Ethics in ACT Ethics in Action Ethics in Traction John Maher MA MD FRCPC.

Ethics in ACTEthics in ACT

Ethics in ActionEthics in Action

Ethics in TractionEthics in Traction

John Maher MA MD FRCPCJohn Maher MA MD FRCPC

Today’s topics: Today’s topics:

Our ACT worldOur ACT world

Compassion fatigue & moral stressCompassion fatigue & moral stress

Ethics in psychiatryEthics in psychiatry

Weaving a value tapestryWeaving a value tapestry

A penny for your thoughtsA penny for your thoughts

Take one for the teamTake one for the team

How are ACT teams different from How are ACT teams different from other community treatment teams?other community treatment teams?

community based in-vivo interventions the ability to provide rapid and intensive responses long-term and full clinical responsibility for individuals with serious and persistent mental illness. multidisciplinary teams working as teams low staff: client ratios (often 1: 8)providing flexible, all inclusive care often a program of last resort—the alternative is frequent or permanent hospitalization“doers not brokers”better outcomes (Szmukler G, 2003)

Why are ACT teams a hot bed for the Why are ACT teams a hot bed for the generation of ethical issues?generation of ethical issues?

“Familiarity begets certain liberties”

small staff-client ratios (intimate knowledge of client’s life story)intensity of involvement infiltration into all aspects of client’s lifeengagement in activities usually limited to friends or familyseverity of client’s illness (impaired insight and capacity is common)ACT teams intervene directly, repeatedly

“Staff are busy trying to prevent mayhem…the constraints of confidentiality, voluntariness, and other moral requirements whose application to the community treatment context is unclear often seem to be issues of bureaucratic nicety.”

(Diamond & Wikler 1985)

When confronted by the chaos of a tense clinical situation some staff respond with greater control and paternalism that then perdures in order to prevent things getting out of control again.

All of the above leads to more ethical confrontation and conflicts with and between personal and team philosophies.

Clients often welcome help with their social needs (e.g. housing, finances) but ACT engagement and treatment plans inexorably foist medical and safety interventions upon them too.

Even with verbal abuse of ACT staff we still don’t stop seeing our clients. And we keep showing up even when repeatedly fired.(Non-psychotic physical violence, or genuine threats of violence are, however, appropriate grounds for discontinuing care.)

“Is treatment that won’t go away ethical?” (Stovall, 2001)

What makes ACT successful? What makes ACT successful? (And from whose perspective?)(And from whose perspective?)

Objectively the endpoints are clearly good:– better health, – better relationships, – better housing, – better food,..– fewer hospitalizations

Subjectively, for some, the means are clearly bad:– forced medication adherence, – threats of hospitalization, – loss of freedom, – living in a world where strangers keep telling

you that you have an illness…

Our ACT WorldOur ACT WorldNice rugNice rugNice couchNice couchBreathe through your mouthBreathe through your mouthLast mealLast mealLying, drug seeking, anger, rejection, Lying, drug seeking, anger, rejection, dangerdangerIntruder, psychiatric policeIntruder, psychiatric policeCompassionate advocateCompassionate advocate

Compassion Compassion

What is compassion?What is compassion?Pity coupled with an urgent desire to Pity coupled with an urgent desire to aid or spare someone their sufferingaid or spare someone their suffering

What are the elements of What are the elements of compassion?compassion?1) Pity: tender or contemptuous 1) Pity: tender or contemptuous sorrow for one in misery or distress sorrow for one in misery or distress (note the moral element)(note the moral element)

CompassionCompassion

2) Empathy: the action of 2) Empathy: the action of understanding, being aware of, being understanding, being aware of, being sensitive to, and vicariously sensitive to, and vicariously experiencing the feelings, thoughts, experiencing the feelings, thoughts, and experience of another of either and experience of another of either the past or present without having the past or present without having the feelings, thoughts, and the feelings, thoughts, and experience fully communicated in an experience fully communicated in an objectively explicit manner objectively explicit manner

CompassionCompassion3) Sympathy: the act or capacity for 3) Sympathy: the act or capacity for sharing the painful feelings of another sharing the painful feelings of another

4) Commiseration: pity expressed 4) Commiseration: pity expressed outwardly in exclamations, tears, or words outwardly in exclamations, tears, or words of comfortof comfort

