” (emphasis added). The APA Code does, however, direct use of the law for guidance with respect to the issues of confidentiality (Ethical Standard 4.01). Professional counselors are urged by the NBCC Code, Section A13, to “avoid behavior that is clearly in violation of accepted moral and legal standards”; there is no additional concern expressed that there might not be any such thing as “accepted moral standards.” The indirect language used within these codes may be a reflection mainly of each profession’s explicit emphasis on defining a unique set of core values; carving out some professional “turf” for each discipline may well be an implicit objective as well. In any event, all professional licensing organizations, including those governing the major behavioral health disciplines, regard their members as owing an obligation to their communities that supersedes any profession-specific consideration.

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.

Defining “law” in mental health decision making

As noted in other blog posts, seeking out the “right” legal answer to a clinical practice dilemma eliminates some of the confusing alternatives one may face in attempting to resolve a frustrating professional problem. This is not an accident. Much law, including law governing practice in the mental health professions, such as the requirement to maintain client confidentiality, is based on at least some sound, rational basis, and presumptively reflects the most basic, shared values of society. For this reason, the operating definition of law applied here is that it is a binding set of shared values within a community; the community being a city, state, nation, or other politically organized jurisdiction that unites people by language, culture, religion, tribal affiliation, or custom.

Defining law as a “set of shared values” serves the purpose of emphasizing the communitarian function—and not simply the binding nature—of law and lawmaking. Communitarianism in the present context is intended to convey the idea that the most effective and socially just practices are the result of cooperative inquiry, a search for common values, and the recognition that all people within a community share some mutual responsibility for their collective good. Viewed in this light, no practice choice can be truly personal because each decision inevitably has consequences that affect others. Unlike the values represented by individual preferences and political ideologies, or articulated within particular codes of ethics, the values advanced by law are shared by most members of a community and not merely espoused by one individual or professional. Understood in this way, the law can be regarded as a means to attaining the greatest good for the most members of a community. Additionally, this utilitarian interpretation of law, when incorporated into an overall decision making scheme, requires that all practice decisions be made at least to some extent from a communitywide, regional, or even global perspective, and not simply from a personal or professional one.

What about law that does not reflect shared community values? A prime example of this problem may exist today in the Indian country of the United States, where tribes that have traditionally defined their communal values through an unwritten religious and social tradition are increasingly finding this customary law displaced by federal and state legislation (see, for example, the Indian Civil Rights Act of 1968 (ICRA)). The assimilationist aim of this lawmaking may be a symptom of the overall trend toward the increasing definition and codification of new laws by Congress and state legislatures. This tendency may well reflect a growing willingness by legislators to use lawmaking as a means of social control in a society that feels ever more out of control. Under the definition of law used here, a credible argument can be made that at least some of this  law is invalid, unconstitutional, or both.

What, then, can be done about law that fails to reflect the shared values of a community? Mental health professionals keenly interested in the pursuit of social justice are well aware of the myriad examples of oppressive, racist, sexist, ageist, and homophobic law that has existed historically. Often these examples are cited in support of the premise that all law is invalid, to be mistrusted, and inherently antithetical to the values associated with social change. This almost nihilistic political ideology is not pragmatic because it tends to ignore the vast body of law that is both useful in ordinary life and professional practice and also representative of the shared values of a community.