Ethical and Professional Responsibilities As a behavioral health technician it is your professional conduct that gets patients safely through their day. You are responsible for a myriad of tasks from charting to the mood in a particular group. Your conduct and choices have much to do with the success of the therapeutic atmosphere.
It is crucial for you to have an excellent understanding of patient’s rights, cultural diversity and how a client’s cultural background effects their treatment, confidentiality requirements and mandatory abuse reporting issues. This course will explore these topics.
Professional Conduct and Ethics
As a result of increased litigation and ethics complaints against mental health practitioners — a significant portion of which alleges some kind of ethics violation — many professional education programs, social service agencies, licensing boards, and professional associations are sponsoring special training and education on ethics-related risk management, especially related to such issues as confidential and privileged information, informed consent, conflicts of interest, dual relationships and boundary issues, termination of services, and documentation. This training and education typically focuses on common ethical mistakes, procedures for handling complex ethical issues and dilemmas, forms of ethical misconduct, and prevailing ethical standards.
The professionals mantra is do no harm. Sometimes with legal stipulations requiring one thing and a code of ethics stating the opposite, as a practitioner in the mental health field you can be left asking, which action is less harmful rather than do no harm.
Ethical decisions made during treatment can be challenging, but the effort of keeping the clients best interest at heart remains primary.
The working definition of ethics includes the study of standards of conduct and moral judgment; this is the system or code of morals of a particular person, religion, group or profession. To be ethical means, as a professional, you are conforming to the standards of conduct agreed upon by a given profession or association. Morals refer to the principles of rightness or wrongness that individuals or groups adhere to. We can differentiate between morals and ethics. To be moral implies conformity with the generally accepted standards of goodness or rightfulness of conduct or character. To be ethical implies conformity with an elaborated, ideal code of moral principles, sometimes with the code of a particular profession. It takes honesty and courage to use introspection and recognize how our morals and values affect how we behave in a professional situation. A mental health technician who was molested at the age of 6 will undoubtedly be affected by this experience, particularly when a convicted child molester is the client. As objective as we want to be, we all see through our own filters. What is most important is rather than insisting we see every client as a blank slate, admit and continually check ourselves for the filters that are part of who we are. To be aware of them and act accordingly is far more ethical than to deny they exist.
The Florida Certification Board provides certification for professionals in the State of Florida. The FCB is dedicated to the principle that certified professionals must conform their behavior to the highest standards of ethical practice. To that end, the FCB has adopted the Certified Professional Code of Ethics (the Code) to be applied to all professionals, certified or seeking certification.
The FCB may refuse to issue a credential to any applicant, may issue a reprimand, or suspend or revoke the credential of any certified individual who have been convicted of a felony, is found to have been in violation of the Code, or falsifies any information on the application or in the Application Portfolio.
All applications for certification require applicants to indicate whether or not the applicant has ever been convicted of a felony. If the applicant indicates “yes” in this section of the application, he/she must provide the FCB with any and all information concerning any arrest(s), convictions, indictments, suspensions, or revocations.
The FCB is committed to investigate and sanction those certified professionals or those seeking certification who breach the Code. Certified professionals or those seeking certification are therefore encouraged to thoroughly familiarize him/herself with the Code and to guide their behavior according to the rules set forth within the Code.
A link to The Florida Certification Board’s Code of Ethics can be found at the bottom of this course. Please familiarize yourself with the code.
Client rights vary widely in substance across different levels of care and treatment settings. The foundation for client rights is in federal statutes and regulations (Medicare, Medicaid, etc.), state statues, licensing requirements for the treatment providers, legal requirements and court mandates, as well as the differing professional codes of ethics.
It is good and standard practice to supply the client with a written copy of their rights upon orientation to a program. It is recommended that the patient sign a copy of these rights and/or a statement that they received the rights. This document should be added to the clients chart.
Again, rights within the public mental health system are founded in the state statutes. To list every states statutes is beyond the scope of this course. It is recommended that each program research the requirements in their state.
The primary purpose of confidentiality is to protect client’s right to privacy by ensuring that matters discussed with a professional are not disclosed to others without the expressed consent of the client. Clients need to be well informed on what is held confidential and what is required by law to be reported. This will help to build trust and through this trust the client will be more willing to be open and honest and participate in treatment more fully.
