anti-Causality


Tuesday, January 18, 2011

Ethical issues surrounding anxiety disorders

Many adolescents (and children) require proactive care for anxiety disorders.  In the most optimistic cases, early intervention can stem serious problems later on.  But for many suffering from anxiety disorders, proactive care means that their rights are limited, and they may be coerced into therapy and medications that they don't want.  There is endless ethical "gray area" between the two extremes: a happy alliance with the therapist, and an  apparent removal of basic rights.

In the happier purely voluntary form of therapy the counselor/client relationship is called the therapeutic alliance, "a collaborative nature of the partnership between counselor and client" (Hawaii State Department of Health), counseling ethics are easily applied as boundaries to the relationship to assure that the therapy is beneficial and that no harm comes to the client.

This is described succinctly as the "four principles for biomedical ethics" (Westra, 2009): respect for autonomy, nonmaleficence, beneficence, and justice.

The phrase "no harm" (Sheppard, 1999), may be added to stress nonmaleficence.  When clients are harming themselves or may be harmed, this comes to mean "preventing harm," and ethical issues become difficult.

Another more subtle situation that equally relevant situation involves what treatment is used, specifically prescribed drugs, rather than if treatment is used.

An approach to these contradictions is to show that adolescents that need to be controlled, have that need because they are victims.  Adolescents who have been sexually assaulted are at risk for PTSD (Lawyer, 2006), and PTSD as often as not leads to anger (Saigh, 2007).  That may require involuntary treatment if the anger is externalized as violence.  Angry adolsecents usually come from angry families (Avci,  2010), and  "school refusal" is most often positively reinforced by family members or cohorts from the surrounding environment (Kearney, 2004).  Other adolescents who "refuse school" are anxiously reacting to real threats at school (Dube, 2009).  Professionals agonize when young assault victims have to be placed in forensic units, really prisons, when they become threatening or self-injurious as a result of their victimization (Welsh, 1998).

Self-injury may be the most dramatic of issues, along with often related suicide, and it is usually an effort to distract from the pain of depression, or the result of low self-esteem depression (Dickstein, 2009) from negative appraisal by others, or assault (Weismoore, 2010).  Effectively, they have neurotransmitter dysfunctions (Dickstein, 2009).

Perhaps the best information is that adolescent "delinquents" have normal empathy, and that they apparently suffer from executive function disorders (Lardén, 2006).  The stresses that they face force them to limit their cognizance of others' feelings, and there is no self-reported empathy gap between girls and boys. 

References

Avci, R., & Güçray, S. (2010). An Investigation of violent and nonviolent adolescents' family functioning, problems concerning family members, anger and anger expression. Educational Sciences: Theory & Practice, 10(1), 65-76. Retrieved from Academic Search Premier database.

Dickstein, D. (2009). A closer look at non-suicidal self-injury in adolescents. (Cover story). Brown University Child & Adolescent Behavior Letter, 25(12), 1-6. Retrieved from Academic Search Premier database.

Dube, S., & Orpinas, P. (2009). Understanding excessive school absenteeism as School Refusal Behavior. Children & Schools, 31(2), 87-95. Retrieved from Academic Search Premier database.

Hawaii State Department of Health (2010). Therapeutic alliance curriculum activity quiz. Retrieved September 16, 2010, from http://www.amhd.org/About/ClinicalOperations/MISA/Training/Therapeutic%20Alliance%20Curriculum%20activity%20quiz.pdf

Kearney, C. (2007). Forms and functions of school refusal behavior in youth: an empirical analysis of absenteeism severity. Journal of Child Psychology & Psychiatry, 48(1), 53-61. doi:10.1111/j.1469-7610.2006.01634.x.

Lardén, M., Melin, L., Holst, U., & Långström, N. (2006). Moral judgement, cognitive distortions and empathy in incarcerated delinquent and community control adolescents. Psychology, Crime & Law, 12(5), 453-462. doi:1068-316X print/ISSN 1477-2744.

Lawyer, S., Ruggiero, K., Resnick, H., Kilpatrick, D., & Saunders, B. (2006). Mental health correlates of the victim-perpetrator relationship among-interpersonally victimized adolescents. Journal of Interpersonal Violence, 21(10), 1333-1353. Retrieved from Academic Search Premier database.

Saigh, P., Yasik, A., Oberfield, R., & Halamandaris, P. (2007). Self-Reported Anger Among Traumatized Children and Adolescents. Journal of Psychopathology & Behavioral Assessment, 29(1), 29-37. doi:10.1007/s10862-006-9026-9.

Sheppard, G., Schulz, W. and McMahon, S. (1999). The code of ethics. Canadian Counselling and Psychotherapy Association: Ottawa.

Weismoore, J., & Esposito-Smythers, C. (2010). The Role of Cognitive Distortion in the Relationship Between Abuse, Assault, and Non-Suicidal Self-Injury. Journal of Youth & Adolescence, 39(3), 281-290. doi:10.1007/s10964-009-9452-6.

Welsh, J. (1998). In whose ‘best interests’? Ethical issues involved in the moral dilemmas surrounding the removal of sexually abused adolescents from a community-based residential treatment unit to a locked, forensic adult psychiatric unit. Journal of Advanced Nursing, 27(1), 45-51. doi:10.1046/j.1365-2648.1998.00502.x.

Westra, A., Willems, D., & Smit, B. (2009). Communicating with Muslim parents: “the four principles” are not as culturally neutral as suggested. European Journal of Pediatrics, 168(11), 1383-1387. doi:10.1007/s00431-009-0970-8.


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