Ethical Challenges in Serving Diverse Population: Whatever Happened to Individual Differences?

1. Ethical Challenges in Serving Diverse Population:Whatever Happened to Individual Differences? Gerald P. Koocher, Ph.D.

2. Learning objectives • Using a mindfulness perspective, participants will reflect on their own ability to recognize client differences that may trigger a stereotypic response in themselves. • Participants will identify significant variations in clinical populations that will require them to adjust their practice approach from an ethical perspective, including (for example) differences in age, race/ethnicity, gender preference, linguistic ability, and physical disabilities. • Using case examples, participants will discuss and share strategies for ethically appropriate steps when confronted with diverse clients for whom they lack specialized competence or training to serve. • Participants will frame strategies to recognize both subtle and obvious client differences that might warrant special ethical considerations and adapt their practices appropriately.

3. 2.01 Boundaries of Competence • (a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

4. 2.01 Boundaries of Competence • (b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.

5. FDA’s “Compassionate Exemption” • The term “compassionate use” or “compassionate exemption” means that a patient is allowed to receive a drug even though he/she does not meet the eligibility criteria of a clinical trialin which the drug is being studied. • The decision to provide a drug in this manner is made on a case-by-case basis and there must be a reasonable expectation the drug will prolong life or improve a person’s quality of life.

6. Psychological Rationale • 2.01 (d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study.

7. 2.02 Providing Services in Emergencies • In emergencies, when psychologists provide services to individuals for whom other mental health services are not available and for which psychologists have not obtained the necessary training, psychologists may provide such services in order to ensure that services are not denied. The services are discontinued as soon as the emergency has ended or appropriate services are available.

8. 9.06 Interpreting Assessment Results • When interpreting assessment results, including automated interpretations, psychologists take into account the purpose of the assessment as well as the various test factors, test-taking abilities, and other characteristics of the person being assessed, such as situational, personal, linguistic, and cultural differences, that might affect psychologists' judgments or reduce the accuracy of their interpretations. They indicate any significant limitations of their interpretations. (See also Standards 2.01b and c, Boundaries of Competence, and 3.01, Unfair Discrimination.)

9. Ten Key Considerations on Addressing Cultural Issues in Psychotherapy, adapted from (La Roche & Maxie, 2003) 1. Recognize that cultural differences are subjective, complex, and dynamic. 2. Understand that forming a good therapeutic alliance requires addressing the most salient cultural differences first. 3. Addressing similarities can form a good prelude to discussion of cultural differences. 4. Recognize that the client’s level of distress and presenting problem will influence appropriate timing for discussion of cultural differences in psychotherapy. 5. Consider cultural differences as assets that can advance the therapeutic process.

10. Ten Key Considerations on Addressing Cultural Issues in Psychotherapy, adapted from (La Roche & Maxie, 2003) 6. Understanding the patient's cultural history and racial identity development is critical to assessing how best to conceptualize presenting problems and achieve treatment goals. 7. The meanings and salience of cultural differences are influenced by ongoing issues within the psychotherapeutic relationship. 8. The psychotherapeutic relationship exists embedded within the broader cultural context that in turn affects the relationship. 9. The therapist's cultural competence will have an impact on the way differences are addressed. 10. Dialogues about cultural differences can have an effect on the patient's cultural context.

11. Are psychologists human, and if so… Where do our biases come from?

12. Examples of Heuristic Biases • Anchoring effect • Base rate neglect • Confirmation bias • Failure to adjust sufficiently from initial anchor points, even when the points are arbitrary. • Overlooking background frequencies in favor of salient anecdotal evidence (e.g., “All my clients are liberal Democrats, so…”). • Seeking out opinions and facts that support our own beliefs and hypotheses (e.g., “I’m sure I’m right, I just need to find the proof”). Name Description

13. Examples of Heuristic Biases • False consensus bias • Fortune teller effect (or Barnum effect) • Inclination to assume your beliefs are more widely held than they actually are (e.g., “Family therapists pretty much agree on this”). • Tendency of people to accept general descriptions as uniquely relevant to them (e.g., “You think about sex from time to time”). Name Description

14. Examples of Heuristic Biases • Groupthink • Homogeneity bias • Lake Wobegon effect • Pressure to irrationally agree with others in strong team-based cultures (e.g., “I better keep my odd ideas to myself because the rest of the team thinks the sky is green”). • Exaggerated conclusions about large populations based on small samples (e.g., “My three clients typify the universe”). • Coined by Garrison Keillor, the tendency of people o assume they are “above average.” Name Description