Biology of affect: mirror neuronsBiology of affect: mirror neuronsCognition: this could happen to meCognition: this could happen to meUnconscious association: this has Unconscious association: this has happened or will happen to mehappened or will happen to me

Compassion Fatigue Compassion Fatigue

Compassion Fatigue: the not Compassion Fatigue: the not inevitable cost of caring…inevitable cost of caring…

Emotional exhaustionEmotional exhaustion

Physical exhaustionPhysical exhaustion

Vicarious traumaVicarious trauma

Compassion FatigueCompassion Fatigue

Compassion Fatigue:Compassion Fatigue:

May be more likely to occur in May be more likely to occur in caregivers who have had difficult caregivers who have had difficult childhoods, and/or have ongoing childhoods, and/or have ongoing difficult emotional challenges in their difficult emotional challenges in their personal livespersonal lives

Compassion Fatigue &Compassion Fatigue & Moral Stress Moral Stress

It has been suggested that a It has been suggested that a significant contributing factor to significant contributing factor to compassion fatigue is moral stresscompassion fatigue is moral stress

Moral stress: caused by repeated Moral stress: caused by repeated exposure to moral challenges or exposure to moral challenges or conflicts in which the path is not conflicts in which the path is not clear, or…clear, or…


……repeatedly finding oneself in repeatedly finding oneself in circumstances in which you are thwarted circumstances in which you are thwarted in your efforts to do what you believe is in your efforts to do what you believe is right…”no-win situations”right…”no-win situations”

Uncertainty and frustration engendered by Uncertainty and frustration engendered by barriers to good care…barriers to good care…

Sound familiar?Sound familiar?


ACT staff show compassion for ACT staff show compassion for marginalized, stigmatized, marginalized, stigmatized, impoverished, suffering individualsimpoverished, suffering individualsWe constantly fight systems: lack of We constantly fight systems: lack of money, lack of housing, ignorance, money, lack of housing, ignorance, medical neglect, unemployment, medical neglect, unemployment, overt abuseovert abuseOthers don’t do what we know to be Others don’t do what we know to be right and fair for our clients…right and fair for our clients…


And our clients often don’t do what we And our clients often don’t do what we know to be good for them…know to be good for them…

As intensive case workers in the As intensive case workers in the community we enter into the lives of our community we enter into the lives of our clients in ways few other caregivers do…clients in ways few other caregivers do…

When people we really care about are hurt When people we really care about are hurt we may feel it deeply…we may feel it deeply…

And the usual recurrent injustices of the And the usual recurrent injustices of the world may be harder to shake off…world may be harder to shake off…


ACT was founded on the premise of ACT was founded on the premise of ensuring patients’ autonomy without ensuring patients’ autonomy without abandoning them in the community…abandoning them in the community…But this is an unsupportable But this is an unsupportable contradiction for front-line staff who contradiction for front-line staff who are busy “massively controlling their are busy “massively controlling their clients, supposedly to guarantee that clients, supposedly to guarantee that clients control their own lives.” clients control their own lives.”

(Brodwin 2008)(Brodwin 2008)

This is an ever present moral This is an ever present moral tension…tension…


““Front-line staff find that the same Front-line staff find that the same clinical gestures required, per ACT clinical gestures required, per ACT guidelines, to prevent hospitalization guidelines, to prevent hospitalization (the prime clinical and ethical ideal) (the prime clinical and ethical ideal) can also decrease clients’ can also decrease clients’ independence, threaten their well-independence, threaten their well-being, and humiliate them in public.”being, and humiliate them in public.”

It is a double bind…It is a double bind…


So what do we do with moral stress So what do we do with moral stress in order to stave off compassion in order to stave off compassion fatigue?fatigue?

1) Emotional awareness skills1) Emotional awareness skills

2) Recognize early warning signs 2) Recognize early warning signs (anger, impatience, heightened (anger, impatience, heightened sense of injustice, not being able to sense of injustice, not being able to let go when you are at home)let go when you are at home)


3) Stress management techniques3) Stress management techniques

and self-care strategies that promote and self-care strategies that promote optimism, happiness, and positive optimism, happiness, and positive attitudesattitudes

4) Discuss issues with colleagues 4) Discuss issues with colleagues (team meetings that allow this are (team meetings that allow this are really important)really important)

5) Debrief with a supervisor5) Debrief with a supervisor


6) Systems mastery (using connections)6) Systems mastery (using connections)

7) Foster effective functional detachment 7) Foster effective functional detachment through recognition that moral conflicts in through recognition that moral conflicts in life are inevitable, and they leave us with life are inevitable, and they leave us with residual anxiety, guilt, and distress residual anxiety, guilt, and distress (“moral residue”)(“moral residue”)

8) Use moral discourse to mollify or 8) Use moral discourse to mollify or mediate intense affective distress. mediate intense affective distress.


