Training Mental Health Professionals on Ethical Issues and HIV/AIDS

Sociological Practice: A Journal of Clinical and Applied Sociology, Vol. 2, No. 4, 2000

Training Mental Health Professionals on EthicalIssues and HIV/AIDS

Ellen Slaten,1,6 Paul Ingmundson,2 Nancy Amodei,3 Camerino Salazar,1

Cervando Martinez, Jr.,4 and Donna Taliaferro5

This report describes the importance of ethics training for mental healthprofessionals working with persons infected or affected by HIV/AIDS. Wefirst describe three major ethical dilemmas (confidentiality, duty to warn,and suicide) faced by mental health providers serving persons with HIV/AIDS, and the legal and clinical aspects of these dilemmas. We present datafrom the South Texas AIDS Training Project describing the types of mentalhealth professionals who have attended workshops on ethical issues andHIV/AIDS. Finally, we report observations about the impact of the ethicstraining sessions on the participants’ knowledge and attitudes.

KEY WORDS: HIV/AIDS; ethical issues; mental health providers; AIDS training; legal issues.

INTRODUCTION

As we enter the third decade of the HIV/AIDS epidemic, mentalhealth professionals continue to face a myriad of ethical dilemmas when

1Epidemiology and Services Research Program, Department of Psychiatry, University of TexasHealth Science Center at San Antonio, San Antonio, Texas.

2South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital,San Antonio, Texas.

3Department of Pediatrics, University of Texas Health Science Center at San Antonio, SanAntonio, Texas.

4Department of Psychiatry, University of Texas Health Science Center at San Antonio, SanAntonio, Texas.

5School of Nursing, University of Texas Health Science Center at San Antonio, San Anto-nio, Texas.

6Correspondence should be directed to Ellen Slaten, Department of Psychiatry, Universityof Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas78229; e-mail: [email protected].

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1522-3442/00/1200-0303$18.00/0 2000 Plenum Publishing Corporation

304 Slaten, Ingmundson, Amodei, Salazar, Martinez, Jr., and Taliaferro

providing services to clients infected or affected by HIV/AIDS. Confiden-tiality, duty to warn, and suicide are some of the ethical issues whichchallenge mental health practitioners. Conflicting policy and legal directivesare often confronted as providers seek appropriate responses to ethicaldilemmas. Providers must also take into account the clients’ social andcultural background as they grapple with ethical dilemmas. There is seldoman obvious solution or a single, correct course of action for mental healthproviders to follow in dealing with HIV-related issues in practice. It istherefore imperative for mental health providers to receive training on theprocess for arriving at sound, ethical decision making when working withHIV-infected or -affected clients. This report provides an overview of threemajor ethical dilemmas faced by providers serving persons with HIV/AIDSand describes the types of mental health professionals who have soughtout educational training on ethical decision making. The data are from theSouth Texas AIDS Training (STAT) for Mental Health Providers ProjectII, an educational program which provides HIV/AIDS training to mentalhealth professionals and utilizes a specially designed curriculum on ethicalissues. We begin with an overview of three major ethical dilemmas encoun-tered by mental health professionals working with HIV-positive clients.

CONFIDENTIALITY

Confidentiality is a fundamental tenet in the ethics of mental healthcare. In order to respect the client’s privacy and maintain trust in thetherapeutic relationship, mental health professionals preserve confidential-ity (Chessa and Walker 1998). Without trust in confidentiality, many personswould not share with their mental health provider information essential todiagnosis and treatment. Persons from poor and ethnic minority populationsmay especially distrust mental health professionals, and thus it is crucialfor clinicians to maintain confidentiality with ethnic minority clients (Heit-man and Ross 1999; Gamble 1997; Angell 1997). Gostin (1996) notes thatfailure to respect the confidentiality of clients drives them away from HIVtesting, counseling, and treatment, and that the unwanted disclosure of aperson’s HIV status can lead to emotional, social, and economic harm. Forthe client, a breach of privacy may lead to embarrassment, social isolation,and the loss of self-esteem, employment, or insurance. The centrality ofconfidentiality to effective HIV/AIDS care is reflected in state laws whichforbid health care providers to disclose a patient’s HIV status without hisor her consent (Heitman and Ross 1999). Mental health providers breachconfidentiality only in extreme cases, and deciding whether to violate aclient’s privacy raises a host of legal and ethical questions.

