LEGAL AND ETHICAL

ISSUES ON THE CRISIS

OF TRAUMA
Le-Anne Cleo Tavira and Cheasca Mae Abellar

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INTRODUCTION

• Crisis intervention services are provided in a variety of

contexts that make it difficult to follow ethical guidelines,
such as when mental health practitioners respond to natural
disasters or talk to survivors in shelters. Many ethical
issues lack clear answers, and most ethical dilemmas fall
into a gray area where resolution depends on situational
variables.
• Ethical codes do not address the unique circumstances of
crisis intervention, leaving professionals to make decisions
based on personal reflection, values, and the opportunity to
help others

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ETHICAL AND LEGAL INTERFACE WITH CRISIS
INTERVENTION

• The ethical challenges faced by crisis intervention workers who may find themselves in
situations where helping others is their primary concern, and they may not have time to
consider ethical guidelines or liability issues.
• Although these workers are trained to follow ethical codes, factors such as emotions
and perceptions can influence ethical decision-making in crisis situations. It is
suggested that specialized training, both ethical and legal, is needed for anyone
involved in this type of service provision to ensure that they can navigate ethical and
legal issues in crisis situations effectively.
• Potential blind spots may arise when relying on non-rational and emotional decision-
making methods in crisis situations.

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 MISCONCEPTIONS REGARDING
ETHICAL DECISION MAKING
Decision – Making Models are
Practical
While models can be helpful for
training and reflection, they can be
impractical in crisis situations where
quick decisions are required.
An example for this is a scenario of a
crisis worker faced with a sudden and
chaotic situation in a hospital
emergency room, highlighting the
need for crisis workers to act quickly
and make ethical decisions in the
moment.
Time to Consult
Models for working through ethical
dilemmas often involve consulting
with peers or professional
organizations, but this may not be
practical in a crisis situation where a
decision needs to be made instantly.
Therefore, crisis workers must rely
on their best judgment and act in the
moment to ensure the safety of
clients and others involved.
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 MISCONCEPTIONS REGARDING
ETHICAL DECISION MAKING

The Role of the Mental

One Correct Answer
Health Professional

Novice human services workers often

Personal attributes and skills are needed
believe that ethical codes provide
f o r e ff e c t i v e c r i s i s i n t e r v e n t i o n , a s w e l l
specific answers to ethical dilemmas, but
as the role of mental health practitioners
experienced professionals know that
in providing assistance, normalizing
there are many factors to consider and
experiences, supporting resilience, and
that codes are only guidelines for
advising on referrals.
decision-making.
The five evidence-based principles for
Ethical decisions involve a wide range of
trauma intervention include: promoting
f a c t o r s , s u c h a s a g e , g e n d e r, a n d t r a i n i n g ,
s a f e t y, c a l m i n g , s e l f a n d c o l l e c t i v e
and ethical codes are not a set of rules
e ff i c a c y, c o n n e c t e d n e s s , a n d h o p e .
that prescribe actions for every situation,
but rather guidelines to direct decision- An ecological or systems approach can
making processes when an ethical assist mental health practitioners in
dilemma is encountered. addressing the multiple ethical domains
relevant to crisis intervention.

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THE CONFLUENCE OF BELIEFS, EMOTION,
MORALITY, AND VALUES

Self-reflection and consultation is important for helping professionals who work in

crisis intervention to prevent ethical violations.

​A helping professional's vulnerability to ethical transgressions and their ability to

withstand them are not fixed but dynamic, meaning that they can change over time.
Thus, before beginning work in crisis intervention, it is important for individuals to
reflect on their own beliefs, background, and values and to consult with others
when possible to better understand how these factors might influence their work.

This can help them recognize their own biases, critique their own work, and
understand how their personal values may impact the quality of services they
provide.

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THE CONFLUENCE OF BELIEFS, EMOTION,
MORALITY, AND VALUES

The various factors that influence ethical thought and behavior include the
context of the situation, perceptions, relationships, emotions, and heuristics.
Physiological perception, such as heart rate, also plays a vital role in moral
decision making.

