Course:PSYC537/2010WT1/Vignette5
VIGNETTE 5
You are conducting therapy with Aboriginal clients in a remote community via telehealth (i.e., secure videoconferencing). One of your toughest clients has severe PTSD and you have been using a well-known empirically supported cognitive behavioral treatment with him. However, your client has consistently failed to complete the record forms that you have provided for homework and prefers instead to follow the advice of his tribal elder, which often involves ceremonial rituals and medicinal herbs. Your client is making poor progress and you are concerned about his well-being.
STEP 1: Who are the people potentially affected by decision?
The client, the client's elder, you, others in the client's community potentially. (KA)
STEP 2: What are the relevant ethical issues/laws? Which ethical values/laws are in conflict?
Demonstrating respect for the knowledge and experiences of others (client and tribal elder, in this case). Respect, listen and learn from clients who are different from oneself in order to understand what is in their best interests. In addition, there is the element of respecting the client’s ability to have an opinion and make decisions. There’s also the freedom to consent, here, to completing the homework, without coercion or pressure.
You are concerned for the well-being of the client and his poor progress. There is a duty to discern potential harm and benefits, protect and promote the welfare of clients, and strive to provide and/or obtain the best possible service for the client.
Cultural/diversity concerns in terms of competency – Being knowledgeable about community and cultural differences of relevance to this client and evaluate how you interact with him given your own background. Recognise that some theories or interventions based on a different group may not be applicable to this client or may necessitate adjustments. In light of this, there is a need to evaluate one’s competency to work with clients of an Aboriginal background, and you may find that you require additional training to provide the best services for this particular client, or refer him to a more appropriate professional.
Be aware of resources and services provided in the community, and recognising that it may be beneficial to coordinate care with other providers (in this case, the tribal elder).
(JK)
Additionally, part of professionalism and competence is to ensure that care is consistently coordinated with other care providers (in this case, the elder) - this is noted under Principle II, Responsible Caring, in the CPA code (II.18). (SV)
STEP 3: How do personal biases, stresses or self-interest affect my choice of action? My personal beliefs about the roles of traditional healers/religious leaders in the client's life and his community, how much impact (positive or negative) they are likely to have on the client's mental well-being, and also how much therpauetic effect, if any, do medical herbs exert in ameoliorating psychological disorders such as PTSD. When treating aboriginal clients, it is very important to acknowledge the importance of traditional healers (e.g., shamans, espiritistas, tribal elders) in these communities. The effects of psychological intervention may be aided by inclusion of and consultation with religious/spiritual leaders (in this case the tribal elder) who are relevant to the client's cultural and belief systems.
Also, my beliefs about the effectiveness of the cognitive behavioural therapy in working with this particular aboriginal client. Even though this kind of treatment for PTSD has been empirically validated, it is still very important to examine the validity of studies on the treatment efficacy, were most of these studies conducted using populations other than aboriginal minorities? Is there more appropriate, empirically validated and culturally sensitive treatment for aboriginals with severe PTSD? From a theoretical standpoint, are the underlying assumptions, values and procedures in the therapy (e.g., changing maldaptive cognitions)consistent with the client's cultural values and beliefs? The conflicts between the two might have contributed to the client's lack of motivation/noncompliance in therapy. (CC)
STEP 4: Consult with colleagues.
STEP 5: Develop alternative courses of action.
Option 1 - Continue therapy as usual.
Option 2 - Discontinue therapy with the client, instead referring him to seek greater consultation with his tribal elder.
Option 3 - Continue therapy, but discuss with client possible alternative homework assignments that better reflect his cultural values (perhaps completing the homework orally, rather than in written form).
Option 4 - Continue therapy, but seek permission from the client to contact the tribal elder to discuss strategies for continuity of care.
Option 5 - Discontinue therapy with the client, instead seeking a referral for him to see a psychologist with greater training in Aboriginal issues (perhaps a practitioner who combines western-style CBT with Aboriginal rituals. (SV)
Option 3a. Continue with therapy, but take a session to discuss your concerns about the client's slow progress, and to explore his feelings about this particular type of therapy. Give him a chance to discuss how he is finding therapy in general, in the context of his cultural background, to see how his lack of adherence is related to cultural versus individual factors. Before the session, do some research to see if there are other empirically supported treatments for PTSD in Aboriginal populations. If the client is unhappy with this style of treatment, and there are other appropriate options, share these with the client and consider changing the treatment plan. (Note: if you are not trained in these other methods, then you should be prepared to refer the client to other practitioners - see option 5). Alternately, try to see if the treatment could be modified to accommodate the client and help him to better engage (probably want to consult with other practitioners on this). (AH)
STEP 6: Analyze likely short-term, ongoing and long term risks and benefits of each.
