Ethics in community mental health care : commonplace concerns

243 Pages·2002·3.58 MB·English

by  Patricia Backlar, David L Cutler

ETHICS IN COMMUNITY
MENTAL HEALTH CARE
ETHICS IN COMMUNITY
MENTAL HEALTH CARE
COMMONPLACE CONCERNS
Edited by
PATRICIA BACKLAR
Portland State University
Portland, Oregon
and
DAVID L. CUTLER
Oregon Health and Science Center
Portland, Oregon
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CONTRIBUTORS
TANYA R. ANDERSON, M.D., is Associate Medical Director of
Comprehensive Assessment and Response Training, University of
Illinois at Chicago.
PATRICIA BACKLAR is Research Associate Professor of Bioethics in
the Department of Philosophy, Portland State University, and Assistant
Director of the Center for Ethics in Health Care, and Adjunct Assistant
Professor in the Department of Psychiatry, Oregon Health & Science
University.
CARL C. BELL, M.D., is President and CEO of the Community Mental
Health Council and Foundation, Inc., and Director of Public and
Community Psychiatry, and Clinical Professor of Psychiatry and Public
Health, University of Illinois at Chicago.
MORRIS A. BLOUNT, M.D., is Psychiatrist at the Community Mental
HealthCouncil, Chicago, Illinois.
DOUGLAS BIGELOW, Ph.D., is Associate Professor in the Department
of Psychiatry, Oregon Health & Science University.
RANDY BORUM, Psy.D., is Associate Professor in the Department of
Mental Health, Law and Policy, University of South Tampa, Florida.
MARY ALICE BROWN, Ph.D., is Executive Director of Laurel Hill
Center, Inc., Eugene, Oregon.
v
vi CONTRIBUTORS
VALERIE COLLINS, M.D., is a Resident in Child Psychiatry, Oregon
Health & Science University.
DAVID L. CUTLER, M.D., is Professor of Psychiatry, and Director of
the Public Psychiatry Training Program, Oregon Health & Science
University.
ROBERT E. DRAKE, M.D., Ph.D., is Professor of Psychiatry and
Community and Family Medicine, Dartmouth Medical School.
GARY FIELD, Ph.D., Director of the Counseling and Treatment
Program, Oregon Department of Directions.
FREDERICK J. FRESE, Ph.D., is Assistant Clinical Professor of
Psychology in Psychiatry, Northeast Ohio Universities College of
Medicine, and Vice President, Board of Directors, National Alliance for
the Mentally Ill (NAMI)
JEFFREY GELLER, M.D., Ph.D., is Professor of Psychiatry, University
of Massachusetts Medical Center.
CHARLES R. GOLDMAN, M.D., is Director of the Public Psychiatry
Training Program, South Carolina Department of Mental Health,
Division of Education, Training, and Research, and is Professor in the
Department of Neuropsychiatry and BehavioralScience, University of
South Carolina School of Medicine.
VIRGINIA ALDIGE' HIDAY, Ph.D., is Professor in the Department of
Sociology and Anthropology, North Carolina State University.
COURTNEY JACKSON, is a medical student,Oregon Health & Science
University.
HARRIET P. LEFLEY, Ph.D., is Professor of Psychiatry and Behavioral
Sciences in the Department of Psychiatry, University of Miami School
of Medicine.
JO MAHLER, M.S., is Senior Research Associate, Oregon Health &
Science University.
CONTRIBUTORS vii
BENTSON H. McFARLAND, M.D., Ph.D., is Professor of Psychiatry,
Public Health, and Preventive Health in the Departments of Psychiatry,
and Public Health and Preventive Medicine, Oregon Health & Science
University.
CAROLYN C. MERCER, Ph.D., now deceased, was Policy Analyst at
the New Hampshire-Dartmouth Psychiatric Research Center.
DOUGLAS L. NOORDSY, M.D., is Associate Professor of Psychiatry,
Dartmouth Medical School, and Chief of Clinical Research in the
MentalHealth Center of Greater Massachusetts.
DAVID A. POLLACK, M.D., is Associate Professor of Psychiatry and
Associate Director, Public Psychiatry Program, Oregon Health &
Science University.
JEFFREY W. SWANSON, Ph.D., is Associate Professor in the
Department of Psychiatry and Behavioral Sciences, Duke University
Medical Center.
MARVIN S. SWARTZ, M.D., is Professor in the Department of
Psychiatry and Behavioral Sciences, Duke University Medical Center.
H. RYAN WAGNER, Ph.D., is Assistant Professor in the Department of
