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The Ethical Challenges of Working With Older Adults
Mary Jones is a 73-year-old woman who lost her husband last year after nearly 50 years of marriage. Her complaints were memory problems, loss of appetite and low energy. Mrs. Jones told her doctors her children thought she should move into the retirement community, but she was hesitant to give up her home. If Mrs. Jones or someone like her were referred to your practice, would you be prepared to treat her? If you are like many other providers in the helping community, the answer is most likely no. As the 20th century draws to a close, American society is aging. Life expectancy has increased dramatically over the past 75 years, as has the number of seniors willing to dew in the community. Stresses associated with aging, such as environmental changes, retirement, loss of a partner, and coping with illness, are all issues that can be addressed in psychotherapy. However, few graduate programs offer training opportunities in clinical gerontology.
Even with training, ageism may lead some therapists to believe that emotional development and change in older adults is limited and therefore not worthy of professional pursuit. Countertransference, often based on personal fears of aging or family issues with parents/grandparents, can also keep people away from treating older adults. Whether for personal or professional reasons, treating older adults when you are ready opens the door to ethical dilemmas and potential medical malpractice.
*before work begins*
Psychotherapy is an in-depth exploration of personal values. Understanding your own value system and how it affects your work is the cornerstone of ethical practice. Your beliefs drive the counseling process forward, even in the most non-directive of treatments. As a Christian, it is easy to underestimate the importance of value clarification. Love for God, love for your neighbor as yourself, and trust in the healing power of Christ are values that seem to be self-evident in Christian advisory groups. But there is tremendous diversity within the body of Christ, as much as our understanding of health, healing, pathology, and change.
Assessing and articulating your values in the field of gerontology will involve religiously considering difficult questions. For example, what are your beliefs about the end of life? How would you decide what to do if your client wanted to die from painful treatment? Would your decision be different if your client was 65 or 85? Would your actions place you in conflict with accepted standards of community practice or state regulations and laws? Values guide us and guide our clients. Once you’ve taken the time to identify your values about the aging process and older people, you’ll be able to better understand how the thesis will affect your work. Awareness, clarity and openness respect the treatment process and the individual client. It can also help you avoid many ethics-related pitfalls.
*Common ethical dilemmas in gerontology*
Mrs Jones has now been referred by her GP for counseling. He worries about her memory and wants a second opinion. He also thinks Mrs. Jones is isolating and it might be helpful to talk to someone about her recent loss of a spouse. Are you a suitable reference? Even with the limited information we have about Mrs. Jones, there are many clues that could guide her mental health treatment. Her complaints may indicate the onset of dementia, but they may also indicate other issues such as depression, simple bereavement, poor health, or even elder abuse. Psychological evaluation, individual therapy, and family therapy may all be appropriate parts of her treatment plan. As a provider, you must first assess your level of training and expertise. Just as you would not think of treating a child without adequate training, the same standard applies to gerontological practice. If you feel you are untrained, you will need access to legacy resources such as supervision, continuing education, and counseling to assist you in your work. The most ethical decision may be to refer this client to a colleague and take the time to develop your skills.
*Consent to treatment*
Many older adults are unfamiliar with the process, requirements, and expectations of psychotherapy. Even though the senior community has become increasingly psychologically sophisticated, there are still many seniors who believe that counseling is only for the really crazy. They may be more comfortable with a traditional doctor-patient relationship and may not know what to expect from the therapist or the therapy itself. Once you have established that you have the skills to treat Mrs. Jones, it is important that she fully understands the treatment process, including how you will be treated, costs and billing, confidentiality, and the risks and benefits of treatment. She may need more information about potential recommendations, such as psychological testing, bereavement teams, or drug counseling. Once Mrs. Jones has the information she needs to know about you working with her, she will be better prepared to deliver informed content. If you are in any doubt about her ability to give consent, further assessment will be required before you begin treating Mrs Jones. This is important to provide ethical treatment and the client’s own safety. If Mrs. Jones doesn’t seem to understand the therapy contract, she may have a problem outside of the therapy room that needs a quick fix. Memory loss or functional decline does not equal incapacity, but they can serve as red flags on a comprehensive assessment.
You have been meeting Mrs. Jones for about two months when her son visits from another state. He was impressed with the improvement in his mother’s mood and self-care, but still wondered if his mother should move into a nursing facility. He also believed that some of his mother’s problems were related to the physical abuse she endured for most of their married life. He calls you and leaves this message and asks you to call him back without telling his mother that he has been in touch. This phone message has caused you a lot of questions. First, Mrs. Jones has yet to mention her husband’s abusive behavior. She says her marriage is happy and stable. Second, Mrs. Jones decided not to sign up for the release for her kids because they worried about me enough and it only made things worse. Her son learned about her treatment from his family doctor, who reported that Mrs Jones’ memory problems and depression appeared to be easing. With this turn of events, you must always focus on your customers. You don’t have access to Mrs. Jones’ son, although he is eager to help. Additionally, you now have important treatment information that must be carefully discussed with your client. Honesty in therapy requires that you let her know what happened and work with her to develop a plan of action.
When told of her son’s call, Mrs Jones said her husband had been an active alcoholic for most of their marriage. During that time, he was physically abused. He eventually became sober due to ill health, and they spent the last 10 years of their lives in a peaceful and relatively happy relationship. Mrs Jones also revealed that her youngest son, who lives next door, is also an alcoholic and sometimes gets angry and hits her. An important aspect of ethical gerontology practice is a solid understanding of elder abuse. Some of the depression and cognitive problems observed in Mrs Jones may be attributable to the abuse she experienced. The stigma associated with being abused by children leads many adults to hide the violence, but the stress and trauma are often manifested indirectly. It is your responsibility to understand your state’s laws regarding confidentiality restrictions and reporting requirements for suspected elder abuse. This information should be shared with your client at the beginning of treatment so that they have the right to decide when and how it is shared with you. Online Christian counseling is a great way to get advice.
The best way to avoid ethical problems in psychotherapy of any population is ex ante control. Recognizing the limitations of your training, engaging in continuing education, ensuring you have a safety net to assist your practice, and maintaining contact with colleagues are all important safeguards against breaches of the Code of Ethics. As Christian healers, we have pledged to be God’s instrument of healing in a broken world. Not only does this require us to practice with the highest ethical standards of our profession, but it requires us to be constantly open to the work God can do through us. Knowledgeable, well-trained, self-aware clinicians who know their values, strengths, and limitations will be best equipped to meet this higher standard of care.
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