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DUTY TO WARN

In the landmark case Tarasoff v. The Regents of University of California(1976), a clinical psychologist and his employer, The University of Californiaat Berkeley, were held liable for the death of a woman whom the therapist’sclient had openly threatened to kill during a counseling session (Heitmanand Ross 1999). In this case, the court established that therapists have alegal ‘‘duty to warn’’ potential victims of their clients’ behavior. Providersare thus obligated to take steps to protect the intended victim from harm,which may include notifying law enforcement of the threat (Schlossbergerand Hecker 1996). Because HIV infection and AIDS are potentially life-threatening diseases, providers in some states are allowed to disclose theclient’s HIV-positive status to a third person (Stanard and Hazler 1995).This may occur in cases where the HIV-positive client engages in needlesharing or unprotected sex with a known third person, but refuses to disclosehis or her HIV status to the person. If the provider makes every effort toconvince the client to disclose his or her HIV status to the third personand the client refuses, some believe it is ethically defensible for the providerto breach confidentiality by warning the third party about potential expo-sure (Melchert and Patterson 1999; Chessa and Walker 1998). State lawsvary, however, and while breaching confidentiality may be a requirementin one state, it can be a violation of clients’ rights in others (Schlossbergerand Hecker 1996). Some states permit physicians to warn a patient’s legalspouse, but the legal authority of mental health professionals with respectto HIV is typically limited, even if they have conclusive knowledge of apatient’s HIV status and high-risk behavior (Heitman and Ross 1999).

In Texas, there is no legal duty to warn known needle-sharing or sexualpartners of HIV-positive persons. According to the Texas Health and SafetyCode 81-051 (g), ‘‘a partner notification program shall notify the partnerof a person with HIV infection with or without the consent of the personwith HIV.’’ Furthermore, health care professionals are expected to notifythe partner notification program ‘‘when the health care professional knowsthe status of an HIV patient and has actual knowledge of possible transmis-sion of HIV to a third party.’’ However, section (h) of the code states that‘‘a health care professional who fails to make the notification required bysection (g) is immune from civil or criminal liability.’’ Thus, mental healthprofessionals in Texas do not have a legal obligation to violate the client’sconfidentiality to protect the third party from harm.

The Texas Supreme Court issued an opinion in the case of Thapar v.Zezulka (1999) which found no ‘‘duty to warn’’ third parties of specificthreats to harm under Texas law. In this case, a patient informed his psychia-trist that he felt like killing a man and did so shortly thereafter. The


psychiatrist did not warn the intended victim or the police about his patient’sthreats. The court held that a psychiatrist’s duty to preserve confidentialityoverrides the risk that a patient may harm someone. Kelso (1999) notesthat the Tarasoff decision has never been formally adopted in Texas becausethe Texas Supreme Court is unwilling to create a new common law causeof action based in negligence. Although mental health providers in Texasare not legally bound to warn third parties, they often feel a moral obligationto do so, and this perceived moral obligation may be in conflict with theethical precepts concerning the confidentiality of patient–provider commu-nications.

SUICIDE

Even with the advent of more effective medications, some HIV-in-fected persons have thoughts of suicide at difficult times. As an HIV-positive individual begins to experience signs of deterioration and progressinto the later stages of AIDS, the physical and neurological symptomsbecome more severe. The physical and emotional strain brought on by theprogression of the disease further compounds the person’s ability to sustaina positive outlook. Houston-Vega and Ward (1998) note that persons enter-ing the final stages of AIDS may become more focused on the idea ofsuicide. Feelings of isolation, loss of social support, fears about futurephysical and or mental deterioration, and depletion of financial means mayreinforce inclinations toward suicide. Hedge (1996) and Chochinov et al.(1998) state that persons diagnosed with AIDS often develop ideas ofsuicide as a way of regaining control. Persons with deteriorating healthbelieve that suicide will allow them to escape the pain and future complica-tions that the disease will bring.

For mental health providers serving persons with AIDS, ethical dilem-mas arise as their clients advance into the final stage of the disease. As thedisease progresses, thoughts of suicide may increase and patients may asktheir health providers to assist them in their release from suffering, butmental health providers are legally bound to prevent suicide (Houston-Vega and Ward 1998). Assisted suicide is a criminal offense in the majorityof U.S. states, including Texas. Mental health providers are encouraged tointervene in ways that bring a greater sense of control to the suicidalclient, by applying basic principles of crisis intervention. Crisis interventionincludes allowing clients to express fears, feelings, and concerns about theirhealth status, discussing the client’s current suicide plan, developing a crisismanagement plan, and making appropriate referrals for treatment (Hous-ton-Vega and Ward 1998). As a primary resource of social and emotional


support, mental health providers can assist clients in seeking alternativeforms of health care and increased support such as hospice, family-centeredcare, and living wills. The design of an alternative plan decreases stressand allows the person with HIV/AIDS to gain greater control over his orher life. Goldblum and Martin (1999) state that working with suicidal clientsplaces mental health professionals in a dilemma requiring examination oftheir personal and professional values, legal proscriptions, and professionalresponsibilities.

