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Administration and Policy in Mental Health Vol. 22, No. 1, September 1994

ETHICAL ISSUES AND DILEMMAS IN THE MENTAL HEALTH ORGANIZATION

Barbara J. Clark, M.A., and Norman Abeles, Ph.D.

ABSTRACT: Agency directors, middle managers in large organizations, and managers in general must be concerned with managing ethics as part of personnel management. The authors discuss the ethical dilemmas that face administrators and how such issues can be resolved.

Agency directors, middle managers in large organizations, and managers in general must be concerned with ethics as part of personnel management, often above and beyond existing ethical codes for psychologists, psychiatrists, social workers, and other mental health professionals. Personnel and human resource activities provided and modeled by managers must be designed to increase the ethical behavior of employees, who, in modeling the managers' ethical sensi- tivity to the rights of others, become role models for their own clients. It is therefore necessary that administrators develop a personal ethic in order to serve as role models, assure quality of service while maintaining the ethical philosophy of the organization, and manage day-to-day agency or system ~activities so that ethical behavior is the norm. Beyond these demands, they also have to apply ethical principles when dealing with broad-ranging issues that may not frequently occur in the organization. These varied responsibilities require administrators to make decisions and solve problems while assuring that ethical codes and values'are not violated. They also recognize that ethical standards are often designed to describe enforceable principles of conduct, knowing that ethical standards cannot be exhaustive. Simply because specific

Barbara Clark is with Psychological Health Systems in Lansing, MI. Norman Abeles is Director of the PsychologicalCl'mlc at Michigan State University.

Address for correspondence: Barbara .J. Clark, Psychological Health Systems, P.C., 617 Seymour, Lansing, MI 48933.

7 �9 1994 Human Sciences Press, Inc.

8 Administration and Policy in Mental Health

conducts are not addressed in an ethics code does not make them either ethical or unethical (American Psychological Association [APA], 1992).

DEVELOPING A PERSONAL ETHIC

Moral and ethical rules of conduct govern our behavior. In the workplace, administrators make decisions and take actions that are the consequence of their own morals, ethics, values, and attitudes. The goal of the mental health care administrator is to become ethically sensitive and to be aware of the rights of the individual and society so that the mental health organization does not cause suffering to others (Barton & Barton, 1984).

Managers enter the mental health care field as professionals who have already developed at least an implicit personal ethic. Building on this framework, a personal ethic about management evolves through introspection and experience. Furthermore, the mental health care administrator can rely on the code of ethics of his or her professional organization and on the organization's philosophy to modify the personal ethic. Even so, a manager's personal ethic develops slowly over time and must be constantly modified and refined, and, since codes of ethics restrict behavior for all individuals in the mental health profession, the manager's personal code of ethics can never be more liberal than that of the professional written code.

For the mental health services manager, a personal ethic is the moral framework that is used to define the appropriate relationship with client, employee, and organization. The manager is the organization's conscience, and his or her decisions and actions, which represent the organization, morally affect many individuals. This underscores the importance of essential elements of the manager's personal ethic which include never using the management position for selfish advantage or personal gain, and never acting in a way that carries the slightest hint of wrongdoing. In order that it apply to the broadest range of ethical issues, the manager's personal ethic should be clear, consistent, and comprehensive.

The organization's philosophy provides a general context for the manager's activities and decision-making. But the presence of an organizational philosophy does not eliminate the manager's need for a personal ethic. The personal ethic provides individual managers with a framework for action, and permits greater refinement of principles, rules, and particular judgments and actions than is likely to be present in the statement of philosophy of the organization.

ETHICAL MANAGEMENT OF QUALITY ASSURANCE

In the mental health agency or system, quality assurance is largely the responsibility of the administrator, although peer-review committees and local professional organizations can help ensure quality. Essentially, it is up to the

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manager to make sure practitioners do not get so caught up in the "business ethic" that treatment of clients suffers. The manager ensures quality of patient care by seeing that clients are diagnosed accurately, receive the best care possible, are treated using a plan that is carefully thought out and thoughtfully implemented in a therapeutic atmosphere, and have their right to confidentiality and privacy protected at all times.