15. Examples of Heuristic Biases • Not my fault bias • Truthiness • Wow effect • If the patient does not improve, it could not have been me (e.g., “They must have not followed my advice or screwed up some other way”). • Coined by Comedy Central's Stephen Colbert, refer-ring to the human propensity for determining truth by what we feel in our gut, independent and frequently in opposition to objective reality or scientific research. • Salient memories override normative reasoning Name Description

16. Unstable Police Officers The client: a gay , 30 something state police officer with depression and axis II features, along with many years of chaotic, unstable relationships, often involving lots of drinking.  Situation:  client gets involved with another trooper who sounds "borderline"....highly emotional, needy, manipulative, history of lots of crazy drama with both men and women. These two break up and get back together frequently, always much drama. My client isn't healthy enough to see where this could go. Is too taken with beauty and wild sex.  Six months later, my client comes in saying she feels "trapped in my own home." Her girlfriend accuses her of cheating, or not being reliable, or not loving her enough, etc. and has made a couple of suicidal "gestures“ (i.e., getting very drunk and cutting her wrists).  Once while my client was sleeping, and once while my client was out of the house. My client says she did not call 911 or use ER because of the possible repercussions to both of them professionally as state police. The girlfriend continues to be very depressed, insecure, irrational and is pretty much living at my clients home. 

17. Unstable Police Officers Ethics questions: • One concern I have (in addition to urging my person to get out of this relationship) is that I am hearing about a clearly impaired police officer, responsible for protecting the public safety. I don't think my client is the only one at risk. These people have guns and fast cars and access to so much.  • Is there any duty to warn her employers regarding her mental status ?  I know we can't predict dangerousness too well but this whole situation made me very nervous. 

18. Diversity Secrets in a “Small World” • I work with a 19 year old female who has a history of sexual abuse. She was a previous client of mine when she was 14 years old and has returned to therapy on and off over the years. This most recent return was due to a break up with her boyfriend, who had lied to her and betrayed her. The client has a Dx of MDD, and still lives at home with her parents. Her older brother and father both have substance abuse issues, mother is not supportive of client. • The client has begun dating a new boyfriend and disclosed the name, workplace and other identifying information of her new boyfriend to me. I immediately recognized the boyfriend as the client of a colleague with whom I share an office and with whom I participate in peer supervision. As a result, I know that my client’s boyfriend is actually a biological female living as a male and at the very beginning stages of transitioning to a male.

19. Diversity Secrets in a “Small World” • My client also told me that during high school, rumors circulated around the school that her boyfriend was actually a female. My client stated that she recently confronted her boyfriend about those past rumors and was told that they were untrue. • Obviously, confidentiality prevents me from disclosing any information to the client, but ethically, it has felt difficult to know this information when she speaks to me about him. I also worry about the ramifications of the clients running into each other in the waiting room (though we have tried to prevent this) for both of their privacy as the therapist whom the boyfriend sees is a gender specialist and I worry that my client might figure this out. • Lastly, I wonder what impact if/when my client learns that her boyfriend is a biological female.

20. Nan Turner • During her first session with Nan Turner, a 28‑year‑old African American woman, Darla Dense, M.D., asked about which part of the urban ghetto Turner had grown up in. Turner explained that she grew up in the same suburban community as Dr. Dense, but the psychiatrist's could not believe some of the experiences Turner reported. Dr. Dense’s perceptions of the town were quite different from Ms. Turner's, and Dense could not recognize the possibility of such things happening, so she concluded that Turner was either misrepresenting her past due to shame or had poor reality testing abilities.

21. Carrie Crouzon • Carrie has Crouzon Syndrome, an autosomal dominant genetic condition sometimes called craniofacial dysostosis. The condition was detected at birth and she has had more than 30 surgical procedures; first to prevent brain swelling in infancy and then to help improve her airway, dental functioning, and physical appearance. During childhood people frequently assumed that she had cognitive delays even though her IQ is well above average. As a college student she has sought psychotherapy to help with pervasive self-esteem problems and concerns about future reproductive issues. She has a boy friend but seems preoccupied with how she might handle a pregnancy. The therapist she is assigned to see at the college counseling center has difficulty making eye contact with her.

22. Marsha Young • Marsha Young, a recent business school graduate, won a job at a prestigious advertising agency. The office was highly competitive, and she soon developed anxiety attacks and insomnia. At times, she felt as though she were the “token woman” in the organization, and she feared that her work was being scrutinized far more critically than that of recently hired males. She sought a consultation with Jack Chauvinist, Ph.D. Dr. Chauvinist soon concluded that Ms. Young suffered from “penis envy” and was afraid of heterosexual intimacy. He advised her that it was critical for her to address these matters in therapy if she ever hoped to be able to be married and bear a child, thus fulfilling herself as a woman.