There are limits to Confidentiality. For example a counselor can request a group keep each other’s information private, but it needs to be understood that lack of privacy is an inherent risk with group counseling. There are other limits of confidentiality, including concerns of safety.
Typical Limits to Confidentiality:
This list is not inclusive, but rather a guide to typical situations where confidentiality often gets limited. Always, always, always inform the client in writing with their signature of any limitations of confidentiality before beginning treatment.
Before releasing ANY client information without written authorization from the client consult a supervisor or attorney and document this consultation.
- Child abuse or Neglect
- A client is deemed a danger to themselves or others
- During a medical emergency, information relevant to the emergency.
- Under defined circumstances, providers are required to reveal
- information on minors to parents, guardians, or surrogate decision makers.
- Third party payers and state oversight agencies.
A consent to release information should follow these guidelines:
It should be in writing and include:
- The name or general designation of the program(s) making the disclosure.
- The name of the individual or organization who will receive the disclosure.
- How much and what type of information is to be disclosed.
- A statement that the client may revoke the consent at any time, except to the extent that the program has already acted on the basis of the consent (already released information).
- The date, event or condition upon which the consent expires, if not previously revoked.
- The date upon which the consent is signed.
Mandatory Abuse Reporting
The lengths to which a community goes to protect its most vulnerable members help define it as a civil society. Different states around the U.S. have varying laws that impose requirements on the reporting of abuse to the proper authorities, with the aim of putting an end to violence and emotional harm. Florida’s legislature has enacted mandatory reporting laws for the abuse of children, the elderly and individuals with disabilities.
Who Must Report?
Unlike many states where only specified legal and health care professionals must report abuse and criminal mistreatment of elders and other vulnerable adults, in Florida any person who knows or suspects abuse must report it. However, in the case of children, the list of mandatory reporters is limited. The list includes health care professionals–including doctors, nurses and dentists; educators–including teachers, school administrators, guidance counselors, and school mental health professionals; child welfare agency personnel; child care providers and their employees; law enforcement officers and staff; and people who process or produce printed or visual materials, such as photo processors. Of course, anyone else aware of child abuse may report it, although not legally obligated to do so.
Under Florida’s mandatory reporting laws, knowledge or reasonable suspicion of abuse, neglect or abandonment are applied as the standards for reporting. The actions that must be reported include physical abuse, sexual abuse, neglect by parties responsible for care, words or behaviors that could cause psychological damage, and exploitation.
The laws prohibit false reporting of abuse for the purpose of harassing the accused abuser, financial gain of the reporter, obtaining legal custody of the child or a vulnerable adult, or any personal benefit. Moreover, legal privileges that normally apply between spouses or between physician and patient are eliminated for abuse reporting, although attorney-client and clergy-penitent privileges do apply.
Mandatory reporters must provide their names, addresses and contact information in their reports. However, their identities will be kept confidential by the investigating agencies. Individuals who comply with the law and report abuse in good faith are protected from civil or criminal liability. On the other hand, those who do not fulfill their mandatory duty to report are committing a second-degree misdemeanor.
Historical documents often refer to the United States as the great cultural experiment or a melting pot as diverse peoples are molded and shaped into the American Way of Life. This undertaking has yielded various shades of success as new citizens adapt to a common language, habits and values. The final outcome of the great culture experiment will be determined over the next several generations. A common view is that we the people have made a lot of progress toward accepting people based on their individual merits but we have a long way to go to overcome all of the cultural barriers. Recent trends appear to be toward cultural pluralism and diversity as concepts being advanced to promote the co-existence of various cultural groups, all of who may simultaneously maintain some of their distinctive characteristics. However, there are other conflicts between ethnic and cultural groups, and there is inequality in the social and economic resources available to different groups. There are also different general acceptances, power and prestige issues between ethnic and cultural groups, as well as differences with the majority cultures. These have a significant impact on minority persons who may also have a social or community need. It is often difficult to separate socioeconomic, ethnic, gender, age and other variables that influence the behavior and attitude of members of these sub-populations. Consequently, they often experience multiple jeopardizes, including minority statues, parenting problems, physical and mental challenges, age, lifestyles and other factors.
Individuals who are disadvantaged and sometimes disenfranchised are sometimes labeled as hidden populations and include individuals such as the homeless, chronically mentally ill, criminal and juvenile offenders, prostitutes, runaways and others. It follows that less personal and research data is available on these groups due in part to their migratory lifestyles and loss of identity. They are generally omitted from surveys because they are not living in typical homes, are not attending school and choose to not cooperate with interviewers. However, many members of these groups have a greater need for social services, medical, food, shelter and other services than the general population.