Crisis workers being knowledgeable about ethical codes and laws relevant to
their profession is also important. While laws are mandatory, requiring
compliance, ethical codes are often aspirational, based on a "higher good"
beyond what is required. Both laws and ethical codes are reactive and change
based on societal values and precedent.

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THE CONFLUENCE OF BELIEFS, EMOTION,
MORALITY, AND VALUES
Professionals may approach ethical codes and legal requirements differently, with
some following them as a risk management practice to prevent lawsuits, while others
prioritize building a quality relationship with clients as the best way to avoid legal
issues. In situations where ethical codes and legal requirements conflict, professionals
may need to choose the least harmful course of action and adjust their standards to the
context of the crisis or emergency response.

However, the American Counseling Association's ethical code does not provide
specific guidance on crisis and disaster response, with only minimal mention of these
topics in relation to confidentiality and a supervisor's responsibilities. Similarly, the
American Psychological Association's ethical principles and code of conduct do not
address ethics in a crisis situation, with the only reference to disaster being a waiver on
soliciting business during disaster or community outreach situations. The 2016
CACREP Standards call for counseling programs to address the ethical standards of
professional credentialing and accrediting bodies, but do not specify how this training
should be accomplished.
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 CONFIDENTIALITY AND PRIVACY

Trust is essential for the success of the therapeutic alliance or working relationship.
Confidentiality refers to the ethical responsibility of mental health professionals to
protect the private communications of their clients. This means that clients expect that
their conversations with their mental health providers will be kept confidential.
Confidentiality is based on the client's right to privacy, which is considered a primary
duty of mental health professionals.

However, there are some exceptions to the duty of confidentiality. In a crisis or disaster
situation, it may be difficult to maintain privacy. In cases where a mental health provider
must break confidentiality, they should only disclose necessary information. The passage
highlights that while confidentiality is important, it is not absolute, and there may be
situations where a mental health provider needs to breach confidentiality to ensure the
safety and well-being of the client or others.

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 PRIVILEGED COMMUNICATION

Privileged communication is a legal concept that protects confidential communications between a mental
health practitioner and their client in a judicial context, and it is generally considered the responsibility of
licensed mental health professionals.

However, privileged communication can be waived in certain situations such as civil commitment
proceedings or malpractice proceedings. The client generally holds the privilege, but mental health
professionals are responsible for maintaining it in legal proceedings.

Confidentiality is a primary duty of mental health professionals, and clients trust that their communications
will be kept private. However, there are situations where a mental health professional may be required to
break confidentiality to protect clients or others from serious and foreseeable harm.
The concept of serious and foreseeable harm is not clearly defined, but three general criteria to consider
include whether the threat is serious and made in earnest, whether it is foreseeable given similar actions
and circumstances, and whether the practitioner's actions align with those of a reasonable practitioner with
similar credentials and training.

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 DUTY TO WARN, PROTECT, AND REPORT

Mental health practitioners have the duty to maintain their client’s confidentiality as well as
the circumstances under which they may be required to break confidentiality to protect a
third party. The duty to protect confidentiality typically ends when a practitioner learns that
a third party is at risk of harm from their client.

The legal duty to protect confidentiality and warn potential victims originated from the
Tarasoff v. Regents of the University of California case in 1976, in which a therapist failed
to warn a potential victim of their client's threats and the victim was subsequently killed.
The court held that when a therapist learns of a threat that is not remote or idle, they have a
duty to disclose the threat to a third party, even if it means breaking confidentiality.
However, not all states have adopted the Tarasoff ruling, and the decision to break
confidentiality can still present a complex legal and ethical dilemma for practitioners.