Key idea: Suffering and sadness co-Key idea: Suffering and sadness co-exist with joy, discovery, and hope.exist with joy, discovery, and hope.

Fight the good fight without Fight the good fight without resignation, and do not despair, for resignation, and do not despair, for what meaning there is in life cannot what meaning there is in life cannot be smothered solely by its passing be smothered solely by its passing injustices injustices

Morality vs EthicsMorality vs EthicsMorality and ethics are tools in the Morality and ethics are tools in the fight… fight…

Morality: right vs wrong (conscience, Morality: right vs wrong (conscience, intuition, personal values, emotion)intuition, personal values, emotion)

Ethics: reflection that is based on the Ethics: reflection that is based on the human capacity for reasoning and human capacity for reasoning and gets expressed through formal gets expressed through formal systematic theorysystematic theory

Ethics Theories Used in PsychiatryEthics Theories Used in Psychiatry

1) professional ethics (e.g. duty to society1) professional ethics (e.g. duty to societyvs duty to patient)vs duty to patient)

2) virtue ethics (ethics of care):2) virtue ethics (ethics of care):desirable qualities in an ethical agentdesirable qualities in an ethical agent

3) Principle-based ethics (autonomy,3) Principle-based ethics (autonomy, beneficence, nonmaleficence, beneficence, nonmaleficence, distributive justice, etc)distributive justice, etc)

Ethics Theories Used in PsychiatryEthics Theories Used in Psychiatry4) Casuistry: paradigm cases as precedents 4) Casuistry: paradigm cases as precedents

(e.g. Tarasoff)(e.g. Tarasoff)

5) Utilitarianism (greatest good for…)5) Utilitarianism (greatest good for…)

6) Deontological (universally true for all6) Deontological (universally true for all time)time)

Ethics Theories Used in PsychiatryEthics Theories Used in Psychiatry

7) Discourse ethics (post-modernist, 7) Discourse ethics (post-modernist, feminist): feminist):

ethical norms are generated through ethical norms are generated through discourse within a context in which discourse within a context in which all members can express their viewsall members can express their views

(I believe such discourse inevitably (I believe such discourse inevitably involves appeal to, or non-explicit involves appeal to, or non-explicit use of, the previous 6 theories)use of, the previous 6 theories)

My Inner Moral World…My Inner Moral World…What guides your thinking? What drives What guides your thinking? What drives your heart?your heart?

Playground rules: “That’s not fair!”Playground rules: “That’s not fair!”

Do unto others…Do unto others…

The Rawlsian Veil of Ignorance…The Rawlsian Veil of Ignorance…(a technique for weighing distributive justice)(a technique for weighing distributive justice)

Ethics in PsychiatryEthics in PsychiatryIt is argued that no one theory is It is argued that no one theory is adequate for the complexities of adequate for the complexities of psychiatric practicepsychiatric practice

Why? Unique vulnerability of mental Why? Unique vulnerability of mental health clients, unique power health clients, unique power relationships, unique relationship of relationships, unique relationship of psychiatry to the law and social psychiatry to the law and social institutionsinstitutions

Ethics in PsychiatryEthics in PsychiatryPsychiatry is a socially constructed Psychiatry is a socially constructed enterprise, continually evolving…enterprise, continually evolving…

Nazi psychiatrists to REBs… Nazi psychiatrists to REBs… Codes of ethics (e.g. ati diki)Codes of ethics (e.g. ati diki)Disease classification (DSM V)Disease classification (DSM V)Treatments (analysis, DBS)Treatments (analysis, DBS)Neuroscience (do we have free will?)Neuroscience (do we have free will?)What counts as normal? (neurodiversity What counts as normal? (neurodiversity movement)movement)

Ethics in PsychiatryEthics in Psychiatry

The Goal: “To achieve a balance The Goal: “To achieve a balance between universal human values and between universal human values and the particularism of different the particularism of different psychiatrists working in different psychiatrists working in different societies at different points in societies at different points in history…”history…”

(Brodwin 2008)(Brodwin 2008)

How do we do this?How do we do this?