The United States remains a nation in which ethnic minorities and other disadvantaged groups (elderly, females, etc) are often subjected to prejudicial treatment, as well as having to continuously deal with negative life experiences including language, religion, family relationships, value system and community norms. Minority groups and other special subpopulations are disproportionately represented among the economically disadvantaged. They are more likely to live in urban centers that have higher crime rates, poorer schools, substandard housing and fewer employment opportunities.
Ethnic populations are set apart from the mainstream culture by differences in language (whether a foreign language or an English dialect) and create communication difficulties. The language barrier (includes reading, writing and verbalizing) increases stress, interferes with psychosocial functioning and increases the difficulty associated with getting the help they need to successfully integrate themselves into the mainstream of society. Consequently, additional services are often needed to overcome previous deficiencies and also to accelerate the interventions needed for complex social problems.
It should be noted that many ethnic group members, and other special populations, often demonstrate remarkable strengths despite many obstacles and hardships. In some cases, powerful religious beliefs help sustain members through difficult situations. Although family relationships and values may be different, supportive bonds may be formed through extended family members (may include non-related individuals) that are not typically found in the mainstream culture.
General Barriers to Social Services
Racial and ethnic populations may face a number of problems (language, transportation, etc) that may impede their access to social services. Individuals from racial/ethnic groups tend to under-utilize healthcare, prenatal care, mental healthcare and substance abuse treatment, or they seek them as a last resort. Treatment may be sought only when the resources of the traditional family support network have been exhausted. At this point, problems may be so chronic and severe that treatment outcomes may be poor.
The individual’s economic status may be a deterrent to the purchase of services. Racial/ethnic populations are not only more likely to have lower incomes than those of the mainstream population, but to be less insured. For example, the US Bureau of Census (1997) indicated Hispanics were the most likely group to have no health insurance. In 1997, approximately 30% of the total US population received health insurance via Medicare or Medicaid.
Those needing social services may live in areas where access to providers is limited because of distance or transportation problems. Also, those with access may often find services are inadequate or inconveniently scheduled. Others may not realize they are eligible or may not be aware of what services a local program offers. Many social services providers are not able to address specific needs of individuals from cultural backgrounds different form their own, even when they speak the client’s language of origin. This is further compounded when trying to develop written material for linguistic and culturally diverse populations. Issues such as literacy levels and regional differences (different dialects) need to be taken into account when developing written program material.
Beliefs and attitudes regarding health and illness may act as obstacles keeping racial and ethnic populations from seeking treatment for social problems. The literature on health and mental health has identified a number of factors that contribute to under utilization of services. For example, reliance on folk remedies may cause some under utilization of medical services. Cultural stigmas attached to psychiatric care, psychotherapy, counseling may invoke fear of losing status and of being judged a failure by the family and the community, and, thereby, contribute to under utilization. Cultures differ in their characterization and acceptance of abnormal behaviors. For example, what is considered abnormal behavior in one culture may be accepted or encouraged in another. For example the practice of voodoo may be accepted in one group and scorned in other groups. Abnormal behaviors may be attributed to physical or psychological causes or they may be viewed as the direct result of supernatural or spiritual factors.
Emergency rooms often serve as the primary care providers for members of racial and ethnic minority groups in urban areas. Individuals with long-standing social problems are more susceptible to serious medical problems and are more likely to use emergency rooms. However, emergency rooms often are unable to provide appropriate referrals to social services or to provide the follow-up to assure appropriate care is provided.
Regardless of the services required, racism on an institutional or individual level can be a significant barrier to effective treatment. Institutional racism within a service organization is evident when the program design is oblivious to the racial, cultural, or ethnic backgrounds, values, and mores of its client population. Latent prejudices on the part of the staff, as well as language and cultural differences undermine efforts to help patients achieve recovery.
A community in social and economic turmoil may reject social service providers who are outsiders. Negative experiences with providers who may have lacked respect, awareness, or concern for cultural differences often reinforce unfavorable attitudes and distrust. For example, some treatment programs may be rendered ineffective if the community has not been involved in their planning and implementation.