The manager assures the quality of his or her staff by making it a policy to monitor whether clinicians update their skills and knowledge, provide compe- tent and consistent care, understand the privilege of confidentiality and other client rights, keep adequate records, and observe personal morality.

Assuring the quality of services also means that managers are responsible for educating staff and support personnel about unethical practices. Some of these include sexual intimacies with current clients, exploitive relationships, sexual harassment, failure to safeguard the public, improper solicitation of business, providing services beyond one's competence, billing for services not rendered or excessive fees, failure to refer to another professional for consultation when appropriate, and violation of confidentiality. While some practices are dearly unethical, other ethical issues are not always dear. Take, for example, the following incident related to one of the authors by a colleague:

A manager of a mental health agency assigned an assessment of a client to one of the agency psychologists at the request of an attorney who represented that client in an automobile injury case. The psychologist completed the assessment and the attorney was most impressed by its thoroughness ,and high quality. About a month later the attorney called the psychologist who had done the assessment and told the professional that he was seeking marital counseling for himself and his wife. Since the psychologist had done such a good job on the assessment, the attorney and his wife wanted to see that psychologist. The psychologist sought the opinion of the agency manager before proceeding.

On the face of it, the attorney's request certainly seemed reasonable. After all, the prior assessment had been completed, and seeing the attorney and his wife was a totally separate undertaking. The manager, however, pointed out a scenario wherein the psychologist would be asked to testify in court about the completed assessment. The opposing attorney in cross-examining the psychologist might well ask about the nature of the relationship between the psychologist and the claimant's attorney. After thinking about this, the psychologist decided that the ethical decision was to refer the attorney and his spouse to a different professional. In these and other cases, managers can provide staff training, supervision, and seminars that caution and educate clinicians about such unethical and potentially conflictual practices.

The administrator has the personal and moral responsibility to see that his or her management ability is of the highest quality. Quality assurance in this area demands that the administrator avoid conflicts of interest, establish professional relationships with staff, conduct business ethically, supply quality support personnel to clinicians, and gracefully accept professional monitoring.


It also is the responsibility of the manager to assure quality by developing financial resources, since cost-containment has resulted in budget cuts for mental health services. Agencies and systems in the mental health organization are left trying to provide quality service while the economy and health-care system become more and more troubled. Even so, the administrator is responsible for assuring quality of care by providing staff with the resources required to provide effective treatment.

The manager is the organization's conscience.

Often resources are stretched so thin that management and staff agree to ration treatment. The ethical d i lemma faced by the manager is determining who receives treatment. Thompson (1990) discusses this di lemma and states that it is appropriate to provide according to need, if it is possible to determine a fair way of measuring need. One way to determine need is to use "crisis" as a criterion by providing services first to those most in need. Thompson continues that a second way is to grant services to those who make repeated requests for services (if an applicant comes in a certain number of times, then he or she will be scheduled). Others would argue that persistence in itself ought not to substitute for assessment since there are some very needy, frightened clients who are simply unable to be persistent as a function of who they are. The only sure way that clients have to assure their own treatment is to have money to pay for services; the manager is left with the responsibility for seeing that this is not the only criterion used when deciding who will receive services.

Another threat to quality of mental health services is the impact of third party payers. Some clinicians argue that third party payers are overly concerned with mental health coverage at the expense of the client's mental health. At times, mental health benefits offered by different insurance companies are not only dissimilar but confusing, since they may question the effectiveness and length of a given treatment. It is up to managers to provide support to those clinicians who become frustrated and burned-out by their work as a result of benefit decisions by third party payers that interfere with autonomous function. There have been suggestions that these types of third party payment decisions drive away quality individuals who might otherwise be attracted to the mental health care profession.