Moral DiscourseMoral Discourse““The Coproduction of Moral Discourse in The Coproduction of Moral Discourse in U.S. Community Psychiatry” U.S. Community Psychiatry”

A two year ethnographic study of ACTA two year ethnographic study of ACT(ethnography: the study and systematic (ethnography: the study and systematic recording of human cultures)recording of human cultures)

Paul Brodwin, anthropologist, Paul Brodwin, anthropologist, University of Wisconsin University of Wisconsin Medical Anthropology Quarterly V.22, Issue 2, Medical Anthropology Quarterly V.22, Issue 2, 20082008

Bioethics – A CritiqueBioethics – A CritiqueFor 20 years, social scientists have For 20 years, social scientists have critiqued formal bioethics. In the real critiqued formal bioethics. In the real world, we don’t have rational and world, we don’t have rational and systematic deliberation in response to systematic deliberation in response to moral uncertainty. Reality is messy…moral uncertainty. Reality is messy…

They say ethical issues in medical care are They say ethical issues in medical care are not addressed by “invoking abstract not addressed by “invoking abstract principles and values (autonomy, utility, principles and values (autonomy, utility, care,etc.) but rather through local idioms care,etc.) but rather through local idioms and reflections on their immediate, and reflections on their immediate, practical activities”practical activities”

Bioethics – A CritiqueBioethics – A Critique

“ “ According to this critique, people’s According to this critique, people’s moral perspective on medical moral perspective on medical treatment emerges from the treatment emerges from the concrete details of inequality and concrete details of inequality and local notions of suffering, not high- local notions of suffering, not high- order virtues or rules of conduct.”order virtues or rules of conduct.”


““Emotional experience and local Emotional experience and local institutional arrangements drive institutional arrangements drive many of the many of the social conflictssocial conflicts that that laterlater get formally labeled as bioethics get formally labeled as bioethics disputes.”disputes.”

(italics and underlining are mine)(italics and underlining are mine)

Bioethics – A CritiqueBioethics – A Critique““Ethical discussions by both staff and Ethical discussions by both staff and patients are thus inseparable from their patients are thus inseparable from their immediate life circumstances, social roles, immediate life circumstances, social roles, political interests, and cultural beliefs.”political interests, and cultural beliefs.”

This critique has intuitive appeal. Bioethics This critique has intuitive appeal. Bioethics is an abstract bunch of theoretical stuff is an abstract bunch of theoretical stuff that doesn’t really have primacy in the that doesn’t really have primacy in the real clinical world…real clinical world…

Bioethics – A CritiqueBioethics – A CritiqueThis critique lead to the following This critique lead to the following categorical distinction and lingo:categorical distinction and lingo:““Moral discourse” is the framework Moral discourse” is the framework used by ordinary front-line used by ordinary front-line practitioners as they handle practitioners as they handle particular illness episodesparticular illness episodes““Ethics” is the codified, reflective Ethics” is the codified, reflective language of elite experts, situated language of elite experts, situated far from the scene of clinical action far from the scene of clinical action

Bioethics – A CritiqueBioethics – A CritiqueIf moral discourse and ethics are really two If moral discourse and ethics are really two separate worlds of thought, then what does that separate worlds of thought, then what does that mean for clinical bioethicists who provide moral mean for clinical bioethicists who provide moral advice and adjudicate disputes in hospitals?advice and adjudicate disputes in hospitals?

““Clinical bioethicists depend on their specialized Clinical bioethicists depend on their specialized theoretical knowledge to legitimize their theoretical knowledge to legitimize their professional identity.”professional identity.”

““They promise clarity, rigor, and coherence, even They promise clarity, rigor, and coherence, even if (indeed, precisely because) they obscure the if (indeed, precisely because) they obscure the local texture and richness of moral life.“local texture and richness of moral life.“


““The social power of clinical The social power of clinical bioethicists – the likelihood that bioethicists – the likelihood that others will follow their advice – others will follow their advice – depends on their cultural authority, depends on their cultural authority, their ability to establish convincing their ability to establish convincing definitions of fact and value. This is a definitions of fact and value. This is a tight power/knowledge link…”tight power/knowledge link…”


But “ethical decision making in But “ethical decision making in health care is a culturally embedded health care is a culturally embedded process, attuned to people’s life process, attuned to people’s life experiences and shifting over time. It experiences and shifting over time. It thus cannot possibly conform to the thus cannot possibly conform to the dictates of prescriptive theory.” dictates of prescriptive theory.” (theory that shows what one ought to (theory that shows what one ought to do)do)

The ConundrumThe Conundrum

So bioethicists are useless?So bioethicists are useless?