Option 1 - Continue therapy as usual. Risks: ignoring the significance of his cultural traditions (eg. listening to his elder) might isolate the client and negatively impact the therapeutic relationship; the client might continue to ignore the homework and not see improvements in his/her mental health Benefits: if client starts to do the homework, they might see the optimal results
Option 2 - Discontinue therapy with the client, instead referring him to seek greater consultation with his tribal elder. Risks: the client might continue to not get the optimal results by following the consultation of his elder; could be seen as abandoning a vulnerable client Benefits: the client’s culture would be respected; the client might have a positive impression of psychotherapy (because of your respecting his traditions) and might seek help in the future if he gives up on the elder’s methods
Option 3 - Continue therapy, but discuss with client possible alternative homework assignments that better reflect his cultural values (perhaps completing the homework orally, rather than in written form). Risks: the client might not get as optimal results as if the client strictly followed the empirically supported CBT treatment Benefits: might preserve the therapeutic relationship because of the cultural sensitivity; might increase the client’s likelihood of doing the homework, consequently getting better results; might maintain the client’s positive image of psychotherapy
Option 4 - Continue therapy, but seek permission from the client to contact the tribal elder to discuss strategies for continuity of care. Risks: the tribal elder might not be responsive to the CBT treatment method and might consequently advise the client to stop seeking treatment with you Benefits: the tribal elder might be responsive to the CBT treatment method and might consequently advise the client to better adhere to the treatment method you prescribe (aka start doing his homework); you might better understand the risks and benefits of the elder’s methods and find a compromise that would satisfy you, the elder, and the client, and consequently increase his adherence to the modified program
Option 5 - Discontinue therapy with the client, instead seeking a referral for him to see a psychologist with greater training in Aboriginal issues (perhaps a practitioner who combines western-style CBT with Aboriginal rituals.) Risks: the client might feel defeated that you can’t seem to help him; the client might feel abandoned that he/she opened up to you and you are now passing him/her on to someone else who he/she might not feel as comfortable opening up to Benefits: the client might get the optimal results by engaging in a therapy that combines the proven CBT with aboriginal methods. (AA)
Option 3a. Re-evaluate and make changes to the treatment plan, after discussing options/opinions with the client.
Risks: The client may have been considering leaving therapy, and take this discussion as an opportunity to discontinue treatment. This discussion might also make him lose faith in the therapeutic process, or in his own ability to recover. If treatment is modified, it may not be as effective.
Benefits: The therapeutic alliance could be strengthened, if the client recognizes that the therapist is trying very hard to understand him. The client may be more engaged in the modified/new treatment, and make better progress. The therapist will possibly learn more about CBT in aboriginal populations, and have increased competence for helping future clients. (AH)
STEP 7: Choose course of action after conscientious application of principles.
I would chose option 3 to start with- Continue therapy, but discuss with client possible alternative homework assignments that better reflect his cultural values (perhaps completing the homework orally, rather than in written form).
If the client still wasn't completing homework assignments, even after we came up with alternative forms together, I would consider trying option 5, so long as the client gave me permission to breach confidentiality and discuss his progress in therapy with the tribal elder.(HM)
STEP 8: Act with commitment to assume responsibility for consequences.
STEP 9: Evaluate results of course of action.
STEP 10: Assume responsibility for consequences, including corrections or re-entry into decision making process if still unresolved.
STEP 11: Take action, as warranted, to prevent future occurrences.
- If you are planning to take on other clients in remote communities from similar backgrounds, further educate yourself on their cultural background and the relationship between individuals in this community and the tribal elder so you can work more collaboratively in the future.
- Review the use of this particular type of therapy in these situations and perhaps see if there are alternative treatments that are more effective in this type of situation for the future. Or similarly, see if there are ways you can alter the homework assignments portion of the treatment to be more conducive to individuals from these and other cultures.
- Indicate at the beginning of your relationship with the client your expectations about homework and how they contribute to the therapy as well as that if they do have other individuals that they seek advice from, encouraging that you would work together rather than choosing one over the other. (KA)
Also, I think it is important to tell your clients at the beginning of the therapeutic relationship how much experience you have with treating individuals of his or her culture, SES, sexual orientation etc to ensure that that the client has realistic expectations of therapy and your level of competency. At this point, it may be beneficial also to point out to the client that there may be other psychotherapists who have more experience with treating clients of his or her cultural background, SES etc. This information could be helpful for the client to make an informed decision about whether to start treatment with you.
Furthermore, it may be advantageous to inform the client whether you think the proposed therapeutic techniques will have a different degree of efficacy when it is used with the client given the client’s culture, SES etc and if so, that the client can expect to work together with you to tailor these techniques to make them a better fit with the client’s demographics. It may be especially important to establish a standard for open communication between you and the client when you are working with a client of an unfamiliar culture, sexual orientation etc because you likely need to learn a lot from your client about these demographics to provide the best care possible. (SC)