On the other hand, there are those who argue that length of t reatment is theory-driven and the ultimate question is the degree to which the mental health provider treats "underlying" as opposed to manifest symptoms. Some schools of thought insist that several "shorter" periods of t reatment during an individual's lifetime is as helpful as one very long period of "reconstructive" treatment. Others insist that this question can only be decided on the basis of careful and extensive assessment. M a n y agencies, however, are forced to


choose between providing intervention services to a larger group of clients as opposed to limiting services to those clients who have been carefully assessed.

Finally, managers may be faced with a demand that their agency or system be especially sensitive to the needs of minority clients. Soon, one in four Americans will be African American, American Indian/Alaska Native, Asian/ Pacific American, or Hispanic (Thompson, 1990). In order to assure quality of care for these populations, the manager has an ethical duty to make services accessible and understandable to minorities that are not familiar with the mental health system. If possible, continuing education for staff and management should include cross-cultural training, and a large minority community might be best served if the manager could recruit bilingual interpreters. As with any other client population, the primary ethical responsibility is to serve clients to the best of the agency's or system's ability.

ETHICAL MANAGEMENT IN DAY-TO-DAY ACTIVITIES

Day-to-day activities that may seem value-free are often based on ethical codes or principles that are derived from the manager's personal ethic, the organizational, philosophy, and the professional code of ethics. Managers can avoid complicated clinical situations, legal issues, and complaints by assuring that staff understand the need for and follow ethical directives. Ongoing activities that are rooted in ethics include setting fees and receiving payment for services, keeping records, protecting confidentiality and privacy while upholding the ethical duty to warn and protect, releasing information, and administering psychodiagnostic tests.

Fees and Payment Policies

Management must be aware that almost daily, clinicians are faced with the ethical di lemma of determining whether or not the diagnosis fits within the constraints of insurance coverage so that the agency or system will be reim- bt~rsed. It is up to managers to monitor staff and to educate them concerning diagnostic issues. Not only is it inappropriate to change diagnoses in order to receive insurance reimbursements but it also is inappropriate to change diagnoses so that the client will not be "stigmatized" by being "labeled." While providing court testimony, one of the authors has noted a number of individuals who were diagnosed "benignly" as adjustment disorders with depression when, in later testimony, these same individuals described symptoms that should have been diagnosed as major depression. That type of underdiagnos- ing often denies individuals benefits to which they are fully entitled.

The managers of agencies or systems also should examine the ethical dilemma created by using a collection agency to collect delinquent fees when the client has not been informed of this breach of confidentiality. The policy of the agency should be to obtain written consent for this limit of confidentiality prior


to beginning treatment. A second way to avoid breaking confidentiality by using a collection agency is to simply postpone payments until the client can pay or to use a sliding scale. A final solution is to accept a predetermined proportion of clients who cannot pay.

Record-Keeping

The pr imary ethical concern in record-keeping is assuring clients that the information contained in their files will be confidential. The administrator has the obligation to be sure that all personnel who handle sensitive confidential information are familiar with the concepts of confidentiality and privilege. Normally, the policy created by the administrator, agency, or system covers who can see charts (the "need-to-know" criterion) and where they can be read. The manager can instruct that staff who have access based on the need-to- know return all records to files which are locked at all times.

In setting the policy about personal notes kept on therapy sessions, managers can suggest that clinicians keep notes made when interviewing and interacting with clients in order to learn from treatment successes and failures. However, notes of interactions with clients that are entered into the record should be confined to descriptions of behavior, not personal speculation about the client.

One frequent concern in agencies has to do with the frequency of record keeping. Most agencies require intake and initial interview notes, occasional progress reports, and summary reports. Other agencies insist that some notes be kept after each interview. Some authorities argue that if it is not written down it did not happen! There is an increasing move toward the maintenance of some notes after each session. One of the authors is familiar with a situation in which the client kept detailed notes of every session while the therapist did not. When disputes arose later, considerable weight was given to the client-generated notes in the absence of notes from the therapist.

