4.2 General Ethical Considerations in Psychological Intervention with Children
4.2.8 Unique Issues in the Consultation-Liaison Setting
When working with children and families in the medical setting, there are a few challenges faced by the mental health professional that are over and above the issues in dealing with them in a general psychiatry setting (Krener 1995; Wright and Roberts 2009). The salient ones relevant to the general hospital setting are enumerated below.
4.2.8.1 Documentation
In a general hospital setting, children usually need to visit various departments for their various problems. As a psychologist working in such a setting, the challenge is to decide what, how, when, and where to write one’s notes. Obviously, details about confidential issues need to be recorded separately where access is limited to the stake holders only.
4.2.8.2 Physical Setting
Very often, a mental health professional working with the child team is asked to screen, evaluate, and manage a child in the ward and at the bedside. There are
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definite issues with confidentiality and the extent of rapport that is possible in such a situation. In India, where extended families usually provide support during inpatient stay, excluding them from discussions can be resented, at best and treated with hostility, at worst. Arranging for a private corner in the ward itself and requesting the staff nurse to ensure that the discussion is not disturbed can be planned easily.
4.2.8.3 Time Constraints
As many mental health professionals working in a general hospital would agree, time constraints play a major role in the extent of involvement possible in the treatment. Many times, referrals are made on the day or the day prior to discharge and keeping the family in the hospital after the medical team has offered discharge can be a challenge. Often, therapy is initiated in the ward and further appointments need to be scheduled for post discharge visits. Working with the treating team to ensure that referrals are made giving some time for evaluation and making the treatment plan by the psychologist would be recommended. Usually it is not the lack of importance to mental health issues that leads to the last minute referrals but more the lack of awareness of the time required and the process of a psychological evaluation.
4.2.8.4 Physician Variables
Given the fact that the treating team has its goals clearly focused on the presenting physical symptom, the shift in emphasis can be a challenge. A lot of times, dis- cussions on clearly confidential information may happen on the corridor, on the bedside, and sometimes over the phone and one needs to bear in mind that a conscious effort may sometimes be needed to get everyone on the treating team to become sensitive to the ethical issues involved in this sharing of information.
4.2.8.5 Therapy Variables
The form, content, and process of therapy is very different in a setting where the primary problem may not be the psychological one. We may need to beflexible in the way the therapy is formatted to suit the needs of the child, family, and the reason for referral. Often, more than one family member may need to be involved in the therapeutic alliance. The frequency of sessions, the duration of sessions, and the therapeutic stance all may need to be tailored to individual needs. Daily sessions, shorter duration of each session and an eclectic approach are all more effective.
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4.2.8.6 Child Variables
When a child in a hospital setting is referred for psychological evaluation, the child may be physically not well enough to handle long therapy sessions. Sometimes, being in the hospital itself is so stressful for most children, that they are not really very cooperative for verbal therapies. Rapport building in this context will require a flexible, individually tailored approach that can only be arrived at through expe- rience. The child may have intravenous treatment going on, may have attached monitors, and may also be isolated in the ward and all of these are not conducive to an ideal therapeutic setting. Including the child in the decision-making process is not usually practised in our setting although it is the right thing to do.
4.2.8.7 Family Variables
When we are dealing with children, it is impossible not to deal with the family as well. This is especially the case in India where almost all decisions regarding the child’s health, including mental health, are made by the family. This may also include extended family members like grandparents, aunts, uncles, cousins, etc. It is a unique challenge in our setting to draw the line to decide who all need to be involved in the care of the child.
4.2.8.8 End of Life Care
There are numerous challenges and conflicts in terminal situations including some medical as well as psychological issues:
• To take a decision to withdraw advanced life support, nutritional support, or resuscitation.
• To avoid prescribing futile investigations and futile therapies.
• To deal emotionally with the situation of patients without taking sides—of either the treating team or the family.
4.2.8.9 Health Professionals’Conduct
Sometimes when working as part of a multidisciplinary treating team, one may come across several conundrums that have ethical implications:
• Disagree with the treating team about the indication for procedures.
• Witness inappropriate attitudes of colleagues.
• Disagree with breach of confidentiality, inappropriate use of investigations, or medication.
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In this context, another important issue that may arise would be when a mental health professional feels compelled to take up an important component of treatment that really comes in the purview of the medical professional’s care. In this kind of scenario, the suggestion would be to gently urge the medical professional to deal with the issue while, at the same time, be available to the child and family tofill in the gaps. Sometimes, working in tandem will be an even better option.