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 DUTY TO WARN, PROTECT, AND REPORT

Handling threats of violent behavior towards oneself or others made by clients is

significant in human services work. The following points are highlighted as crucial in
guiding the actions of human services workers:

1. It is important to clearly convey what can and cannot be held in confidence before
intervention is started.
2. Planning ahead and developing contingency plans for different client reactions is
important in crisis intervention, especially with children.
3. If unsure about what to do, consult with another professional or supervisor and keep
notes of the consultation.
4. If the client makes a concrete threat, it is the worker’s duty to warn the victim and take
action to keep the client safe.
5. Threats of legal reprisal should not dissuade the worker from reporting threats against
others, and documenting potential danger signs is recommended.
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 DUTY TO WARN, PROTECT, AND REPORT

Mental health practitioners, specifically therapists and school counselors, have the legal
responsibility to warn potential victims of harm from their clients or students.

The Tarasoff case established three conditions that must be met in order for the duty to
warn to be mandated: a special relationship between the practitioner and client, a
reasonable prediction of danger, and a foreseeable victim. However, the nature of this duty
varies between states, so practitioners are encouraged to review the respective jurisdictions'
laws before responding to a disaster.

In California, case law has supported the precedent for the duty to protect those who could
be foreseeably harmed by a client's threat or actual act of violence. Recent cases have
expanded the therapist's duty to protect a third party from harm when the knowledge of the
threat is relayed by a client's family member rather than the client themselves.

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 DUTY TO WARN, PROTECT, AND REPORT

School counselors are not exempt from the duty to warn, and they are responsible for
notifying their administration if their policies are unethical or untenable. If a school
counselor through assessment determines a student is at a low risk for suicide, they are
responsible for contacting the student's parents. Safety contracts are controversial for
school counselors to use with students expressing suicidal ideation. Essentially, a school
counselor's liability ends once they have notified the student's parents and school
administrators that a student is at risk and have recommended reasonable preventive
actions.

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NEGLIGENCE AND
LIABILITY

Negligence is defined as the unintentional breach of a

duty that one person owes another, involving four
elements:

a. the practitioner has a duty

b. that duty has been breached through an
unprofessional act or omission
c. the client sustained an emotional or physical harm
d. the practitioner’s act or omission is the proximate
cause of the client’s injury.

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NEGLIGENCE AND
LIABILITY

Mental health practitioners providing counseling-related

services in crisis or disaster contexts need to recognize that
this can be considered treatment and the basis for ethical and
legal culpability.

In cases of negligence, comparisons are made to community

or professional standards for what the reasonable practitioner
would do in a similar circumstance, and practitioners are
vulnerable to malpractice lawsuits for various reasons,
including the use of procedures outside accepted practice or
a lack of competence.

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NEGLIGENCE AND
LIABILITY
Volunteers in crisis and disaster contexts face many uncertainties, particularly when responding to
a disaster. Practitioners considering whether to volunteer during a disaster need to consider their
potential liability coverage, liability for harm to clients, and potential compensation for their own
harm as a volunteer professional.

The Emergency Medical Assistance Compact (EMAC), authorized license reciprocity for
healthcare practitioners during declared emergencies in 48 states and territories, with liability
protections contingent upon the practitioner working for a state during a declared emergency.
Many states have adopted Good Samaritan laws to provide immunity for persons who assist at the
emergency site, although their coverage and protections vary among states.

The liability exposure of volunteers remains unclear, and despite calls for uniform standards for
public health in emergencies, mental health practitioners considering volunteering to serve in
disasters are advised to be aware of the potential risks they might incur.

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THE 5 MORAL PRINCIPLES OF ETHICAL
DECISION MAKING

Autonomy
- This principle emphasizes the importance of respecting an individual's right to
make their own decisions and choices.
- Autonomy means giving people the freedom to act in accordance with their own
values and beliefs, as long as they do not harm others.

Beneficence
- This principle highlights the obligation to do good and to promote the well-being
of others.
- It involves taking actions that will benefit others and prevent harm, and
prioritizing the interests and needs of others over one's own.