The importance of culture increases in individuals living in a socio-cultural setting other than the one they came from. Also, for those who have not experienced socio-cultural change, cultural issues may come to the forefront in interactions with individuals who do not share the same culture of origin. Such encounters prompt the realization that different cultures view the world in different ways. A way to help bridge those differences is through the acquisition of knowledge about other cultures. Cultural knowledge enhances the understanding of different views and also helps to develop more effective problem solving strategies.
A cultural competency program is one that demonstrates sensitivity and understanding of cultural differences. It is a fundamental ingredient that helps to develop trust, as well as an understanding of the way members of different cultural groups define health, illness and health care. Consequently, culture is a set of academic and interpersonal skills that allow individuals to increase their understanding and an appreciation of cultural differences and similarities within, among, and between cultural/ethnic groups.
A culturally competent social service provider recognizes and utilizes the clients strengths, values and experiences while encouraging behavioral and attitudinal change. Culturally responsive services generally focus on the following:
- Knowledge of the clients native language
- Sensitivity to the cultural mores of the client population
- Staff background similar to clients
- Treatment/services modalities that include values of the client population
- Representation of the client population in decision-making and policy implementation.
It has been recommended that cultural competency programs need to implement cultural competence at all levels: Policy, structure, attitude, staff, and policy. Stated slightly differently, culturally competent systems include professional behavioral norms that are built into the organization’s mission, structure, personnel, and program design and treatment modalities.
Cultural competence also infers the willingness of professionals and the programs they operate to conduct self-appraisals to develop an understanding of how they may differ from the clients they serve. Cultural competence also entails acknowledgement of existing inherent cultural biases on ones attitude and behavior. A providers discomfort in relating to individuals who are different can be communicated many non-verbal ways. Common factors that influence comfort include ethnic and racial characteristics, socioeconomic background, religion, and physical and mental handicaps. However, cultural competence requires communication that goes beyond language proficiency to focus on meanings and interpretations. Consequently, within a culturally competent framework, knowledge of cultural beliefs and expectations are necessary for effective communication.
A conceptualization of a continuum of cultural competence was developed by Georgetown University in 1989. It can be used to assess the level of cultural competence. It includes:
CULTURAL DESTRUCTIVENESS: Attitudes, policies and practices
which are destructive to other cultures.
CULTURAL INCAPACITY: Lacks the capacity to help, but is not
CULTURAL BLINDNESS: Attempts to treat all people as though they
are alike. It infers that one’s color or culture does not matter.
Services are so culturally neutral they are not relevant to
CULTURAL PRE-COMPETENCE: Individuals or agencies realize they
have weaknesses in their cultural competence and attempts to
improve. The risk at this stage is that token change may be
accepted as sufficient.
CULTURAL COMPETENCE: Others are accepted and respected for
their differences and cultural knowledge is continually
expanded. In program settings, staff who are committed to
their particular culture are hired; staff are encouraged to
become comfortable working in cross-cultural situations.
CULTURAL PROFICIENCY: Different cultures are held in high
esteem. Agencies and staff advocate and work to improve
relationships among cultures throughout society.
The melting pot continues to blend people from all cultures into one people. I think the great American experiment has proven successful, as we have adapted the strengths of each culture into the mainstream culture. Again, we have made a lot of progress but there remains a lot of work to be done.
One of the greatest barriers to acculturation of racial/ethnic groups into the American way of life is language. Most early immigrants that came to the U.S. did not speak, read, write or understand spoken English. Fortunately, some of the more recent immigrants have a better command of the English language, but problems still exist especially with low socioeconomic individuals who migrate to the US to avoid poverty and unemployment in their native country.
The language barrier also extends into the workplace. For example, over half of US companies provide limited training material in languages other than English. It appears some progress is being made in this area in recent years and more written materials are becoming available in Spanish but seldom in other languages. There are also additional risks to the workforce due to the language barrier.
o Non-English speaking (and reading) workers are at greater risk due to their inability to recognize hazardous operations.
o Verbal commands or warnings often are misunderstood or not acted upon because of uncertainty.
Due to these factors and other considerations, OSHA requires that employers establish effective communication with non-English speaking workers. Again, some progress is being made but there is a long way to go. One way an employer can bridge the gap is to recognize the need for language interpreting and translation services. Employers may also hire and train bi-lingual staff and translate safety sensitive documents into native languages. The employer may also provide cultural diversity training for all staff.
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