Markkula Center of Applied Ethics

Delinquency or Mental Health Problem: Reflections by Thomas Plante

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Sadly, Pablo Sanchez's challenges (and those of his family) are not uncommon. Furthermore, the manner in which he and his family were treated by the mental health and juvenile justice systems is not uncommon either. Although many mental health and juvenile justice professionals strive to provide state-of-the–art, culturally competent services—and are even mandated to do so by professional codes of ethics (e.g., American Psychological Association, 2002)—the reality is that they all too often fall short….very short!

Why is this the case, and what can be done about it? First, too few providers know how to offer culturally competent care, and stretched resources for training and services are shrinking by the day. I recently provided an all-day ethics workshop for county mental health workers where the issues discussed in the Pablo Sanchez case came up. Most of the clinicians in attendance expressed their desire to provide high quality, culturally competent services for their many clients, yet they also spoke of their escalating frustration with the many financial cut backs to their already limited resources. "Do more with less" seems to be the battle cry heard daily in their worlds.

Second, those clients with few financial, language, and other resources have limited access to services even under the very best of circumstances. The poor, marginalized, undocumented, and uneducated have few options in most jurisdictions. This is true even during good economic times.

Third, many clinical professionals ultimately burn out trying to provide services to those most in need, as in the case of Pablo and his family. Often, professionals gravitate towards more comfortable and lucrative careers over time, leaving young trainees and lower-level staff members to care for those who are most challenged and difficult to work with. Even those who are dedicated to work with the Pablos of the community frequently find themselves being channeled into administrative positions over time. My friend and colleague Cassandra is an excellent example. I've known her for 20 years as a dedicated social worker; she is culturally competent and fluent in Spanish, working in a very poor area of San Francisco. Over that time, she's been compelled to do more administration and supervision (and thus less direct clinical work). On top of that, she's been challenged by more and more reductions in staffing and budget. Her enthusiasm and optimism have taken a terrible hit over time.

Finally, as our community becomes more diverse, we are hard pressed to keep up with the demands for culturally competent professionals. The vast majority of licensed mental health professionals today are native born, middle and upper middle class, and Caucasian. Certainly the members of the national professional mental health organizations don't come even close to the American demographic in terms of diversity, broadly defined. While we can find at least some professionals who can speak and administer psychological tests in Spanish, finding professionals with the appropriate specialties who are culturally competent and can speak Vietnamese, for example, is another matter entirely. Additionally, the professional testing companies haven't yet translated and normed many of their testing instruments in languages other than English and Spanish. State-of-the-art culturally competent services just don't exist yet in some communities and specialties, or if they do, they are provided by too few professionals given the demand.

So, how are we to better serve Pablo Sanchez and others like him? We can't use the difficulties described here as excuses for doing nothing. Approaching the matter ethically can give us some guidance for treating all patients, regardless of their racial or ethnic background.

If we review the ethics codes from all of the major mental health professional organizations (e.g., psychology, social work, marriage and family counseling) we see that five important virtues are highlighted over and over again. These include respect, responsibility, integrity, competence, and concern for others. RRICC is a useful acronym to recall the values that must guide all of our actions (Plante, 2004).

Most critically, Pablo and his mother could have been treated in a more respectful manner. Regardless of limited resources, the dearth of Spanish-speaking and culturally competent professionals on staff, and so forth, being respectful of others is a critical value that needs to inform all that we do and say. The professionals interacting with Pablo and his mother must find ways to respect them and treat them with dignity. Respect for others goes a long way toward building trust and rapport.

Second, the professionals involved could have treated Pablo and his mother with more thoughtful responsibility. Being responsible means not only providing state-of-the-art professional service in the office but also doing everything possible to assist clients in getting their service needs met and achieving their treatment goals. For example, in order to more fully serve their client in a culturally competent manner, clinicians may wish to supplement the mental health care they offer by partnering with community resources, such as churches, community healers, and schools. Sadly, many mental health professionals fail to take advantage of clergy and faith communities, which can provide a wide range of helpful low and no-cost services, as well as useful perspectives. However, this has been improving in recent years (Plante, 2009).

Third, Pablo and his mother could have been treated with more integrity. Integrity means wholeness, and the clinician could have treated Pablo and his mother in a more holistic manner by considering a variety of biological, psychological, social, cultural, spiritual dimensions of their concerns. Additionally, integrity means honesty. In this regard, the clinician could have been more careful to be sure that Pablo and his mother were giving full and complete informed consent to the terms of their work together and the potential limitations of services. Sometimes integrity can fall between the cracks when a busy professional is working with clients who may not be powerful, wealthy, or liable to complain, which may have been the case here.

Fourth, the Sanchezes could have been treated with more competence by someone who could speak Spanish well and was more culturally attuned to the needs of patients from Mexico. Again, lack of financial and other resources often make this goal challenging to accomplish.

Finally, concern for the welfare of others is so important that it can trump all of the other, sometimes conflicting ethical values in our work. Even with limited resources, sincere expression of concern for others can make the most reluctant clients put aside their defenses and connect with the professional for positive change.

Pablo Sanchez and his family have many challenges ahead. Unfortunately, their experience with the mental health community wasn't very productive—a situation that is all too common for people from minority communities. Ethical principles such as respect, responsibility, integrity, competence, and concern need to be further highlighted within the mental health profession so that culturally competent service is more the norm rather than the exception.

Return to the case
Introduction to Culturally Competent Care
Introduction to Culturally Competent Care for Latino Patients

References

American Psychological Association (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.

Plante, T.G. (2004). Do the Right Thing: Living Ethically in an Unethical World. Oakland, CA: New Harbinger.

Plante, T. G. (2009). Spiritual Practices in Psychotherapy: Thirteen Tools for Enhancing Psychological Health. Washington, DC: American Psychological Association.

Thomas Plante, Ph.D., ABPP is professor of psychology and director of the Spirituality and Health Institute at Santa Clara University as well as an adjunct clinical professor of psychiatry and behavioral sciences at Stanford University School of Medicine. He teaches courses on ethics at Santa Clara, Stanford, and for mental health professionals around the country while maintaining a private clinical practice as a licensed psychologist in Menlo Park, CA.

April 2011


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