THE SOUTH TEXAS AIDS TRAINING PROGRAM

Due to the challenging ethical dilemmas encountered when workingwith HIV-positive clients, mental health professionals often seek trainingprograms on ethical issues and HIV to help guide their decision-makingprocess. The South Texas AIDS Training (STAT) Project for Mental HealthProviders II is one such program providing workshops on ethical issuesand HIV to mental health professionals in Texas. The STAT Project isfunded by a grant from the Center for Mental Health Services (CMHS) aspart of the Mental Health Care Provider Education in HIV/AIDS ProgramII (MHCPE II). MHCPE II is an interdisciplinary program designed tohelp all types of mental health providers better address the psychosocialand neuropsychiatric needs of people living with and/or affected by HIV/AIDS. The program funds seven universities and three professional associa-tions and supports a comprehensive, multisite evaluation designed to assessthe processes by which training and education are delivered most effectively.The STAT Project was previously funded by CMHS from 1994 to 1997and the project targeted providers serving the largely Hispanic populationof South Texas, particularly those located in remote areas along the Texas–Mexico border. Analyses of pre- and postintervention data from the firstSTAT Project indicate that full-day and half-day educational workshopsyield consistent gains in provider knowledge outcomes (Neff et al. 1999).The current STAT Project is funded from 1998 to 2001 and continues totrain mental health providers on the psychological, neuropsychiatric, andethical aspects of HIV/AIDS care. STAT Project trainers utilize speciallydesigned curricula for the ethics training sessions.

The CMHS Mental Health Care Provider Education in HIV/AIDSProgram II Ethical Issues & HIV/AIDS: A Multi-Disciplinary Mental HealthServices Curricula (Center for Mental Health Services [CMHS] 2000) weredesigned to increase participants’ proficiency in making ethical decisionsin response to dilemmas encountered in providing HIV-related mentalhealth services. The MHCPE II project sites participated in the develop-


ment and pilot testing of the ethics curricula, which is being used acrossnine of the funded sites for all CMHS-sponsored ethics training sessions.Ethics workshop participants are encouraged to consider ethical dilemmasin terms of their profession’s ethics code, identify some of the legal issuesencountered in providing HIV-related mental health services, and applya systematic decision-making model to case examples involving ethicaldilemmas faced by HIV/AIDS service providers. Trainers guide the partici-pants through the learning process by presenting important concepts andassisting participants in applying these concepts to their unique problemsand issues. The ethics curricula can be presented in a 60- to 90-min, a 2-hr, or a half-day (4-hr) version. The training format places a heavy emphasison learning through group discussion and problem solving, especially inthe longer (2- and 4-hr) versions. More information about the ethics curricu-lum can be found on the Center for Mental Health Services website (http://www.lewin.com/cmhsprogram2).

DESCRIPTION OF THE ETHICS TRAINING SESSIONS

The STAT Project held seven ethics training workshops for mentalhealth professionals in four Texas cities (San Antonio, Dallas, Laredo, andSouth Padre Island) from February 1999 to June 2000, training a total of249 mental health professionals. Two of the ethics training sessions were4 hr in length, two sessions were 3 hr long, one session was 2.5 hr long,and two sessions were 90 min in length. The 4-hr version of the curriculumwas adapted for use in a 3-hr workshop. The number of trainees per sessionranged from 17 to 56, with an average number of 35 persons attendingeach workshop.

After each ethics workshop, trainees completed an Ethics ParticipantFeedback Form to describe themselves and their perceptions of the training.The Ethics Participant Feedback Form is a single-page, two-sided instru-ment designed to evaluate the MHCPE II ethics curriculum. Side one ofthe instrument coded the major demographic characteristics of trainees,their professional background, primary work setting, and the number ofyears providing direct clinical mental health services, direct services, andother services to HIV-positive individuals. Side two of the instrument codedsatisfaction with training and knowledge gain. This report presents datafrom only side one of the instrument, the demographic characteristics. Dueto the multisite nature of the MHCPE II program, findings from side twoof the form will not be available until data is obtained from the othersites using the new ethics curricula. Completion of the Ethics ParticipantFeedback Form at the time of training was voluntary (but strongly encour-


aged) and response rates ranged from 69% to 98% for the seven trainingsessions. Of the 249 mental health professionals who attended the ethicstraining sessions, 222 (89%) completed an Ethics Participant FeedbackForm.

