Ethics in psychiatric practice: essential ethics skills, informed consent, the therapeutic relationship, and confidentiality

Psychiatrists routinely encounter ethical complexities in caring for patients with mental illness, and they are held to the highest levels of accountability in their ethical practices. In this article, the authors first outline skills that are essential to ethical psychiatric practice. They then articulate three domains of clinical and ethical practice that represent the foundation of clinical care for people with mental illness: informed consent, the therapeutic relationship, and confidentiality. Key concepts concerning these domains are presented and relevant empirical evidence concerning each domain is reviewed. An understanding of these clinical and ethical practices will help psychiatrists serve patients with mental illness in their everyday clinical activities in a manner that is respectful, engenders trust, and ultimately fosters optimal clinical care.     

Writing reports for lawyers and courts

Psychiatrists and other mental health professionals are asked from time to time to provide reports that will be used in legal or administrative actions ("forensic" reports, expressing "opinions" beyond personal observations). This article provides general guidance and recommendations for forensic report writing, particularly when the writer has limited forensic experience. Forensic reports are quite different from ordinary clinical reports. Their appearance, purpose, context, format, vocabulary, and legal or administrative "rules" should be carefully considered by professionals who choose to write them. Conflict of interest dictates that most such reports not be written about one's own patients. Requests from complainants or litigants themselves, rather than from lawyers, judges, or agency/company officials, should usually be declined. Although most attorneys and others who ask for reports do so in good faith, some requests, especially last-minute or "rush" demands and those from complainants or litigants themselves, can encourage misguided or even unethical behavior. Clinicians who write forensic reports should adhere to a careful routine of completeness, honesty, and objectivity. They should decline cases in which they sense inappropriate pressure or ethical problems, and treat every report as a lasting and public example of their work, expertise, and professionalism.     

Psychiatrists and the General Hospital Ethics Committee.

General Hospital Ethics Committees (GHECs) have emerged as institutional forums for addressing bioethical dilemmas. Hospital psychiatrists have important roles to play on these committees. Their skills in group process assessment, mental status examination, and character assessment have diverse applications. Psychiatrists can facilitate communication, both on the committee and as GHEC-based clinical ethics consultants. Ethics committees must be concerned with how they arrive at ethical decisions, guarding against political influence or individual monopolization. Psychiatrists can assist these efforts as organizational consultants to GHECs. The perception of psychiatrists as reflective, tolerant of ambiguity, humanizing, and approachable about moral aspects of health care suggests they would make excellent committee leaders. Hospital psychiatrists also have important committee roles to play as ethics educators and policy-makers. More demographic research is needed to investigate psychiatrists' participation on GHECs. Studies of how they are perceived by their ethics committee colleagues may reveal new roles and potential pitfalls for GHEC psychiatrists.     

OpenMinds: creating a mental health workshop for teenagers to tackle stigma and raise awareness

As a group of four clinical medical students from Cambridge University, we undertook a Student Selected Module (SSC- "OpenMinds") whereby we designed and delivered a workshop about mental health to year 9 pupils. The aim of our SSC was to produce an interactive, informative lesson which addressed the complex issues of stigma and discrimination against those suffering from a mental illness as well as teaching the pupils how to recognise mental health problems and provide them with guidance on how to seek help. We split a fifty minute session into the following sections: tackling stigma; how common mental illness is; celebrity examples; real life examples; role play; and small group work. To engage the pupils we used a combination of teaching modalities targeting all learning. We delivered the workshop to four separate classes and received feedback from the pupils after each. We used this feedback to adapt and improve our presentation and assess the efficacy. Feedback was overwhelmingly positive with the striking results of 101/109 pupils saying that they would recommend the workshop to a friend and 68/109 pupils saying they enjoyed all aspects. Our SSC built upon work by a contingent of trainee Psychiatrists who undertook a similar project of mental health education for teenagers, called "Heads above the rest", in Northern Ireland with great success. By continuing their work we were able to demonstrate that medical students can successfully complete the same project under the guidance of a Psychiatrist, thus increasing the sustainability of the project by reducing the time burden on the Psychiatrists. Participating in the project was also valuable to our own personal development of teaching skills.     