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THE 5 MORAL PRINCIPLES OF ETHICAL
DECISION MAKING
Fidelity
- This principle involves the obligation to keep promises and to be trustworthy.
- It requires individuals to act in good faith, be truthful, and honor commitments and
agreements made with others.

Justice
- This principle focuses on the fair and equitable treatment of all individuals.
- It involves ensuring that resources and opportunities are distributed fairly, and that
individuals are treated impartially and without discrimination.

Nonmalificence
- This principle stresses the importance of avoiding harm or injury to others. It involves
refraining from actions that could cause harm or injury, and taking measures to
prevent harm.
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BENEFITS OF ETHICAL DECISION MAKING
MODELS

• Each mental health profession, voluntary organizations, and

NGOs have their own ethical codes or standards of conduct.
• Professional guidelines are necessary but not sufficient for
ethical problem-solving.
• Helping professionals can avoid ethical violations by taking
time to think.
• Consultation, review of ethical codes, knowledge of
jurisdictional laws, and use of ethical decision-making
models are methods to ensure sufficient time is taken to
process and consider the implications of a decision.
• The goal is to develop the best course of action. 20
LIMITATIONS OF IMPLEMENTING EDM IN THE CONTEXT
OF CRISIS

• Crisis implies immediacy and urgency, but time does not preclude ethical considerations.
• Ethical decision-making models exist, but complex models may not be practical during a crisis.
• Cross-cultural counseling is vulnerable to ethical conflicts.
• Ethical decision-making models and codes are helpful but not sufficient.
• Understanding basic ethical principles and one's own values can aid in ethical decision-making.
• Validation of actions and decisions is necessary.
• The Triage Assessment Form (TAF) is an evidence-based method for triaging individuals after a
crisis or disaster

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 DISCERNMENT AND HEURISTICS

• Discernment is the ability to perceive a course of action during an ethical dilemma.

• Helping professionals need to interpret the circumstances of the crisis, identify the moral
principles involved, and select a course of action grounded in those principles.
• Discernment should also consider the community of people relevant to the decision.
• Heuristics are mental shortcuts that can influence ethical decision-making.
• The affect heuristic suggests that judgments and decision making are primarily based on
personal biases and context.
• Practitioners should be aware of their biases and motivations to critically evaluate their
work.
• Naturalistic decision-making models emphasize clinician experience and long-term
memory to make decisions under stress.
• Effective crisis interventionists possess situational awareness and the ability to rapidly
analyze and synthesize information.

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 REFLECTIVE PRACTICE

• Reflective practice is essential for ethical decision-making in crisis and disaster work.
• Four attitudes necessary for ethical decision-making are balance, collaboration,
context, and reflection.
• Reflective practice involves reflecting on reasons for entering crisis work and actions
during a crisis response to improve future responses.
• Maintaining balance and considering the perspectives of all parties involved is
important in crisis intervention.
• Practitioners need to recognize their own involvement in the crisis resolution process
and maintain an attitude of reflection to facilitate sound decision-making.

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 SELF-CARE

• Practitioners have a duty to care for themselves as stated in codes of ethics and
standards of conduct.
• The Green Cross Academy of Traumatology published ethical guidelines emphasizing
self-care, recognizing that without it, practitioners cannot carry out their duty.
• Reflective practice based on ethical principles of beneficence, fidelity, and non-
maleficence can benefit helping professionals.
• Welfel (2005) proposed a four-step model of recovery for practitioners who have
transgressed ethical guidelines: recognition, regret or remorse, evaluation, and
rehabilitation.

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 SELF-CARE

Four-step model of recovery for Practitioners who have transgressed ethical

guidelines (Welfel, 2005)

• The first step is recognition and self-appraisal of the unethical behavior

• Consultation with a peer or supervisor can aid in maintaining objectivity and
perspective
• Regret and remorse are necessary for motivating change, not punishment or shame
• The practitioner can assess whether to address the quality of services provided
• Reflection and development of skills/strategies are necessary to prevent future ethical
transgressions.