TRAINEE CHARACTERISTICS

Table 1 presents the demographic characteristics of the 222 individualswho attended one of the seven ethics training sessions. These traineesreflect a subset of individuals (159 females; 61 males; 2 gender unknown)who described themselves on the Ethics Participant Feedback Form directlyfollowing their educational experience. Most trainees were female (72%),white (47%), or Hispanic (38%), with a smaller percentage being AfricanAmerican (10%). In terms of educational level, most trainees held a master’s(34%), bachelor’s (20%), or associate (11%) degree.

Three fourths of the trainees (75%) provide direct services to HIV-positive individuals and these were primarily nurses (32%), counselors(17%), case managers (14%), and social workers (12%). Smaller percentagesof trainees were psychologists (5%), outreach workers (4%), psychiatrists(3%), and physicians (nonpsychiatrists) (2%). Over half the trainees (57%)provide direct services to family members and/or significant others of HIV-positive individuals. Most trainees had 2–5 years of experience (18%) pro-viding direct services to HIV-positive individuals, and equal numbers re-ported less than 2 years (15%) and 5–10 years (15%) of experience. Thesmallest percentage of trainees had been providing direct services for 10years or more (8%). Of those providing direct HIV-related clinical mentalhealth services (i.e., therapy), a slight majority had been providing clinicalmental health services for less than 2 years (16%), and fairly even numbershad 2–5 years (14%) or 10 years or more (15%) of experience. The smallestpercentage of mental health clinicians (12%) had provided clinical servicesfor 5–10 years.

Trainees who report serving in an indirect capacity include students(17%) volunteers (16%), administrators/supervisors (13%), faculty members(12%), and health educators (10%). Equal numbers of indirect serviceproviders had less than 2 years (15%) or 2–5 years (15%) of work experience,and the rest were divided between 5–10 years (14%) and 10 years or more(13%) of experience. Over three fourths of trainees (76%) work in urbansettings, with much smaller numbers located in rural (11%) or suburban(2%) settings. Most trainees work for community-based organizations(20%), and others are employed in hospital clinics/units (17%) or academicinstitutions (12%). Smaller percentages work for substance abuse treatment


Table 1. Characteristics of Ethnics Training Participants (N � 222)a

SexFemale 72.3

EthnicityWhite 47.3Hispanic/Latino(a) 38.3African-American 9.5Otherb 5.0

EducationHigh school 8.7Associate degree 11.6Bachelor’s degree 20.0Master’s degree 34.9Ph.D. 6.4M.D. 6.0

Reason for attending trainingKnowledge/skill development 43.9CME/CEUs 39.4

Direct service provision to HIV� persons 75.2Direct service provision to family/significant others 56.6Direct service capacity

Nurse (LPN, RN, APN) 32.0Counselor 16.6Case manager 14.2Social worker 11.8

Indirect service capacityStudent 16.9Volunteer 15.7Administrator/supervisor 13.3Faculty/teacher 12.0

Primary work settingCommunity-based organization 20.2Hospital clinic/unit 16.8Academic institution 11.5Substance abuse treatment 9.1

Years of direct service provision to HIV� individualsLess than 2 15.22–5 17.55–10 15.2More than 10 8.1

Years of direct HIV-related clinical mental health service provisionLess than 2 16.12–5 14.15–10 12.1More than 10 14.6

Years of indirect service provision to HIV� individualsLess than 2 14.72–5 14.75–10 13.6More than 10 13.1

aSource: Mental Health Care Provider Education HIV/AIDS Program II Ethnics ParticipantFeedback Form. All values are as percentages unless otherwise indicated.

bOther race or ethnicity includes individuals who chose not to indicate their racial or ethnicbackground (N � 3) or indicated that they were of Asian (N � 5) or Native American(N � 3) background.


centers (9%), public health clinics (5%), long-term care facilities (4%),nonhospital mental health clinics (3%), and correctional facilities (3%).