Commentary: Medical errors, sentinel events, and malpractice

Medical errors do not necessarily represent negligence. Even when a mental health professional deviates from the standard of care, minor injury to a patient is unlikely to result in a lawsuit. The standard of care is not the same as the quality of care. Quality of care refers to the total care a patient receives, the patient's health care decisions, and the available mental health services. As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), "sentinel events," such as a patient's suicide, do not necessarily imply that a deviation in the standard of care occurred. Psychiatrists and hospital staff are held to an "ordinarily employed" standard of practice. The Institute of Medicine (IOM) guidelines recommend evidence-based care related to patient needs and values. Both JCAHO and IOM promote best practices. Experts err when they testify to a best practice standard in malpractice cases.     

Psychiatry and the death penalty: Dilemma for mental health professionals

The arguments for and against mental health professionals' participation in death penalty proceedings are presented against the background of U.S. Supreme Court decisions which have had a bearing on this issue. It is concluded that the possibility of presenting mitigating psychologic testimony in such proceedings necessitates the possibility of exacerbating psychiatric testimony and that hence, mental health professionals who testify for the prosecution in such cases do not, on a wider view, violate their hippocratic oaths or other ethical codes. A number of safeguards, however, should be instituted with respect to such testimony. Psychiatrists, psychologists or other qualified mental health professionals should (1) testify with medical possibility or probability, (2) not be permitted to address ultimate legal issues and (3) be permitted, in fact encouraged, to present alternative interpretations of forensic psychiatric findings. It is further argued that in addition to being justified in testifying for the prosecution on death penalty cases, mental health professionals may have a moral rationale for treating death row prisoners and restoring them to competency.     

What about psychiatrists' attitude to mentally ill people?

OBJECTIVE: Firstly, to assess and, secondly, to compare experts' and lay attitudes towards community psychiatry and the respective social distance towards mentally ill people. METHOD: Comparison of two representative Swiss samples, one comprising of 90 psychiatrists, the other including 786 individuals of the general population. RESULTS: The psychiatrists' attitude was significantly more positive than that of the general population although both samples have a positive attitude to community psychiatry. The statement that mental health facilities devalue a residential area has revealed most agreement. Psychiatrists and the public do not differ in their social distance to mentally ill people. Among both samples, the level of social distance increases the more the situation described implies "social closeness". CONCLUSION: The strategy to use psychiatrists as role models or opinion leaders in anti-stigma campaigns cannot be realised without accompanying actions. Psychiatrists must be aware that their attitudes do not differ from the general public and, thus, they should improve their knowledge about stigma and discrimination towards people with mental illnesses.     

Demoralization in Mental Health Organizations: Leadership and Social Support Help

Demoralization is a commonly observed feeling state that is characterized by a sense of loss of or threat to one??s personal values or goals and a perceived inability to overcome obstacles toward achieving these goals. Demoralization has features in common with burnout and may precede or accompany it. Psychiatrists working in many mental health care organizational settings, be they in the public or private sectors, may be at particular risk for demoralization. This is due partly to stressors that threaten their own professional values because of factors such as programmatic cut backs, budgetary reductions and changing social emphases on the value of mental health treatments. They also may be at risk for demoralization because of the effects on them of the governance styles of the agencies in which they are employed. The leadership or governance style in large organizational settings often is authoritarian, hierarchical and bureaucratic, approaches that are antithetical to the more participative leadership styles favored by many mental health professionals in their clinical activities. Clinical leaders in mental health organizations must exhibit various competencies to successfully address demoralization in clinical staff and to provide a counterbalance to the effects of the governance style of many agencies in which they are employed. Appropriate leadership skills, sometimes too simplistically termed ??social support??, have been found to reduce burnout in various populations and are likely to lessen demoralization as well. This paper reviews these important leadership issues and the relationship of social support to recognized leadership competencies.     

Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness

OBJECTIVE: Studies show a high potential demand for psychiatric advance directives but low completion rates. The authors conducted a randomized study of a structured, manualized intervention to facilitate completion of psychiatric advance directives. METHOD: A total of 469 patients with severe mental illness were randomly assigned to a facilitated psychiatric advance directive session or a control group that received written information about psychiatric advance directives and referral to resources in the public mental health system. Completion of an advance directive, its structure and content, and its short-term effects on working alliance and treatment satisfaction were recorded. RESULTS: Sixty-one percent of participants in the facilitated session completed an advance directive or authorized a proxy decision maker, compared with only 3% of control group participants. Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the advance directive to refuse some medications and to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment. At 1-month follow-up, participants in the facilitated session had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the mental health services they believed they needed. CONCLUSIONS: The facilitation session is an effective method of helping patients complete psychiatric advance directives and ensuring that the documents contain useful information about patients' treatment preferences. Achieving the promise of psychiatric advance directives may require system-level policies to embed facilitation of these instruments in usual-care care settings.     