So ethics is remote and irrelevant to So ethics is remote and irrelevant to front line workers?front line workers?

So moral discourse at the front-line So moral discourse at the front-line always has analytic primacy and is always has analytic primacy and is useful simply because bioethics is useful simply because bioethics is not?not?

A Middle Road: Coproduction of A Middle Road: Coproduction of Moral discourseMoral discourse

Brodwin argues that “moral Brodwin argues that “moral discourse is coproduced by formal discourse is coproduced by formal bioethics, on the one hand, and the bioethics, on the one hand, and the circumstances of everyday clinical circumstances of everyday clinical practice, on the other hand.”practice, on the other hand.”

What does this mean? It is like a What does this mean? It is like a pentimento…pentimento…

Coproduction of Moral DiscourseCoproduction of Moral Discourse

Pentimento: a reappearance in a painting Pentimento: a reappearance in a painting of a design which has been painted over of a design which has been painted over

The tools at hand to solve clinical The tools at hand to solve clinical dilemmas were “created in part by prior dilemmas were “created in part by prior ethical decisions made by other actors, ethical decisions made by other actors, responding to different circumstances and responding to different circumstances and demands at an earlier historical period.”demands at an earlier historical period.”The “outcome of prior ethical debates is The “outcome of prior ethical debates is woven into the terms and tools used by woven into the terms and tools used by today’s clinicians.”today’s clinicians.”


““Over time, bioethics decisions Over time, bioethics decisions (systematic, explicit, and made by (systematic, explicit, and made by experts) become sedimented into the experts) become sedimented into the very conditions of work for front-line very conditions of work for front-line practitioners. They help create the practitioners. They help create the roles that clinicians play, the roles that clinicians play, the guidelines and goals for intervention guidelines and goals for intervention with patients, and their moral with patients, and their moral perspective on every day work.”perspective on every day work.”


In short, ethics matters and moral In short, ethics matters and moral discourse matters, and neither can discourse matters, and neither can flourish without the other.flourish without the other.

Teeth need something to chew on…Teeth need something to chew on…

Mental health reform is driven by Mental health reform is driven by front-line conflict and vice versa!front-line conflict and vice versa!

Moral Discourse on ACT TeamsMoral Discourse on ACT TeamsBrodwin’s observations about ACT:Brodwin’s observations about ACT:

High-order ethics debates (autonomy & High-order ethics debates (autonomy & human dignity vs abandonment & the human dignity vs abandonment & the failure of deinstitutionalization) spurred failure of deinstitutionalization) spurred the invention of ACT 35 years agothe invention of ACT 35 years ago

These debates have been “braided” into These debates have been “braided” into our moral discourse as it continues our moral discourse as it continues through many mediationsthrough many mediations

Moral Discourse on ACT TeamsMoral Discourse on ACT Teams

““High-order ethical discussions about High-order ethical discussions about right and wrong hover above the site right and wrong hover above the site of clinical action, leaking into the of clinical action, leaking into the words people use, constraining words people use, constraining people’s actions without their people’s actions without their knowing it, and sometimes entering knowing it, and sometimes entering their most personal anxiety about their most personal anxiety about the obligatory and the forbidden.”the obligatory and the forbidden.”