23. Henry Tower • When Henry Tower, an African American college student over 6‑feet tall, went to the University Counseling Center for help in dealing with difficulties he was experiencing on campus, he was assigned to Biff Jerko, Psy.D. In an effort to “forge an early alliance,” Dr. Jerko attempted to greet Mr. Jackson with a “high five” instead of a more traditional handshake. During the course of the session, Dr. Jerko continued his “attempt to connect” by using profanity and slang that he regarded as emulating “ghetto talk.” Mr. Jackson wanted to talk about the fact that his imposing stature and dark skin seemed to make people uncomfortable. Dr. Jerko quickly attempted to reassure Mr. Jackson that he would be judged only by his character and studies on campus and resisted exploring the impact of prejudice that may accrue to tall black males. Neither the hand greeting nor slang use were a part of Mr. Jackson's background, and both were perceived as alienating. Adding insult to injury, Dr. Jerko asked Mr. Jackson whether he planned to try out for the college basketball team. Jackson did not have the energy or assertiveness to attempt reeducation of the therapist, and he never returned for another appointment.

24. Carlotta Familia • Carlotta Familia, a Latino woman in her early 20s, was struggling with issues involving her relationship with her mother when she sought consultation with Carl Cutter, M.S.W. Ms. Hernandez was the first college‑educated person in her extended family and was torn between traditional obligations to family and her newly experienced social mobility. Mr. Cutter praised her academic achievement and encouraged her to sever or at least minimize contact with her family, which continued to reside in a poor inner‑city neighborhood. He did not understand the importance of balancing family connections with individual achievement manifested in many Latino cultures. Ms. Hernandez needed to pursue options of how to stay connected in an emotionally healthy way. The more Mr. Cutter pressed her to disconnect, the more depressed she felt.

25. Inda Closet • Inda Closet had always felt attracted to other women, but had dated men from time to time because it was what her parents and society seemed to expect of her. Concerned about sexuality, fearful of social rejection, and wondering about how to explore her sexual feelings, Ms. Closet built up the courage to consult a psychotherapist and made an appointment with Heda Knowsitall, Ph.D. After taking a brief history Dr. Knowsitall informed Ms. Closet that she was “definitely heterosexual” because “she had a history of dating men and, therefore, instinctual drives toward heterosexuality.” Closet was advised to enter behavior therapy to “unlearn” her attraction to women.

26. Pam Passer • Pam Passer, a very fair‑skinned African American, was concerned about just how “black” she was, given that she could “pass” as White. Robert Blinders, L.M.H.C., her therapist, dismissed such concerns, stating that she should just see herself “as an American.” Passing for White might give her greater social and professional mobility, but the price would be disconnection from her family and the community in which she was raised. Mr. Blinders can not seem to hear the implications of the disconnections for her, as these were not his values.

27. Carl Quandry • Helena Sistine, M.D., is a psychiatrist and a conservative Christian who holds deep traditional values. She works in the counseling center of a state university. Carl Quandary came in for an initial appointment and wanted to discuss the anxiety he has experienced over several homosexual contacts he has had during the prior 6 months. Mr. Quandary reports, “I don't know what I'm supposed to be. I want to try and figure it out.” Dr. Sistine realizes that her own feelings of opposition to homosexuality would make it difficult for her to work with Quandary objectively, especially if he should decide to continue having sexual relationships with other men.

28. Yochi Tanaka • Yochi Tanaka was the eldest son of a proud Japanese family, who was sent off to attend college in the United States at age 17. He had some difficulty adjusting at the large state university and failed midterm exams in three subjects. Mr. Tanaka sought help at the college counseling center and was seen by Hasty Focus, M.A., an intern. Mr. Focus, became misled by Tanaka's excellent command of English, Western‑style fashion consciousness, and tendency to nod in seeming assent whenever Focus offered a suggestion or interpretation. Focus failed to recognize the subtle, but stressful, acculturation problems or to detect the growing sense of depression and failure Tanaka was experiencing. Tanaka was apparently unwilling to assert his concerns over the interpretations of the “expert” in an impolite or unseemly fashion. After 5 sessions and 6 weeks, fearing failure on his final exams and disgrace in the eyes of his family, Tanaka committed suicide.