Ethics and Accountability in Forensic Mental Health - Essay Example

Ethics and Accountability in Forensic Mental Health In looking at the case of Wayne it is very clear to see that the consumer perspective can be vastly different from the clinical perspective. Wayne is a 26 year old male who has been charged with hurting a 15 year old girl at a bus stop. He suffers from delusional behaviour that appears to be attributed to paranoid schizophrenia. He saw a girl whom he thought was laughing at him and he created a full story around the situation. He also has been off his medications and is reluctant to take anything as he does not believe he needs it. Wayne was admitted to a hospital, was uncooperative, and . He was violent with a nurse when she tried to give him an injection. He does not want to sleep for fear that he will be harmed. Wayne also abuses drugs (primarily marijuana) which seems to increase his paranoia. The case study does not say that Wayne was on a compulsory admission to the hospital but since the police admitted him, it was probably compulsory. According to The World Health Organization: No treatment should be provided against the patients will, unless withholding treatment would endanger the life of the patient and/or of those who surrounded him or her. Treatment must always be in the best interest of the patient (As cited in Steinert et al., 2005, p. 635). In Waynes case, withholding treatment both for medicine and mental health has exacerbated his paranoia and his behaviour. In this case, it is ethically correct to give him the medication against his will in order to stop him from causing harm to himself or others. To put Wayne into the hospital, the police or the hospital would have had to use informed consent with him. In other words, they would need to be aware of Waynes privacy and they would have had to follow the principles of beneficence and malfeasance (do no harm) (American Mental Health Counsellors Association (AMHCA) Code of Ethics). Also, they must tell Wayne what is going to happen to him, how they will use any information received and the type of treatment he can expect. Since Wayne is an adult and he does not want his family to be contacted, under the law and under ethics they cannot tell his family. This may go against what the health practitioners think but it would be important to honour his wishes. Wayne appears delusional. According to his account, he has magic spells being put on him by witches. He states that the police took him to the hospital. He sees himself as a victim of this situation, and sees all those around him as his enemies. According to his account, his actions are due to his anticipation of how others are going to treat him or are currently treating him. Howe (2008) states that clinicians must tell patients the truth about their conditions no matter what the situation. He states that "the degree to which a psychiatrist withholds information may disrespect a patients autonomy …" (p.1). He also states that withholding information may meant that they are doing harm to the patient. One blatantly unethical situation that presented in the clinical perspective was that Waynes case manager was on vacation and no other provisions were made for him while the case manager was gone. This meant that he was without supervision for at least four months prior to the incident at the bus stop. This issue suggests that Wayne may not have acted out in the way that he did if he had the supervision needed. According to the AMHCA Code of Ethics (2010) one of the clients rights is "to expect quality service provided by concerned, trained, professional and competent staff" (Code of Ethics, "Clients Rights", 7a, p. 8). The clinicians working with Wayne in the Housing Commission Unit also created problems for him by not being professional or competent. "The primary responsibility of mental health counsellors is to respect client dignity and promote client welfare" (AMHCA Section A-1a, p. 2). In this instance, Wayne showed a disrespect for his dignity and his welfare. As stated previously, Waynes behaviour isdelusional. He says he has an angel, Miranda, who warns him about the witches around him. Everyone he knows, whether it is family or friends, is suspected of being a witch or conspiring with the witches against him. When Wayne is on medication, this delusional behaviour seems to lessen. Wayne feels coerced to accept his diagnosis of schizophrenia especially when it comes time to take his medicine. Winick (2004) studied the issues that made clients feel coerced and found that they felt coerced when: 1. The attitudes of the individuals who admitted them acted as though they were acting out (the patients fault) rather than seeing the admission to be in the best interest of the patient. 2. The patient had no voice in what was happening to them. 3. The patients voice was not heard or taken into consideration during the admission process. Patients also expect to be treated fairly rather than to be tricked into the hospital admission and do not want to be pressured to do it. (Winnick, 2004). Wayne was not coerced by the police because he did not act out until the nurse tried to give him medication at the hospital. From his point of view, he did not like the fact that he had to go to the hospital and stay, but he did not fight it. In the hospital on the medication, he showed improvement. Wayne was seen in the hospital by a psychiatrist that he had previously seen. She disclosed information to the hospital staff about him. The question is whether the psychiatrist had Waynes permission to give this information to the hospital. A release of information form should have been signed by Wayne in order for the psychiatrist to share any information. Also, the hospital shared information with the psychiatrist about Waynes criminal history and information from other agencies. This action again needed a release of information form from Wayne. Otherwise, they could be breaking the do no harm edict because giving this information could have created more problems for Wayne if the psychiatrist was not honourable with this interaction. Wayne had a hospital stay of six months. During this time, many of