Record-keeping that involves recording appointment times, keeping data for insurance purposes, and collecting other personal data for various reasons may threaten confidentiality. Most clients being seen are scheduled in an appointment book. All appointment book information is confidential, and under no circum- stances should an appointment book be left in a place where clients and un- authorized staff can see who is scheduled.

As computer application in the area of therapy and data-gathering expands, t he 'manage r must be concerned with the ethical di lemma created by this technology. Information about clients that has been entered into data banks should be accessible to only those with a need-to-know, in order to protect confidentiality. The use o f security codes ensures that personal information about clients entered in a computer file are kept private.

Duty to Warn and Protect

The Tarasoffdecision in California (1976) resulted in the mandate that the therapist has a legal (and therefore ethical) duty to warn potential victims of


dangerous clients. Many other states have now adopted that position. Man- agers in agencies or systems face an ethical dilemma of whether or not to take action if a client being treated poses a danger to others. Managers can provide staff with support in this regard by making it a policy to inform clients in a written statement that is signed prior to beginning treatment that in cases of clear and present danger to another person, the therapist reserves the right to inform the person in danger and to involve third parties as necessary to protect the life and well-being of the endangered person.

While state laws may vary, the ethical duty to protect applies to clients who intend to take their own lives. The manager in an agency or system that handles a large number of crisis cases must be prepared to support staff in determining at what point the client's ability to reason is so impaired that the therapist must stop a suicide attempt by any available means, including police intervention and involuntary commitment. Explicit threat, a history of past attempts, and a plan and means to execute the plan are all important factors to consider when grappling with the ethical dilemma of whether to intervene in the best interest of the client (Thompson, 1990).

The manager also faces an ethical dilemma when setting or enforcing policy concerning the duty to report a communicable disease. Note the following example:

One .of the therapists in your agency is treating a business manager who experiences considerable stress and sees himself as a "Type A" personality. After about four months of t reatment the client, who is married and has children, discloses that he has recently had a homosexual affair. Therapy focuses on whether or not the client would disclose his homosexual affair to his wife. The client strongly believes he should not. About one year later the client discloses to the therapist that he has been tested as H I V positive. He states that this does not mean he has AIDS and insists that he is not going to disclose the fact to his wife. Is the therapist obligated to do anything further?

There has been much debate in the mental health community over whether the duty to warn extends to those who might he infected by sexually active clients who have acquired immune deficiency syndrome (AIDS). In deciding thttt his or her staff has the ethical duty to warn in cases of HIV-infected clients, the manager has to !mplement policy to this effect. Some mental health professionals advocate that the therapist be instructed to confirm the diagnosis and then ask the client to inform their partners of the danger. If the client refuses to do so, some argue that the therapist has the legal and ethical duty to break confidentiality in order to warn potential victims. Given the likelihood of multiple anonymous partners, the manager may have to provide reassurance and guidance while instructing the therapist to inform the state public health officer. Managers also may be held responsible for making sure that the agency or system is prepared to supply support and reassurance to the person who is told they are at risk.

The reader should be aware, however, that the duty to warn in HIV-infected cases is a highly controversial topic, especially when there is no legal mandate to do so. There are many who argue that the nonmedical health provider is not


qualified to determine the accuracy of client statements concerning HIV status. It is the contention of many of these providers that the locus of informing is within the medical community, and those responsible for receiving and interpreting the laboratory report of testing (i.e., the physician) bear the responsibility for the duty to warn.

Finally, the duty to protect extends to those who are victims of child abuse, which has become a major concern in our society. One ethical dilemma with which a manager must grapple is risking the confidentiality of the client who is doing the abusing or the confidentiality of the child who is being abused. Other ethical dilemmas with which the manager must deal are risking further harm to the child by not reporting abuse and risking legal action for either reporting or not reporting.

A related population at risk for abuse is older adults. Increasingly, managers need to be concerned with the duty to protect older family members from abuse. As a guide, managers can use decisions by the courts that support notifying the appropriate government agency whenever there is reasonable cause, not necessarily certainty, of elder abuse.

Release of Information The ethical duty of confidentiality also includes the obligation not to release

information about a client without his or her permission except when manda- ted by the courts. Requests for the release of information comes from third party payers, families, schools, and courts. As in record-keeping, the release of information contained in the clinical record should be granted only to those with a "need to know." Before beginning treatment, clients should be informed as to the limits of their confidentiality, and many agency and systems managers make it a practice to have clients sign a release of information or informed consent each time information is requested.

Managers encounter an ethical dilemma in deciding whether clients have the right to determine what use will be made of the information in their records and whether they can examine their records. Most professionals believe that clients have the right to examine records in a supervised setting unless there is a good reason to believe that access to certain information is not in the client's best interest, in which case the manager can help the clinician determine whether access should be refused.

Ethical Dilemmas in PsychodiagnosUc Testing Managing psychodiaguostic testing confidentially is also an ethical chal-

lenge. It is considered ethical to make certain that there is no misunderstanding about the nature and purpose of any test and access to the results is restricted to those with a need-to-know. The manager may encourage test administrators to have clients submit questions they wish to have answered by the test, with the promise that these questions, as well as the referral questions., will be answered during feedback.


Managers must also be aware that the client is the person being assessed, not tl~e referral source. Often the courts or other agencies require assessments and, in effect, they believe the client being assessed has waived the right to confidentiality. It is vital for the manager to be certain that professional judgments will not be compromised, that objectivity will be maintained, and that others will not be mislead as to the clinician's role (APA, 1992). The following example should provide some insight:

Your agency has been asked to complete a comprehensive custody evaluation at the request of the district court. Your staff member has done assessments of both parents, the children individually, and the family collectively. The judge is most impressed by this staff membeFs work and requests that the staff member "monitor" the family for the next six months to see that the wishes of the court are carried out. The staff member consults you, the director of the agency concerning the request by the judge.

Computers have revolutionized the way mental health professionals admin- ister tests and create an entirely new ethical dilemma for managers of agencies and systems. Clients can be assessed and the resulting information easily sorted, scored, and interpreted. However, although computerized assessment is a viable technique and serves as an organizer and time saver for busy practitioners, not many studies have been conducted to determine whether the information obtained using computerized test administration is valid or even comparable to tests or interviews given under more personal conditions (Rinas & Clyne-Jackson, 1988). These authors point out that clients vary significantly in their understanding of the written or spoken word, in their frustration tolerance when working with mechanical devices, and in their level of atten- tiveness and motivation. Furthermore, the very real possibility of a difference between computerized and noncomputerized testing conditions necessitates that test interpreters guard against making comparisons between the client and the normative group on which the test was developed if the test was standardized under noncomputerized conditions. Finally, Rinas and Clyne- Jackson stress that in adapting traditional tests to computerized administra- tian, it is critical for the manager to implement appropriate testing guidelines in order to establish equivalent procedures and norms, rather than to assume that standardized procedure and data from one modality can be generalized to a dissimilar format.

ETHICAL AND LEGAL ISSUES

Malpractice The administrator has the responsibility to protect the agency or system and

its staff from liability actions. The best defense is always prevention. Even so, administrators, agencies, and systems have been held responsible for the acts of those under their supervision. Managers can protect their agency, system, and


staff by making sure that the therapist establishes as good a rapport as possible with each client, has skills and knowledge equivalent to those of other clinicians, maintains current clinical records, practices within the limits of his or her competence, exercises judgment in setting a value on services, always secures informed consent, and is clear with the client about all aspects of treatment.