Psychiatry and Behavioral Sciences, Duke University Medical Center.
DEE WIRAK, M.S.W., is Co-Director, Rehabilitation Services, Laurel
Hill Center, Inc., Eugene, Oregon.
PREFACE
Why ethics and why now? Its certainly seems unusual for me to be con-
cerned about ethics. It is an area that I always took for granted. I have
always managed to see ethical problems as clear-cut and having sim-
ple, straightforward solutions. After all aren't there professional codes
of ethics associated with each of the mental health disciplines to guide
us? Don't we all know what these standards are?
The American Psychological Association has been working for
years on drafting a new ethics Code. The finalrecommendations were to
be made to the Executive Board of the American Psychological Associa-
tion by the end of December 2000. This new version would need to be
approved and that could take quite a while. In addition, the APA is con-
sidering no longer arbitrating ethics cases (it is time-consuming and
burdensome financially to the organization). If that should become
policy, then some in the organization feel there should be no updated
Code produced as the APA will not be enforcing it.
Of course, a professional code of conduct is written from the per-
spective of a particular professional group, and does not take into
account the needs of other stakeholders such as individual consumers
or workers. In fact, most mental health workers are not even connected
to an organization such as the APA so for most people such a relativis-
tic account doesn't even matter.
With these thoughts in mind, I've begun to wonder about the
validity of my assumptions regarding ethical practice in the mental
health system. Three things have forced me to think like this (some-
thing I never intended to do). The first has been my involvement with
the struggle for the rights of consumers to have a say in not only their
ix
x PREFACE
treatment but also the systems that serve them. (A struggle I never con-
sciously planned to be involved in.) The second is the revolutionary
marketplace changes in the funding of public mental health programs.
(A revolution that I still don't want to be involved in.) And the third is
not a concept or a trend but a person. Patricia Backlar who is a health-
care ethicist, author of the Family Face of Schizophrenia, a parent of a
mentally ill person, and someone who refuses to face these dilemmas
using denial as a defense strategy as I would prefer to do if she'd let
me. On the contrary, she has persistently reminded me both formally
and informally on a regular basis about all this ambiguity that is going
on around us. What do you think of ...? or Have you an idea about
how we are going to deal with ...? I finally decided that if I was going
to have to face these things maybe the rest of you should also. And so
I invited her to submit a series of papers regarding these various dilem-
mas to the Community Mental Health Journal. This was indeed a good
decision judging from the cards and letters which have poured in. And
so it occurred to both of us that maybe there is even a wider audience
of earnest people who would choose to remain silent except for some
prodding by our little chain letter of an idea. That is, what do some of
the leaders in our profession, both consumers and providers, think
about these things, and, specifically, what experiences have they had in
dealing with them.
DAVID CUTLER, M.D.
CONTENTS
Introduction xvii
Patricia Backlar
PART I.COMMONPLACE ENCOUNTERS WITH CONSUMER/PATIENTS
Chapter 1
EthicalIssues in Mental Health Services
for Culturally Diverse Communities 3
Harriet P.Lefley
Good practice involves a psychological component to cultural
sensitivity that can enhance observational and therapeutic skills
with individuals of all culturalbackgrounds, including one's own.
Chapter 2
Ethical Dilemmas in Providing Supported Housing and
Rehabilitation Services 23
Mary Alice Brown and Dee Wirak
Three vignettes illustrate critical ethical dilemmas that clinicians
in community-based services are likely to encounter.
xi