the staff attributed his behaviour to an "anti-social personality disorder" and thought he could be using drugs or perhaps was sexually motivated (judging by their fear of him interacting with young girls). These staff created a climate that may not be conducive to Waynes healing. In fact, there could be a setting for countertransference. Pirzada, Pinols, and Gutheil (2002) studied countertransference as it applied to psychiatrists in forensic training. According to their research, the American Academy of Psychiatry and the Law states that "a forensic psychiatrists role is to give an honest, objective, impartial, and unbiased opinion to the retaining agency" (p. 65). This means that Waynes psychiatrist should strive to do what she can to help him and not become biased because of his current behaviour or criminal record. Many issues can evolved from the psychiatrist that show countertransference. As an example, in Waynes case, the psychiatrist could feel uncomfortable or threatened when Wayne shows what appears to be an antisocial behaviour. She could give the wrong diagnosis based on her own feelings about what Wayne is doing or has done rather than staying objective. (Pirzada, Pinals, and Gutheil 2002). The issue of countertransference also goes back to the ethics of doing no harm as well as being a competent healthcare professional. The psychiatrist can do harm to Wayne if the diagnosis is not correct. She can also show incompetence if she has no background in forensics. The AMHCA Code of Ethics also states that mental health counsellors must have the knowledge and competence of forensics and a knowledge of specialized populations, testing and interview techniques. It would seem that that a psychiatrist would need to have the same background. The Code of Ethics states that mental health workers do not "evaluate for forensic purposes, individuals whom they are currently counselling or have counselled in the past" (AMHCA Code of Ethics, 2010). Because Waynes psychiatrists saw him in the past, there may be a challenge for Wayne if he goes to court about the present situation. Heilbrun, DeMatteo, Marczyk, and Goldstein (2008) suggest that a standard of care should be established in forensic mental health. They suggest that the standard of care makes sure that all health care practitioners are adhering to the same professional standards. It is important to note that a good standard of care creates a way for patients to be taken care of within any mental health facility. Waynes standard of care, seems very good in the hospital but in the community, it seems more relaxed. . He was given his medication and he was receiving mental health services, in an attempt to stabilize his behaviour. Bota, Sagduyu, Filin, Bota and Munro (2008) suggest that there is a better way to identify schizophrenia and that it should be done in the preprodromal period if possible. This period is when symptoms are nonspecific but where schizophrenia is beginning. They observed that schizophrenic patients often have "multiple developmental and achievement [problems]" (Bota et al. p. 219) before they actually enter the prodromal period. Thinking of this information, it stands to reason that there would be other challenges leading up to a diagnosis of schizophrenia which may be true in Waynes case. Wayne has challenges with achievement because it seems he has never achieved anything for his life. He hears voices and appears to be delusional without his medication. In order to work he would need to stay on medication. Although he likes Gary and Gary was able to get him to take medication, Wayne is not self-motivated to stay on medication. In fact, outside of the hospital, he cannot resist temptation to do drugs with his friends. Clearly, Waynes attitude is keeping him away from managing his illness. Wayne does not take responsibility for his current or past actions which in this researchers opinion, poses a threat to the community. This issue is apparent in his current interaction in the community. From the consumer point of view, Wayne states that he is working and still looking for a girlfriend. However, he has also identified a woman in the community who he blames for his behaviour. In his words, "it was all the fault of the bitch on the telephone, the one who has been talking to me for a while now…" and he says he knows who she is, where she lives and "I know how to fix her--I know where she lives". This could be another one of Waynes delusions and the woman could be nonexistent. However, he may have targeted someone in the community or the centre to focus on and his statement "What he doesnt know wont hurt her" is disturbing. Staff does not seem to be aware that he is lying when he talks to them. Ethically, Waynes standard of care may be compromised because the staff is not paying attention to what he is saying. The clinical view does not state that the staff was concerned about his statements. There are two issues however that are important to discuss that should concern the staff. The first issues is that Waynes delivery route includes a school that has young children, including the niece of one of the staff. The second issue is confidentiality and whether the staff should tell Waynes employer about his past criminal history. In the first issue, ethics does not come into play unless Wayne knows the case managers niece. If he knows here, then this may cause a problem, but if not, his confidentiality must be kept. Also, in the second situation, Waynes history has no relevance to his job (legally) unless something happens or unless the staff feels that there is a danger to others. The staff would have to ask themselves about their professional roles and whether it is in their role to tell his history. Grubin (1999) studied antisocial behaviour to identify where confidentiality must be followed. He suggests that individuals working with certain types of clients may have to make a "moral decision between their obligations to the person they are treating and their duty to the public … or in relation to potential but unidentified victims" (p. 77). In understanding Waynes situation from the clinical viewpoint, this may be more a moral dilemma than an ethical one. However, the Tarasoff ruling made other issues apparent in understanding the rights of the client to confidentiality. Under this case, confidentiality could be broken if staff felt Wayne would commit a crime again with another child. In most instances, a clinician cannot predict the dangerousness of an individual (Grubin, 1999) which makes it more difficult to predict whether Wayne would be dangerous. The clinician must understand that there is a gentle balance between what they know and what can be told to people who are not clinicians. Their first duty is to their client except when there client is a danger to themselves or to others. However, there must be evidence that clearly shows that the client has the intention to harm someone. The Tarasoff case clearly shows that when a client make allegations or open threats towards someone, they should be taken seriously and the clinicians have a duty to warn the individual. In Waynes case, he has made a threat against someone that the staff does not know, and they must take this threat seriously and question Wayne more to find out who his intended victim is and whether he has plans to harm them. To tell his boss, the school personnel or anyone else would not be ethical unless they are sure he poses a real threat. The last area to discuss for Wayne is his recovery from drugs as well as from schizophrenia. Schizophrenia is a mental illness that some people recover from over time. Beeble and Salem (2009) studied steps in the recovery process for schizophrenics who attended Schizophrenics Anonymous (SA) meetings. They found that there were four phases in recovery from schizophrenia: "1) mourning and grief, b) awareness and recognition, c) redefinition and transformation, and d) enhanced well-being and quality of life" (p. 249). Within the first phase of the model, the individual stated they lost hope and often had feelings of despair, anger, or denial. This also meant hat the individual had to see and understand how schizophrenia was impacting their lives in Phase 22. In looking at Waynes case, it would seem that he is in the first phase but he has not identified that he is angry or feeling hopeless because of his schizophrenia. This would be something that the mental health program working with him should explore. He has strong feelings about having to take medication and he does not like being labelled schizophrenic, but he has not identified any other feelings around his disease other than to blame others for his behaviour. Westermeyer (2006) studied comorbid schizophrenia and substance abuse (SCZ-SUD). What he found was that many people who experienced co-morbid schizophrenia also experienced use of cannabis, and this cannabis abuse could start at any part of their identification as schizophrenic. This could be a natural state for some people with this mental illness but marijuana is still illegal unless it is used for medicinal purposes in many states. This must be more directly addressed with Wayne and there may be a need for rehabilitation for him. Conclusion Schizophrenia is a difficult mental illness to work with, especially when the individual does not stay on their medication. In Waynes situation, the major ethical considerations are confidentiality, Waynes rights as he was admitted to the hospital, his standard of care while he was there and his job that could possibly put others at risk. These situations can cause more difficult for him and for people around him if not addressed. Wayne seems to do better when he is taking medication, but he may also have an anti-social personality disorder. This was indicated in the case study but it is not clear whether this is a true diagnosis or one brought on by his drug use and inability to deal directly with his issues. Wayne will need to go through some type of rehabilitation for his drug use, in earnest, if he is to move towards recovery of any kind. He may eventually be able to recover from schizophrenia but he will need to be in a better place emotionally. References American Mental Health Counsellors Association (2010). Code of ethics. Accessed 22 September 2010 http://www.amhca.org/assets/content/ AMHCA_Code_of_Ethics_11_30_09b1.pdf Beeble, M.L. and Salem, D.A. (2009) Understanding the phases of recovery from serious mental illness: The roles of referent and expert power in a mutual-help setting. Journal of Community Psychology. 37 (2) 249-267 doi: 10.1002/jcop.20291 Bota, R.G., Sagduyu, K., Filin, E., Bota, D. and Munro, S. (2008). Toward a better identification and treatment of schizophrenia prodrome. Bulletin of the Menninger Clinic. 72 (3) 210-227. Accessed 22 September 2010 from Academic Source Premier database (AN: 35215882) Grubin, D. (1999). Therapist or public protector? Ethical responses to anti-social sexual behaviour. Sexual and Marital Therapy, 14 (3) 277-288. 10.1080/02674659908405412 Heilbrun, DeMatteo, Marczyk and Goldstein (2008) Standards of practice and care in forensic mental health assessment: Legal, professional and principle based considerations. Psychology Public Policy and Law 14 (1) 1-26. doi: 10.1037/1076-8971.14.1.1 Howe, E. (2008). Ethical considerations when treating patients with schizophrenia. Accessed 22 September 2010 from http://www.psychiatrymmc.com/ethical- considerations-when-treating-patients-with-schizophrenia Pirzada, S., Pinals, D.A. and Gutheil, T. (2002). Countering countertransference: A forensic trainees dilemma. Journal of American Psychiatry Law. 30 (1) 65-69. Accessed September 23, 2010 from http://www.jaapl.org/cgi/reprint/30/1/65.pdf Steinert, T., Lepping, P., Baranyai, R, Hoffman, M., and Leherr, H.(2005) Compulsory admission and treatment in schizophrenia. Social Psychiatry & Psychiatric Epidemiology. 40 (8) 635-641. doi: 10.1007/s00127-005-0929-7 Westermeyer, J. (2010). Comorbid schizophrenia and substance abuse: A review of epidemiology and course. American Journal on Addictions. Accessed 22 September 2010 15 (5) 345-355. doi: 10.1080/10550490600860114 Winnick, B.J. (2008). A therapeutic jurisprudence approach to deal with coercion in the mental health system. Psychiatry Psychology and Law. 15 (1) 25-39. doi: 10.1080/13218710801979084 Read More