Moral Discourse in ACT CultureMoral Discourse in ACT CultureWhen you started your ACT job you entered an When you started your ACT job you entered an established culture with:established culture with:rules (e.g. confidentiality, consent)rules (e.g. confidentiality, consent)policies (college, hospital, legal)policies (college, hospital, legal)duties (e.g. ORB monitoring)duties (e.g. ORB monitoring)particular interpersonal norms (e.g. particular interpersonal norms (e.g. assertiveness, coercion, respect)assertiveness, coercion, respect)expectations of mutual support (teamwork, expectations of mutual support (teamwork, safety)safety)black humourblack humourmandates (TAP, provincial standards)mandates (TAP, provincial standards)values (e.g. recovery, rehab)values (e.g. recovery, rehab)consumer rights and movement as a backdropconsumer rights and movement as a backdropmental health reform in the wingsmental health reform in the wings

Moral Discourse on ACT TeamsMoral Discourse on ACT TeamsWe navigate culturally complex waters…We navigate culturally complex waters…

Brodwin highlights that there are “ethical Brodwin highlights that there are “ethical black boxes” behind the scenes that black boxes” behind the scenes that establish limits of allowable conduct, and establish limits of allowable conduct, and these are used by front-line staff who these are used by front-line staff who neither know the history nor internal neither know the history nor internal complexity of the box, but simply use it complexity of the box, but simply use it everyday for routine tasks and decisions.everyday for routine tasks and decisions.The boxes serve their essential purpose, The boxes serve their essential purpose, but can also “precondition certain but can also “precondition certain tensions, blockages, and frustrations in tensions, blockages, and frustrations in everyday work”everyday work”

Moral Discourse on ACT TeamsMoral Discourse on ACT TeamsThe iterative process of moral The iterative process of moral discourse and its emergent trail of discourse and its emergent trail of black boxes has shaped:black boxes has shaped:

Regulatory paperwork and formsRegulatory paperwork and formsThe mandates and micro-politics of The mandates and micro-politics of staff-client interactionsstaff-client interactionsThe idealized self-image of front-line The idealized self-image of front-line ACT staffACT staff

Moral Discourse on ACT TeamsMoral Discourse on ACT Teams Mostly, the black boxes are under the Mostly, the black boxes are under the

discussion table sending out their ethics discussion table sending out their ethics beacon signals. However, when a beacon signals. However, when a substantial moral conflict arises, a black substantial moral conflict arises, a black box is sometimes set right on the box is sometimes set right on the discussion table. When this happens, I discussion table. When this happens, I suggest the more fitting image may be of suggest the more fitting image may be of Russian nesting dolls… Russian nesting dolls…

The craftsmanship, history, and layers of The craftsmanship, history, and layers of ethics can be appreciated if explored…And ethics can be appreciated if explored…And you can stop at the level needed to restore you can stop at the level needed to restore balance to the clinical culture and get on balance to the clinical culture and get on with the jobwith the job

A caveat about how teams work…A caveat about how teams work…

Teams are a disparate mélange of acculturated professionals with differing world views, different clinical paradigms, and conflicting values, duties, or operating principles.

Obvious competing forces: personal morality, laws, culture, professional college guidelines, hospital rules, team views, limits/goals of the service mandate, role of client wishes, beliefs about efficacy and success.

Given this, there are many ways that team structure and function can hinder treatment goals and outcomes, and more to the point, smother effective moral discourse.

Potential Flaws in Team Potential Flaws in Team Functioning and OperationsFunctioning and Operations

1. Increased risk taking: greater willingness to accept risk as a team member as compared to individual decision making.

2. Diffusion of responsibility: unclear accountability to a team that is supposed to serve as as a support / resource / supervisory system. Abrogation of duty amidst a busy flow.

(1-7 are based on Szeczeskiewicz 2005)

3. Mutual confirmation bias: shared view on manufacturing desired outcomes.

4. Belief in the inherent morality of group members: presumptions of goodness and craft knowledge may abound.

5. Mutual protection from criticism: trauma bonding, alliances, and sub-groupings leading to “us against them” mentalities or justifications.

6. Conformity: the pressure to conform to group norms or get out of the way; being punished for questioning; scapegoating as an inevitable group phenomenon; reenactment of family of origin dynamics; repetition compulsions; “Go along to get along”.

7. Restricted response repertoire: this is a closed shop that always does it this way…

8. Illusion of invulnerability: group strength phenomenon…

9. Role diffusion: “Staff members serve multiple roles – job coach, money manager, and medication assistant, as well as counselor. This necessary flexibility produces a role diffusion that can lead to a risky boundary diffusion”

(Stovall 2001)

10. Allowing less skilled clinicians to get by with splinter skills: some team members function without a rich or encompassing paradigm and don’t know what they don’t know (e.g. ignorance of basic interviewing skills, limited understanding of boundaries. Intolerance of affect: silencing clients with cheeriness, encouragement, or a practical task focus in ways that are both distancing and emotionally alienating).

