Ethics in Crisis Assessment and Intervention Assessing a crisis can be challenging due to the emotions in moment and brief amount of time to identify immediate needs to resolve the

Journal of Counseling & Development ■ July 2017 ■ Volume 95260 © 2017 by the American Counseling Association. All rights reserved.

Received 06/15/15 Revised 01/23/16

Accepted 02/15/16 DOI: 10.1002/jcad.12140

Ethical Guidelines for Mass Trauma and Complex Humanitarian Emergencies Vilia M. Tarvydas, Lisa Lopez Levers, and Peter R. Teahen

Issues pertaining to trauma, especially mass trauma and complex humanitarian emergencies, are explored through the lens of ethical counseling guidelines. In mass trauma, particular attention must be paid to the experiences of both survivors and counselors to enhance understanding of ethical best practices and to emphasize the importance of contextual factors in framing effective responses to trauma and humanitarian crises. Recommendations regarding ethical guidelines for counseling practice, clinical involvement, and training are offered.

Keywords: trauma/crisis counseling, ethical and legal issues, mass trauma, complex humanitarian emergencies

Vilia M. Tarvydas and Peter R. Teahen, Rehabilitation and Counselor Education Department, University of Iowa; Lisa Lopez Le- vers, Department of Counseling, Psychology and Special Education, Duquesne University. Correspondence concerning this article should be addressed to Vilia M. Tarvydas, Rehabilitation and Counselor Education Department, University of Iowa, N338 Lindquist Center, Iowa City, IA 52242-1529 (e-mail: [email protected]).

Systematic response to a variety of traumatic events, includ- ing individual trauma, mass trauma or disaster, and complex humanitarian emergencies, is a relatively recent phenomenon. The definition of trauma can vary, and every traumatic event is unique in its circumstances and impact on people and their communities. This article focuses on guidelines for appropri- ate counselor ethical response in extreme circumstances of mass trauma and complex humanitarian emergencies. The negative consequences that are inherent in situations involv- ing mass trauma make the application of counseling ethical best practices much more difficult (Levers, 2012b; Tarvydas & Ng, 2012).

Trauma commonly involves actual or threatened death or serious physical or psychological injury to the individual or to others. However, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) emphasizes the variability of responses to trauma, from person to person. During political strife or military fighting, innocent populations often are unwillingly involved. Challenges may increase when disaster occurs or when large groups are displaced and need assistance. The delivery of aid can be compromised, and relief workers may be put in harm’s way (Mathieu, 2012; Watts & Horne, 1994). Such events are termed complex humanitarian emergencies (CHEs) or mass traumas (Brennan & Nandy 2001).

Simply put, CHEs refer to deep social crises in which large numbers of people die from war, displacement, disease, and hunger; mass trauma may include CHEs along with large- scale catastrophe, disaster, any type of community violence, and terrorism (Klugman, 1999). Because of the close inter- relatedness of these phenomena, the term mass trauma is

used in this article but also is intended to encompass CHEs, disasters, and related trauma. Within complex and multilevel contextual situations, such as those just described, individual counselors seek to provide ethical care to victims in often difficult and challenging circumstances. Professional ethical standards in counseling and related professions traditionally have addressed more mainstream types of practice; however, these standards have not directly addressed the types of high-stakes dilemmas that may emerge in CHE-specialized practices. Both the formative elements and the solutions to these ethical problems for individuals are linked intimately to the specific social systems and hierarchies from which they emerge (Levers, 2012a, 2012b), making traditional forms of ethical analysis (Tarvydas & Ng, 2012) and counseling standards insufficient (Webber & Mascari, 2009).

We conducted a content analysis of four practice-relevant professional codes of ethics: American Counseling Asso- ciation (ACA; 2014), American Psychological Association (APA; 2010), Commission on Rehabilitation Counselor Cer- tification (CRCC; 2010), and National Association of Social Workers (2008). We searched for and counted the singular and plural forms of the following terms most related to the ethical discussion at hand: trauma, crisis, emergency, and disaster. While a full analysis is beyond the scope of this article, in brief, the terms had perfunctory mention only 17 times across all four codes. Considering the ubiquitous nature of trauma, crisis, emergency, and disaster in the presentation of client problems to helping professionals, we found the lacuna of these terms in major codes of ethics to be a reflection of an important gap in ethical orientation to professional practice. Across all the codes, specific mention of the terms tended to

Journal of Counseling & Development ■ July 2017 ■ Volume 95 261

Ethics and Mass Trauma

be merely cursory (e.g., “not to withhold client records in an emergency,” “call supervisors to assist with handling crises”) rather than substantive. For this reason, we consulted relevant best-practice documents (e.g., APA, 2008; American Red Cross [ARC], 2012; Green Cross Academy of Traumatology [GCAT], 2015; Inter-Agency Standing Committee, 2007; Substance Abuse and Mental Health Services Administration [SAMHSA], 2013, 2014a, 2014b; Tarvydas, 2012; Tarvydas & Ng, 2012) and concluded that the lack of substantive men- tion of key aspects of trauma, crisis, emergency, and disaster in the major codes of ethics is representative of an absence of sufficient understanding of an important category of cli- ent suffering and resilience. We explore relevant issues to illuminate the ethical complexities of mass trauma work and the need for aligned ethical guidelines. In this article, we (a) identify specific ethical issues and obligations that pertain to mass trauma survivors, (b) describe the current state of ethical guidelines related to trauma counseling ethics in counseling and related professional organizations, (c) recommend ethical practice guidelines, and (d) identify professional implications.

Unique Ethical Context Mass trauma counseling should be understood as a unique and emerging specialty field (Cook, Newman, & New Haven Trauma Competency Group, 2014; Lopes Cardoso et al., 2012; Saleh, 1996). Ethical practice in mass trauma counseling is ex- traordinarily intense in the demands that it places on counselors, and this intensity influences counselors’ ethical considerations and responses. Although it is beyond the scope of this article to flesh out a job description and a full set of responsibilities, such work entails specific existential burdens for counselors as individuals, typically requiring counselors to (a) work under chaotic and difficult hardship conditions; (b) cope with ex- treme physical and emotional demands related to safety risks, extreme weather, widespread damage, and lack of utilities; (c) use nontraditional or indigenous approaches; and (d) attend to the physical and emotional well-being of survivors (SAMHSA, 2014b). Thus, mental health responders serve in conditions that are difficult at best, and mass trauma work requires use of systemic ethical analysis and response skills beyond those of typical practitioners in more traditional settings (Smith, 2005; Trippany, White Kress, & Wilcoxon, 2004).

Counselors who work in mass trauma practice must ad- dress the myriad clinical and ethical challenges that would affect any complex counseling practice. Beyond that, situational complexities mean that mass trauma counselors routinely are in situations that involve competing interests as well as intersecting and disparate social systems, cultures, and interpretations of social justice—in essence, broader social contexts than typically form the boundaries involved in professional practice in more settled community-based settings (Hoffman & