You have been asked to counsel an 11-year-old aboriginal youth who is withdrawn in school and spends a lot of time

alone. He is accompanied by his grandmother who says that they need each other very much because her husband has died recently. The youth describes feeling alone, remembering times when he has been abandoned, and hearing voices singing and the voice of an old man speaking to him in the tribal dialect. The grandmother is not eating or sleeping well and she thinks a lot about traumatic events experienced in residential school. You are uncomfortable about counselling without first obtaining a psychiatric assessment to evaluate what may be psychotic symptoms. A psychiatric assessment would require a trip some 100 miles away to a large urban centre.

How do you respond to the grandmother and the youth?

Decision Making Process: Step 1. Identification of the individuals and groups potentially affected by the decision The grandmother and the 11-year-old boy will be most affected by my decision, but from the fact that a psychiatric assessment would necessitate a trip of 100 miles I would guess that I am working in a small community and my reputation and the other people in the community would also be affected. I am also concerned about losing the trust of the community and leaving the residents feeling distrustful towards future psychologists or other counselors that come to the village to try to help. In a way this also affects the members and employees of the psychiatric service I may be referring the boy and his grandmother too.

Step 2. Identification of Ethically Relevant Issues and Practices, Including the Interests, Rights, and any Relevant Characteristics of the Individuals and Groups Involved and of the System or Circumstances in which the Ethical Problem Arose
Principles/ Vales Principle I: Respect for the Dignity of Persons Value: General Respect I.1 Demonstrate appropriate respect for the knowledge, insight, experience, and areas of expertise of others Value: Non-discrimination I.11 Seek to design research, teaching, practice, and business activities in such a way that they contribute to the fair distribution of benefits to individuals and groups, and that they do not unfairly exclude those who are vulnerable or might be disadvantaged Value: Informed Consent I.16 Seek as full and active participation as possible from others in decisions that affect them, respecting and integrating as much as possible their opinions and wishes I.18 Respect the expressed wishes of persons to involve others (e.g., family members, community members) in their decision making regarding informed consent. This would include respect for written and clearly expressed unwritten advance directives. I.19 Obtain informed consent form all independent and partially dependent persons for any psychological services provided to them except in circumstances of urgent need (e.g., disaster or other crisis). In urgent circumstances, psychologists would proceed with the assent of such persons, but fully informed consent would be obtained as soon as Perhaps we need to speak with Grandma and find out if she is concerned about the voice of the old man and if she is willing to make the trip This is a culture that highly values the role of extended family and I need to respect this and allow for time to consult with other members and also ensure that it is alright before I speak with psychiatric professionals if we decide to send the boy to the city I need to make sure at the very least that the boy and the grandmother consent and assent to any treatment plans I recommend Know that the boy and grandmother are denied fair distribution of psychiatric care on the basis of geographic location (and possible SES) Am I questioning the ability of the psychiatric facility staff to correctly diagnose him and come up with an appropriate plan? My Thoughts

possible I.23 provide, in obtaining informed consent, as much information as reasonable or prudent persons would want to know before making a decision or consenting to the activity. The psychologist would relay this information in language that the persons understand (including providing translation into another language, if necessary) and would take whatever reasonable steps are needed to ensure that the information was, in fact, understood I.26 Clarify the nature of multiple relationships to all concerned parties before obtaining consent, if providing services to or conducting research at the request or for the use of third parties. This would include, but not be limited to: the purpose of the service or research; the reasonably anticipated use that will be made of information collected; and the limits on confidentiality. Third parties may include schools, courts, government agencies, insurance companies, police, and special funding bodies Value: Freedom of Consent I.30 Respect the right of persons to discontinue participation or service at any time, and be responsive to non-verbal indications of a desire to discontinue if a person has difficulty with verbally communicating such a desire (e.g., young children, verbally disabled persons) or, due to culture, is unlikely to communicate such a desire orally. Value: Confidentiality I.45 Share confidential information with others only with the informed consent of those involved, or in a manner that the persons involved cannot be identified, expect as required or justified by law, or in circumstances of actual or possible serious I need to make sure that I obtain consent to consult with psychiatric team and that all conversations are done in private Suggesting a psychiatric assessment amy lead to a desire to discontinue treatment with me despite the fact that there is no one else to treat them Reminds me that I need to have an open discussion with Grandmother about my concerns and what I think would be of benefit from the psychiatric assessment and make sure that there are no language issues (since she was in a residential school she probably speaks English but I need to be sure)

Is the psychiatric assessment team a third party?

physical harm or death Values Statement Psychologists acknowledge that all persons have a right to have their innate worth as human beings appreciated and that this worth is not dependent upon their culture, nationality, ethnicity, color, race, religion, sex, gender, martial status, sexual orientation, physical or mental abilities, age, socio-economic status, or any other preference or personal characteristic, condition, or status. Principle II: Responsible Caring Values Statement [Psychologists] engage only in those activities in which they have competence or for which they are receiving supervision, and they perform their activities as competently as possible. Value: General caring II.1 Protect and promote the welfare of clients, research participants, employees, supervisees, students, trainees, colleagues, and others II.3 Accept responsibility for the consequences of their actions I will not be protecting the welfare of my client if I allow psychiatric symptoms to go unchecked I have to accept responsibility for the way this situation turns out- if the Grandmother says no to assessment than I have to do my best to treat the boy I am not competent to assess psychiatric symptoms and am not under supervision to do this I want to make sure that the male voice is not something that comes from the religionmay be ascertained through conversations with Grandma

Value: Competence and self-knowledge II.8 Take immediate steps to obtain consultation or to refer a client to a colleague or other appropriate professional, whichever is more likely to result in providing the client with competent service, if it becomes apparent that a clients problems are beyond their competence II.10 Evaluate how their own experiences, attitudes, culture, beliefs, values, social From this principle I need to refer because I am aware that I am unqualified to assess these symptoms

I come from a background where ensuring my child has the appropriate treatment would be

context, individual differences, specific training, and stresses influence their interactions with others, and integrate their awareness into all efforts to benefit and not harm others Value: Maximize benefit II.18 Provide services that are coordinated over time and with other service providers, in order to avoid duplication or working at cross purposes II.21 Strive to provide and/or obtain the best possible service for those needing and seeking psychological service. This may include, but is not limited to: selecting interventions that are relevant to the needs and characteristics of the client and that have reasonable theoretical or empirically-supported efficacy in light of those needs and characterizes; consulting with, or including in service delivery, persons relevant to the culture or belief systems of those served; advocating on behalf of the client; and, recommending professionals other than psychologists when appropriate Value: Minimize harm II.30 Be acutely aware of the need for discretion in the recording and communication of information, in order that the information not be misinterpreted or misused to the detriment of others. This includes, but is not limited to: not recording information that could lead to misinterpretation and misuse; avoiding conjecture; clearly labeling opinion; and, communicating information in language that can be understood clearly by the recipient of the information II.31 Give reasonable assistance to secure needed psychological services or activities, if personally unable to meet requires for needed psychological services or activities

worth a great deal of sacrifice but this culture may be more mistrustful of psychiatric treatment or feel that the child can be better treated within the community and I need to respect that

I need to be prepared to work with the psychiatric assessment team to meet the best interests of the boy

I need to do whatever I can to ensure this client gets what he needs to be treated successfully. If the trip is too costly than perhaps I have to contact the government about sending someone to our community to do an assessment or try to find other ways for the family to get to the city

I need to ensure that all communication I have with the psychiatric assessment team makes clear my opinion about the voice and how this differentiates from what the boy has reported about the voice. Also make sure I discuss the particulars of the culture if relevant

I need to do my best to help the family get to the city to access the psychiatric assessment

II.33 Maintain appropriate contact, support, and responsibility for caring until a colleague or other professional begins service, if referring a client to a colleague or other professional Value: Extended responsibility II.49 Encourage others, in a manner consistent with this Code, to care responsibly

I need to begin/ continue counseling until the trip can be arranged

I may need to encourage the psychiatric assessment place to help me get the family access to their care.

Principle III: Integrity in Relationships Value: Accuracy/honesty III.2 Accurately represent their own and their colleagues credentials, qualifications, education, experience, competence, and affiliations, in all spoken, written, or printed communications, being careful not to use descriptions or information that could be misinterpreted (e.g., citing membership in a voluntary association of psychologists as a testament of competence). III.8 Acknowledge the limitations of their own and their colleagues knowledge, methods, findings, interventions, and views I need to make sure that Grandma understands the difference between a psychiatrist and psychologist and what a psychiatrist can bring to the situation to help.

If the grandmother has concerns I need to be careful not to overstate the qualifications or competence of the psychiatrist while trying to convince her of the benefits

Value: Objectivity/lack of bias III.11 Take care to communicate as completely and objectively as possible, and to clearly differentiate facts, opinions, theories, hypotheses, and ideas, when communicating knowledge, findings, and views Value: Reliance on the discipline III.38 Seek consultation from colleagues and / or appropriate groups and committees, and give due regard to their advice in arriving at a responsible decision, if faced with difficult situations If the family cannot make the trip or perhaps even before sending them I should consult with a psychiatrist and get his/her opinion about whether this case needs to be evaluated by him/her Make sure that I am differentiating facts about what the psychiatrist can do from my opinion about what the psychiatrist can do

Principle IV: Responsibility to Society Value: Respect for society IV.15 Acquire an adequate knowledge of the culture, social structure, and customs of a community before beginning any major work there. Value: Development of society IV.29 Speak out and/or act, in a manner consistent with the four principles of this Code, if the policies, practices, laws, or regulations of the social structure within which they work seriously ignore or contradict any of the principles of this Code I may need to bring to the attention of the public/government the accessibility issues for this population of people and try to bring about change to increase accessibility Do I have an adequate knowledge of this culture to understand whether these voices are part of the religion or part of a psychiatric disorder?