11. Sheltering and compensation for colleagues who are under skilled: this is an extension of the ACT protective posture to its own structures.

Moral discourse in ACTionMoral discourse in ACTion

Let’s have some moral Let’s have some moral discourse…discourse…

Three topics:Three topics:

1) Weaving a value tapestry1) Weaving a value tapestry

2) A penny for your thoughts2) A penny for your thoughts

3) Take one for the team3) Take one for the team

1) Weaving a Value Tapestry1) Weaving a Value Tapestry

A shared piece of work…A shared piece of work…

Would you do any of the following Would you do any of the following jobs at this stage of your life:jobs at this stage of your life:

Sell pop and popcorn in the stands at Sell pop and popcorn in the stands at BC Lions football games?BC Lions football games?

Work as a cook at Kentucky Fried Work as a cook at Kentucky Fried Chicken? Chicken?

Weaving a Value TapestryWeaving a Value Tapestry

Be a security guard at a movie Be a security guard at a movie theatre?theatre?

Clean hot tubs at an after-ski facility?Clean hot tubs at an after-ski facility?

Be a car jockey at a rental agency?Be a car jockey at a rental agency?

Be a camp counselor?Be a camp counselor?

Be a high school supply teacher?Be a high school supply teacher?

Teach courses at a university?Teach courses at a university?


If you said “no” to any of the job If you said “no” to any of the job possibilities, would you change your possibilities, would you change your mind if you had to do it to feed your mind if you had to do it to feed your family?family?

Would you do it if you thought it was Would you do it if you thought it was a socially responsible and good thing a socially responsible and good thing to take part in our collective creation to take part in our collective creation of a civil society? of a civil society?

Weaving a Value TapestryWeaving a Value TapestryAre some jobs only suitable for Are some jobs only suitable for slaves, lower classes, immigrants, slaves, lower classes, immigrants, high school drop-outs, trailer park high school drop-outs, trailer park boys, teenagers, women, or mentally boys, teenagers, women, or mentally ill people?ill people?What social biases and prejudice What social biases and prejudice have permeated our collective have permeated our collective unconscious? Let’s make covert unconscious? Let’s make covert barriers overt…barriers overt…


Is every ACT client capable of Is every ACT client capable of working?working?Too sick all the time? No energy? No Too sick all the time? No energy? No motivation?motivation?

Is my bias an unconsciously Is my bias an unconsciously insinuated impediment that supports insinuated impediment that supports a client’s sense of entitlement or a client’s sense of entitlement or helplessness?helplessness?


Yes, every single ACT client Yes, every single ACT client can work, under the right can work, under the right conditionsconditions

Assisted, supported, modified, Assisted, supported, modified, adapted, part-time, seasonal, adapted, part-time, seasonal, volunteer…volunteer…


My value: We must not forget that My value: We must not forget that our society is like a mobile whose our society is like a mobile whose fragile equilibrium and success fragile equilibrium and success depends on a shared commitment to depends on a shared commitment to all vocational roles. No work is below all vocational roles. No work is below me or above me if it needs doing for me or above me if it needs doing for our shared good. All work is noble our shared good. All work is noble and enobling. and enobling.

1) A Penny for your Thoughts: 1) A Penny for your Thoughts: Paying patients cash to take medsPaying patients cash to take meds

Fostering medication compliance Fostering medication compliance in patients with serious and in patients with serious and persistent mental illness who persistent mental illness who lack insight and who are lack insight and who are repeatedly non-compliantrepeatedly non-compliant

A Penny for your Thoughts: Our A Penny for your Thoughts: Our Social BackdropSocial Backdrop

Financial incentive programs have helped Financial incentive programs have helped with tuberculosis treatment compliance; with tuberculosis treatment compliance; encouraged dental care, weight loss, encouraged dental care, weight loss, cocaine abstinence, births, stopping cocaine abstinence, births, stopping pregnant moms from smoking and pregnant moms from smoking and drinking, getting parents to take kids to drinking, getting parents to take kids to the doctor…the doctor…

In short, many social goods are prompted In short, many social goods are prompted and accomplished through the use of and accomplished through the use of direct financial incentives…direct financial incentives…

A Penny for your ThoughtsA Penny for your Thoughts70 % of psychiatric patients do not 70 % of psychiatric patients do not take their meds as prescribedtake their meds as prescribed

By introducing payment into the By introducing payment into the equation, will voluntary adherence equation, will voluntary adherence falter or disappear?falter or disappear?Does paying for adherence Does paying for adherence undermine the basis for informed undermine the basis for informed consent?consent?