ETHICS TRAINING OBSERVATIONS

The CMHS Mental Health Care Provider Education in HIV/AIDSProgram II Ethical Issues & HIV/AIDS: A Multi-Disciplinary Mental HealthServices Curricula (CMHS, 2000) were designed to promote a more experi-ential than didactic educational process. The curriculum does not providea set of correct answers to ethical dilemmas, but assists providers in applyinga decision-making model to examples of clinical cases. As examples ofethical dilemmas are presented, mental health providers are encouragedto begin thinking about them. The ethical dilemmas presented in the casestudies often elicit strong emotional responses in participants and theseresponses seem to be mediated by the providers’ HIV/AIDS experience.For example, during one workshop, the participants who were not specialistsin HIV/AIDS care verbalized rather punitive attitudes toward the fictionalpatient in a particular case study. Some participants, angered by the caseexample, felt that it would be appropriate to breach confidentiality andreveal the client’s diagnosis to a third party. Many trainees were unclearabout Texas law regarding the confidentiality of medical information. Theywere also unclear about the lack of legal precedent authorizing a ‘‘duty towarn’’ in Texas, where current case law confers no such duty on healthcare providers (see Thapar v. Zezulka). Some participants cited nonexistingor misunderstood legal precedents or administrative regulations as groundsfor breaking confidentiality. The prevailing ethos differed significantly fromethics training sessions using the same case example, but presented toprofessionals whose primary responsibilities were in HIV/AIDS care. Themore HIV-experienced providers often demonstrated more sensitivity tothe risk of harm to the client associated with an involuntary disclosure ofhis or her HIV status, although they were often uncertain with regard tothe existing legal requirements regarding disclosure and confidentiality.

During the course of the training experience, the participants’ beliefsand views moderated considerably. Participants developed more accuratefactual knowledge concerning the legal and regulatory constraints on theethical problem under consideration and learned new approaches to evalu-ating and reconciling the problem. This knowledge led to a visible softeningof the trainees’ judgmental attitudes. Participants appeared to leave thetraining with more compassion for persons with HIV and a greater willing-ness to incorporate the consideration of patients’ rights and welfare inethical decision making.


Workshops with providers who are more experienced in direct AIDScare yield similar, if less dramatic, reactions. More seasoned mental healthproviders do not initially display the punitive attitudes, but they also comeaway from ethics workshops with greater clarity about legal issues and anincreased understanding of how to utilize ethical decision making in theirclinical cases. Ethics training is therefore important for mental health pro-viders at all levels of experience, but especially those who are less seasoned.This is confirmed by studies of education interventions for primary careservice providers conducted by Neff et al. (1998a, b), which find that thegreatest gains in knowledge, attitude, and practice dimensions were ob-served among participants with the lowest initial knowledge and practicelevels.

CONCLUSION

The AIDS epidemic has brought an array of complicated ethical, legal,and clinical challenges that mental health professionals must navigate inorder to provide high-quality care to their clients (Haghbin et al. 1998). Inthe absence of clear legal and policy guidelines, providers must ‘‘act attheir own peril’’ when faced with ethical dilemmas such as confidentiality,duty to warn, and suicide (Schlossberger and Hecker 1996). Ethics trainingprograms can help guide mental health practitioners through the challeng-ing process of making ethical decisions in the context of HIV/AIDS. Ethicstraining in this curriculum appears to foster changes in both knowledge andattitudes. The training format, with its heavy emphasis on group interaction,discussion, and problem solving, seems to foster a movement away from amonological to a dialogical ethical decision-making process. In a monologi-cal process, participants seek sanction from absolute, inviolate sets of stan-dards, which converge on a single correct interpretation and prescribe aspecific course of action. In a dialogical process, in contrast, countervailingprinciples are weighed and conflicting rights and interests are considered.The process encourages divergent thinking and the development of a varietyof possible interventions. The dialogical process fostered by this ethicstraining tends to promote a deliberative consideration of the rights andinterests which must be balanced in reconciling ethical dilemmas.

The STAT Project has provided ethics training to nurses, counselors,social workers, and other mental health professionals at various levels ofHIV/AIDS experience. The Ethical Issues and HIV/AIDS workshops ledto insights into legal issues and assisted providers in creating treatmentplans that reconcile ethical problems while serving the best interests of theclient. In the third decade of the HIV/AIDS epidemic, ethical issues will


continue to grow in significance, especially with the increasing number ofadolescents being infected (Auerbach and Coates 2000). Mental healthprofessionals will likely encounter increasing numbers of HIV-infectedyouth in their caseloads and the arising of ethical dilemmas as these clientscome of age. Mental health professionals who receive training on ethicalissues will be better equipped to assist clients as they face the challengesof living with HIV disease.

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http://www.supremecourts.state.tx.us

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Training Mental Health Professionals on Ethical Issues and HIV/AIDS