Ethical Considerations for Mental Health Clinicians Working with Adolescents in the Digital Age

Purpose of Review

Adolescents’ use of digital technologies is constantly changing and significantly influences and reflects their mental health and development. Technology has entered the clinical space and raises new ethical dilemmas for mental health clinicians. After an update on this shifting landscape, including a brief review of important literature since 2014, this article will demonstrate how core ethical principles may be applied to clinical situations with patients, using vignettes for illustration.

Recent Findings

The vast majority of adolescents (95%) across all demographic groups can access smartphones (Anderson et al. 2018?). Technology use in mental health is also expanding, including a proliferation of “apps.” While qualitative data from technology experts reports overall positive effects of technology (Anderson and Rainie 2018), concern about its potential negative impact on youth mental health remains high, and an association between technology use and depression is strong. Internet addiction, online sexual exploitation, and accessing illicit substances through the “dark net” pose additional clinical and legal concerns. In this context, clinicians have an ethical responsibility to engage in education and advocacy, to explore technology use with teen patients and to be sensitive to ethical issues that may arise clinically, including confidentiality, autonomy, beneficence/nonmaleficence, and legal considerations such as mandated reporting.

Summary

New media and digital technologies pose unique ethical challenges to mental health clinicians working with adolescents. Clinicians need to stay abreast of current trends and controversies about technology and their potential impact on youth and engage in advocacy and psychoeducation appropriately. With individual patients, clinicians should watch for potential ethical dilemmas stemming from technology use and think them through, with consultation as needed, by applying longstanding core ethical principles.

     

Informal Role Expansion in Australian Mental Health Nursing

PURPOSE.  This study aims to determine the extent to which community mental health nurses are currently practicing beyond the traditional scope of nursing practice .
DESIGN AND METHODS.  A self-administered questionnaire was distributed to community mental health nurses in Victoria, Australia.
FINDINGS.  The majority of participants reported routine involvement in practices that would normally be considered beyond the scope of nursing practice, such as prescribing, ordering diagnostic tests, and referral to specialists.
PRACTICE IMPLICATIONS.  The extent to which the current mental health service system is dependent upon nurses transgressing professional and legal boundaries warrants further study. Psychiatrists and community mental health nurses need to work collaboratively to understand their respective knowledge and skills and to be clear about how they take responsibility for client care.     

Assertive community treatment in Japan: results of fidelity measurements

Mental health system reform oriented toward realizing the transition from "institution-based medical treatment" to "community-based care" is now taking place in Japan. Although the number of psychiatric beds is slow to decrease, community resources are increasing, and differentiation of those services is the next challenge. Assertive Community Treatment (ACT) is a service which provides 24/7 community outreach by a multidisciplinary team to persons with severe mental illness. Currently, some 10 to 15 ACT teams are providing services in Japan; this number is far from adequate. This is due to the lack of direct funding for ACT in the current mental health system. However, ACT is increasing as a result of combining available funding sources, such as psychiatric home visit nursing and welfare funding. The ACT Network, a voluntary association, was established to disseminate ACT and ensure its quality. Fidelity scales measure faithfulness to the original model. DACTS, a fidelity scale developed in the U.S., is widely used to measure ACT fidelity. In Japan, ACT Network implements a Japanese version of fidelity measurement for ACT around Japan. Results of fidelity measurements of 12 ACT teams in 2009 showed that the ACT teams were providing services which adhered more closely to the original model than in the previous year, but problems remained. Some issues, such as increasing care management in services, can be addressed through maturation of ACT teams, but other issues, such as relatively low service density and allocation of employment specialists, cannot be resolved without a funding mechanism. To disseminate ACT and support more people with severe mental illness in the community, it is necessary to build ACT into the community mental health system with sufficient funding, and to monitor its quality using measures such as fidelity scales.     