A Penny for your ThoughtsA Penny for your Thoughts

In a survey, 50 of 75 Managers of In a survey, 50 of 75 Managers of ACT Teams in Britain said paying ACT Teams in Britain said paying cash for compliance is unethicalcash for compliance is unethical

We already use strong incentives and We already use strong incentives and coercion (reward or punishment) with coercion (reward or punishment) with ACT clients (coffee, outings, housing, ACT clients (coffee, outings, housing, admissions). Why is cash different?admissions). Why is cash different?


British ACT managers feared money British ACT managers feared money was too coercive with poor clients was too coercive with poor clients and would affect the therapeutic and would affect the therapeutic relationship (make clients suspicious)relationship (make clients suspicious)

In 2003 a British ACT team offered to In 2003 a British ACT team offered to pay 5 clients $10-$30 for each pay 5 clients $10-$30 for each injection of medicationinjection of medication

4 accepted…4 accepted…

A Penny for your ThoughtsA Penny for your ThoughtsOutcome: Outcome:

better compliancebetter compliancemore likely to stay in independent more likely to stay in independent accommodationaccommodationfewer problems with neighbours and fewer problems with neighbours and the policethe policeno admissionsno admissions

Just coincidence? Attributable to Just coincidence? Attributable to other supportive ACT elements?other supportive ACT elements?


So spending a bit may save a lot of So spending a bit may save a lot of money for the system… money for the system…

How to select…How to select…

Just those who lack insight?Just those who lack insight?

High risk for non-compliance?High risk for non-compliance?

History of violence?History of violence?

Heaviest users of services?Heaviest users of services?

All other interventions, persuasions, All other interventions, persuasions, and coercive techniques have failed?and coercive techniques have failed?


Behavioural therapies are based on Behavioural therapies are based on explicit and consistent rewards…explicit and consistent rewards…

Is paying cash really immoral Is paying cash really immoral exploitation of the poor and exploitation of the poor and vulnerable, or just a more positive vulnerable, or just a more positive variation on what we do already?variation on what we do already?


Bonus question: Bonus question:

Should we pay patients with drug Should we pay patients with drug induced metabolic syndrome to induced metabolic syndrome to exercise?exercise?

3) Take One for the Team3) Take One for the TeamThe scenario:The scenario:

25 years old with schizophrenia25 years old with schizophreniaFollowed by ACT TeamFollowed by ACT TeamHistory of noncomplianceHistory of noncomplianceDecompensates slowlyDecompensates slowlyNo history of violence or self-harmNo history of violence or self-harmLacks insight; otherwise well on IMLacks insight; otherwise well on IMNot capable for treatmentNot capable for treatmentSDM authorizes IMSDM authorizes IMClient repeatedly refuses IMClient repeatedly refuses IMRepeated ACT-client confrontation every two Repeated ACT-client confrontation every two weeks over taking the IMweeks over taking the IM

Take One for the TeamTake One for the TeamThe Health Care Consent Act The Health Care Consent Act (Ontario) authorizes valid substitute (Ontario) authorizes valid substitute consent for treatment for an consent for treatment for an incapable clientincapable clientDoes it also authorize the Does it also authorize the meansmeans necessary to deliver the treatment? necessary to deliver the treatment? Can we override the client’s refusal Can we override the client’s refusal of the IM in the community when of the IM in the community when there is no threat to life or limb, and there is no threat to life or limb, and no likelihood of self-harm or harm to no likelihood of self-harm or harm to others? others?

Take One for the TeamTake One for the TeamYes!Yes!A 2008 case settled before the A 2008 case settled before the Ontario Superior Court has spelled Ontario Superior Court has spelled this out clearly for the first time and this out clearly for the first time and it has not been appealed…it has not been appealed…

How do you do this in reality?How do you do this in reality?

Can you maintain the relationship?Can you maintain the relationship?

Date post:	26-Dec-2015
Category:	Documents
Upload:	maximilian-payne
View:	221 times
Download:	3 times

Ethics in ACT Ethics in Action Ethics in Traction John Maher MA MD FRCPC.

Documents