Step 3. Consideration of How Personal Biases, Stresses, or Self-interest Might Influence the Development of or Choice Between Courses of Action My own biases from living in a large, urban area of Ontario may lead to some misunderstandings or misinterpretations of the culture and religion and therefore incorrectly interpret the meaningfulness of the voices. Additionally, I may have some self-interest in having someone else assess this boy as it takes some responsibility off of me.

Step 4. Development of Alternative Courses of Action Alternative 1. My first step would be to contact a psychiatrist at the urban center and speak in general terms about the situation and find out if the psychiatrist deems it necessary to see the boy. If the psychiatrist believes that the boy is not exhibiting psychiatric symptoms than I can resume counseling and contact the psychiatrist if further concerns arise. If the psychiatrist believes that the boy should be evaluated than I need to speak to the grandmother and explain my concerns and that I feel the boy needs to be taken into the city to be evaluated. At this time I would want to discuss her feelings about the situation, concerns, timeframe for making the journey, and get her permission to discuss what I know with the psychiatrist in order to increase the speed with which the psychiatrist can offer his/her services. At this point the grandmother may be agreeable and willing to take the grandson to the city, which is a positive outcome. It is also possible that the grandmother shows resistance over a mistrust of the treatment the boy will receive, an inability to get to the city, or a desire to have the boy treated in his own community. I need to do my best to express my point of view without being overly forceful and making her mistrustful of me while respecting her right to make decisions about her grandsons care. I also have to be prepared to do my best to counsel the boy without going out my own bounds of confidence if she decides only to seek care in the community.

Alternative 2. Speak to the grandmother about her interpretations of the voices the boy hears and any other possible signs of psychiatric disturbance and then discuss with her the bounds of my competence and then recommend that her grandson be evaluated by a psychiatrist before you commence counseling. At this point help her to break through any barriers to accessing the service such as helping her make the appointment, arrange transportation etc.

Step 5. Analysis of Likely Short-term, Ongoing and Long-term Risks and Benefits of Each Course of Action on the Individual(s)/group(s) Involved or Likely to be Affected (e.g., Client, Client's Family or Employees, Employing Institution, Students, Research Participant, Colleagues, the Discipline, Society, Self)
Possible Positive Consequences Alternative 1 Psychiatrist tells me there are no concerns and I can continue counseling Possible Negative Consequences Grandmother feels that myself and the psychiatrist are ganging up on her and decides to remove her grandson from all services and may speak negatively of the situation to others in the community making them less likely to receive services Grandmother is unable to access service in the city and I need to find a way to try to help her- I may not be able to get her to the city (if money is an issue) and then I have a whole new problem to solve

Psychiatrist wants to evaluate the boy and grandmother agrees to this and is able to take him to the city

Grandmother feels that the mental health system is looking out for her grandson and is thankful for my initiative in speaking to a more qualified professional Alternative 2 Grandmother feels empowered because her expertise is being requested and respected I may have to suggest further assessment despite the fact that the grandmother already believes it is unnecessary I explain away symptoms as cultural differences and miss an important opportunity to help the child Grandmother may agree to services and then be unable to access them leaving me with the ethical dilemma of finding a way for her to access the services which may or may not be possible

I learn more about the culture from listening to the grandmothers interpretation of the boys symptoms

Step 6. Choices of Course of Action After Conscientious Application of Existing Principles, Values, and Standards I believe that the best course of action is alternative 1 because speaking with the psychiatrist generally respects confidentiality while seeking the aid of a competent professional. This solution also allows for the Grandmothers input without allowing her to become entrenched in a belief before I have decided whether or not to recommend the psychiatric treatment. This action also places me in a better position to decrease barriers as the psychiatrist is already aware of the case.

Step 7. Action with a Commitment to Assume Responsibility for the Consequences of the Action Considering that I am expecting barriers to access upon the grandmothers agreement to the psychiatric assessment I want to speak with a psychiatrist as soon as possible and schedule a meeting with grandma and any other stakeholders as quickly as possible. I would also like to provide the grandmother with a couple of days to consider the options so that she does not feel pressured.

Step 8. Evaluation of the Results of the Course of Action After speaking with the psychiatrist I need to prepare myself to speak with the grandmother professionally and sensitively in order to present her with options and try to help her make a good choice. If the grandmother says no the psychiatric assessment or needs help with barriers to access than I need to be prepared to accept her decision or find ways to access the service.

Step 9. Assumption of Responsibility for the Consequences of Action, Including Correction of Negative Consequences, If Any, or Re-engaging in the Decision-making Process If Ethical Issue Is Not Resolved It is possible that the grandmother will feel I have violated confidentially through consultation with the psychologist or that her barriers to access are so great that I cannot help her gain access. If this happens then I will need to reevaluate how to treat the client without having the psychiatric assessment completed.

Step 10. Appropriate Action as Warranted and Feasible, to Prevent Future Occurrences of the Dilemma (e.g., Communication and Problem Solving with Colleagues, Changes in Procedures and Practices I am aware that practicing in an isolated community will present barriers to access and I may need to work on advocating to the government some access to these services such as having a psychiatrist visit once every three months to do assessments and investigate medications and consult on treatment plans. I may also need to expand my education to improve my ability to meet the needs of the community.