Increasing mental health capacity in a post-conflict country through effective professional volunteer partnerships: A series of case studies with government agencies,local NGOs and the diaspora community

Abstract

The focus of this paper is on working in partnership with local practitioners and communities to strengthen local capacity building in the area of mental health and well-being in Sri Lanka. This paper will examine the context, organizing concepts, organizational processes, and the development of good working relationships and partnership building behind this work. Our involvement was based on requests which came to the authors as a result of their previous work in Sri Lanka over several decades. This work had been undertaken on behalf of the UK–Sri Lanka Trauma Group (UKSLTG), a UK-based charity which was set up in 1994, and of which the authors are founding members (www.uksrilankatrauma.org.uk). In the first section of the paper, contextual issues will be discussed. The second section of the paper provides details of the training undertaken on mental health promotion among young people in Sri Lanka for the Directorate of Mental Health. The third section of the paper reviews work undertaken with a major psycho-social/mental health organization on issues relating to writing and implementing an ethical code for mental health practitioners and briefly discusses some of the dilemmas associated with this.     

Evaluation of competence to consent to assisted suicide: views of forensic psychiatrists

OBJECTIVE: Mental health evaluation of competence to consent has been proposed as an important safeguard for patients requesting assisted suicide, yet mental health professionals have not developed guidelines or standards to aid in such evaluations. The authors surveyed a national sample of forensic psychiatrists in the United States regarding the process, thresholds, and standards that should be used to determine competence to consent to assisted suicide. METHOD: An anonymous questionnaire was sent to board-certified forensic psychiatrists between August and October 1997. RESULTS: Of the 456 forensic psychiatrists who were sent the questionnaire, 290 (64%) responded. Sixty-six percent believed that assisted suicide was ethical in at least some circumstances, and 63% thought that it should be legalized for some competent persons. Twenty-four percent indicated that it was unethical for psychiatrists to determine competence; however, 61% thought such an evaluation should be required in some or all cases. Seventy-eight percent recommended a very stringent standard of competence. Seventy-three percent believed that at least two independent examiners were needed to determine competence, and 44% favored requiring judicial review of a decision. Fifty-eight percent believed that the presence of major depressive disorder should result in an automatic finding of incompetence. Psychiatrists with ethical objections to assisted suicide advocated a higher threshold for competence and more extensive review of a decision. CONCLUSIONS: The ethical views of psychiatrists may influence their clinical opinions regarding patient competence to consent to assisted suicide. The extensive evaluation recommended by forensic psychiatrists would likely both minimize this bias and assure that only competent patients have access to assisted suicide, but the process might burden terminally ill patients.     

A transdisciplinary approach to adolescent forensic mental health

OBJECTIVE: To examine new strategies which may be implemented to address the significant mental health and substance abuse problems of young people within the juvenile justice system. METHOD: Wide-ranging literature review of mental health problems within the juvenile justice population is given, illustrating the high prevalence of mental health problems within this cohort of young people. Reference is made to the differing demographics and agendas of the American justice system compared to that found in Australia. RESULTS: It is suggested that new initiatives stemming from quality Australian studies are required in order to facilitate reform within adolescent forensic mental health. Psychiatrists need to be at the forefront of innovative policy delivery within the juvenile justice system. CONCLUSIONS: A transdisciplinary approach is required to meet the changing needs of young people within the juvenile justice system. Such a system of care recognizes that these young people and their families have multiple needs that cross traditional boundaries and a collaborative approach across agencies is essential at both the policy and practical level. Psychiatrists have an important role to play in the development of these services. A systemic process to address such needs is offered.     

Who should perform the AIMS examination?

Psychiatrists and nonphysician mental health professionals working in community mental health centers have difficulty establishing the scope of their expertise, defining the limits of their roles, delegating responsibility, and sharing professional liability. The clinical, political, and administrative aspects of these tensions are examined in the context of arguments for and against physicians' delegating to nonphysician mental health professionals the task of screening CMHC patients for tardive dyskinesia using the Abnormal Involuntary Movement Scale. In 43 percent of mental health centers in Massachusetts surveyed by the authors, nonphysicians perform tardive dyskinesia screening. The authors suggest that the benefits of involving nonphysicians in tardive dyskinesia screening in the CMHC setting outweight the disadvantages.     

Ethical Challenges in the Provision of Mental Health Services for Children and Families During Disasters

Purpose of the Review

As mental health professionals assist individuals and communities affected by disaster, they are likely to encounter ethical issues. We conducted a review of academic and grey literature to identify ethical issues associated with the provision of mental health care during disasters, with particular attention to children and families.