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Legal Issues
- refer to concerns related to laws, regulations, and policies that govern a
particular activity or situation. These issues often involve legal rights and
responsibilities, such as complying with legal requirements or enforcing legal
consequences for actions.

Ethical Issues
- pertain to questions of right and wrong, and concern the moral principles and
values that guide behavior. These issues often involve moral dilemmas, such
as balancing competing values or making decisions that may harm some
while benefiting others.

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Moral Issues
- refer to broader questions about what is right and wrong, just and unjust,
good and bad. These issues often involve fundamental moral principles,
such as fairness, justice, and human dignity.

Political Issues
- are concerned with power, authority, and the distribution of resources and
opportunities in a society. These issues often involve questions about who
should have access to resources, how decisions should be made, and how
different groups should be represented in decision-making processes.

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CASE STUDY

Benjamin, a young disheveled man in his late 20s or early 30s, shows up
unannounced at a mental health clinic in Memphis. He appears confused, is crying,
and has been wandering the streets for three days, sleeping little. Benjamin confides
to the crisis worker, Keith, that he has been diagnosed with HIV and is afraid his
partner will break up with him. He is in tears as he talks and says he has lost
everything that meant anything to him. Keith assesses Benjamin's affect as an 8 on
the TAF, with fear being the primary emotion, and his behavioral reaction as a 6,
because his situation is not immediately dangerous. Keith rates Benjamin's cognitive
reaction as a 7 or 8, with loss being the primary reaction. Benjamin denies being
suicidal, but he says the situation is hopeless. After talking with Benjamin for 30
minutes, he seems more coherent and significantly calmer. Benjamin says he does not
know much about his prognosis but knows he has to find out. Keith discovers that
Benjamin had contacted his partner right after he found out about his diagnosis and
said that he had to leave town for a sudden business trip. Since then, Benjamin has
had no contact with his partner but says he wants desperately to talk with him and
asks Keith for help in knowing what to say.

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 CASE STUDY
Legal Issues
• Benjamin's diagnosis of HIV is protected
health information under the Health
Insurance Portability and Accountability Act
(HIPAA). The mental health clinic must
ensure the confidentiality and privacy of
Benjamin's medical information.
• Additionally, as a corporate attorney,
Benjamin may have certain legal obligations
regarding disclosure of his HIV status to his
employer and colleagues. There may also be
legal implications if Benjamin's partner
contracts HIV from him.
Ethical Issues
• The mental health clinic must adhere to ethical
principles such as respect for autonomy,
beneficence, non-maleficence, and
confidentiality. The crisis worker, Keith, should
respect Benjamin's autonomy and allow him to
make his own decisions regarding his medical
care and disclosing his HIV status to his partner.
Keith must also ensure that Benjamin receives
appropriate medical treatment and support, and
should not cause any harm to him.
• Additionally, Keith must maintain the
confidentiality of Benjamin's medical
information unless he has obtained informed
consent from Benjamin or is legally required to
disclose it.
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 CASE STUDY
Moral Issues
• There are several moral issues that arise in
this case. Benjamin's diagnosis of HIV can be
stigmatized and may affect his relationships
and social standing. There is a moral
obligation to reduce the stigma surrounding
HIV and support individuals living with the
condition.
• Additionally, Benjamin's situation highlights
the importance of safe sex practices, honesty,
and communication in relationships. There is
also a moral obligation to provide access to
healthcare and support for individuals living
with HIV, regardless of their socioeconomic
status.
Political Issues
• The case raises political issues related to
access to healthcare, particularly for
individuals who are homeless or low-income.
Benjamin's situation highlights the
importance of affordable and accessible
healthcare for all individuals, regardless of
their ability to pay.
• Additionally, HIV is a public health issue
that requires political attention and funding
for research, prevention, and treatment.
There are also political debates regarding the
criminalization of HIV transmission and
disclosure laws, which may affect
Benjamin's legal obligations and rights.
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THANK YOU!

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