The legal threat of malpractice precludes sexual intimacies with any current client. However, the issue of sexual intimacies with former clients is currently under debate (APA, 1992). While some practitioners and mental health managers would argue that sexual intimacies with former clients are always unethical, others argue that such intimacies must not occur for at least two years after therapy has ended. Even then it is the therapist's responsibility to demonstrate that there has been no exploitation (APA, 1992). The manager can prevent unethical exploitation of clients more easily if agency personnel are required to maintain a consulting, supervisory relationship with another professional or with a peer-review group.

Conflicts of interest

Conflicts of interest including expectations, values, and responsibilities are also major ethical concerns. An ethical d i lemma occurs when the manager cannot meet the duty to one person or organization without having this duty affect the relationship with another. It is not surprising that conflicts of interest arise when the manager tries to maintain a relationship with other agencies or professionals while working for his or her organization. The manager has an ethical responsibility not to put himself or herself in a position where duties to both sides make it impossible to be objective. Unfortunately, a failure to recognize a conflict of interest usually means a manager is well into a conflict situation without realizing it.

Ethical Dilemmas in Advertising

The ethical issue for solicitation is whether advertising is truthful and whether there can be objectively measurable standards for judging the truthful- ness of advertising claims. Fur thermore, the manager must grapple with the ethical di lemma of using advertising to gain purely monetary rewards, power, and status.

Ethical Dilemmas in Legal Situations

Managers have the responsibility to see that therapists initially assert the privilege not to reveal any material pertaining to their client unless or until the client or the attorney of the client explicidy grants permission. In some instances, the court itself may order the release of pert inent records. It is never ethical for managers to allow tampering with or destruction of evidence. Managers can offer as much protection of the client's rights as possible by

Barbara J . Clark and Norman Abeles 17

instructing the therapist to explain the impact that testifying will have on the client. They can also suggest that therapists request a private conference with the appropriate fact-finder or provide only the evidence the court requires them to produce.

CONCLUSION

Managers are decision-makers and problem solvers; these are the reasons they are hired. It is crucial that the manager prevent, and if this is not possible, identify and solve ethical problems while making sure the agency or system continues to operate smoothly. The impact of third parties and the develop- ment of new technologies threaten confidentiality and make more critical the decision-making and implementation process, while at the same time causing greater penalties for those who ignore their ethical implications.

Administrators have an obligation to be ethical in the conduct of personal and business affairs. It is the responsibility of administrators to see that the most effective use of economic and other resources be made and that these resources be distributed equitably. Managers also must maintain the quality of mental health service by establishing and enforcing internal policies, standards of clinical practice, and a systematic method of evaluation. One of the most important responsibilities managers are given is protecting the rights of the clients of their agency or system while, at the same time, protecting the organization and staff from legal action. In handling these and other ethical dilemmas, managers must achieve the delicate balance of maintaining loyalty to the organization's and profession's ethical principles and fidelity to their own personal ethic and professional integrity. The best way for managers to become more sensitive in their ethical actions and decisions is to study ethical problems in a detailed way and to think carefully about what is involved in each problem. By learning from experiences with prior ethical dilemmas and the results of decisions made in order to solve those problems, managers can use what they have learned to refine and develop their own personal ethic and the ethical policies of the organization in order to make moral and unbiased decisions when faced with new ethical dilemmas.

REFERENCES

American Psychological Association. (1992). APA continues to refine its ethics code. APA Monitor, 23, 38- 42.

Barton, W.E., & Barton, G.M. (1984). Ethics and law in mental health administration. New York: International University Press.

Rinas, J. , & Clyne-Jackson, S. (1988). Professional conduct and legal concerns in mental health practice. Norwalk, CT: Appleton & Lange.

Tarasoff v. Regents of the University of California et al., 551 P. 2d 334 (1976). Thompson, A. (1990). Guide to ethical practice in psychotherapy. New York: Wiley.