Recent Findings

We identified nine categories of ethical challenge: ensuring competent care; protecting confidentiality and privacy; obtaining informed consent and respecting autonomy; providing culturally sensitive care; avoiding harm; allocating limited resources; maintaining neutrality and avoiding bias; addressing issues of liability and employer responsibilities; and conducting research ethically.

Summary

The organization and provision of mental health services during disasters presents ethical challenges for care providers—as well as for communities, coordinators, and policymakers. Mental health professionals need to navigate this ethical terrain in order to provide needed care to individuals and communities affected by crisis.

     

Mental health referral patterns by family medicine educators

Directors of Family Medicine residency programs were surveyed to ascertain which mental health professionals are utilized to deliver psychosocial treatments. Family practitioners themselves are frequent providers for a wide variety of psychosocial treatments. Psychiatrists are referred patients for activites that are traditionally within the realm of psychiatric treatments such as management of chronically psychotic patients, inpatient hospitalization, and utilitization of antidepressant medication. These patterns are important as they may reflect future clinical behavior of Family Medicine residents.     

Ethics of administration: The California crisis

Summary Administrators encounter problems in the ethical sphere substantially different from those encountered by personnel involved mainly in the diadic therapeutic relationship. Although they can never neglect their ultimate responsibility for the individual patient's welfare, it is in the broader reaches of that responsibility that they become involved in local and regional economics, politics, and health policy.Many of the administrator's problems center around lack of resources for maintenance of quality care, progressive erosion of that level of care over time, increasing threats to humanitarian standards and ideals, and the ethical and moral obligations related to their numerous constituencies.Thus, inequitable access to health care, the favoring of clients with good insurance coverage, discriminations in direct service due to crowded facilities, undue physical and mental risks borne by service staff, unavoidable flouting of legal or regulatory standards, the compromising of professional integrity and ideals—all burden the ethical and judicial consciousness of the administrator.In addition, pursuit of one's duty to the public versus one's own institution is worrisome, particularly when untoward events occur in one's institution for which one may take blame. There is also the decision if and when the administrator should take social/political action after other measures have failed and the situation has deteriorated to unacceptable levels.This paper was presented at the symposium Ethical Issues and Changing Health Care Economics of the American Psychiatric Association's Annual Meeting held in San Francisco in May 1989.     

The administration of school-based mental health services.

Challenges and proposed solutions in the administration of school-based mental health services have been addressed. Differences depend on whether the services are provided by the mental health component of an SBHC or by an ISBMHP. Seven common elements relevant in developing and administering school-based mental health services, whether in an SBHC or ISBMHP, have been identified: funding, assessment and resources, program structure, staffing and training, partnership and collaboration, quality assurance, and evaluation. How these elements are addressed varies from school district to indivdual school to individual principal to agencies providing services to specific clinicians. One of the most important lessons learned is that the ecosystem of each school is different; one size does not fit all. When external agencies enter a school, they are in the best case guests, in the worst case foreigners or invaders. Agencies and their clinicians must be respectful, adaptable, flexible, and competent professionals. With such attributes, the chance for an effective collaboration is enhanced. Contributions of school-based mental health services to the child and adolescent mental health delivery system include (1) access to services for disadvantaged and underserved youth, (2) system-wide collaboration, (3) prevention of acute psychiatric intervention, (4) gate-keeper role for more acute or specialized care, (5) systematic program evaluation in a "naturalistic" setting, (6) professional training in working with a range of systems and cultures, and (7) outreach and community-based care. With the emphasis on partnership and collaboration, school-based programs have the potential to benefit the children and families, schools, communities, and managed care organizations. The provision of access and early intervention is cost effective in the long run, and findings indicate that school-based mental health service is as effective as that of a central clinic. With the emphasis on collaboration, partnership, and bridging systems and cultures, the provision of school-based mental health care may be able to offer tools and experience to create integrated systems of care. This is a reciprocal process and an ongoing dialectic, however. Providers and planners of a school-based mental health programs, schools, and managed-care leaders can learn from one another, and all have major contributions to make to the overall delivery system. Schools and mental health service providers contribute knowledge and skills in working with this population; managed care organizations bring administrative and fiscal expertise and a focus on and mandate for quality and cost-effective care. For-profit and not-for-profit agencies must enter into a dialogue to educate and understand each other so that they may become collaborators in the underutilized service for children and youth.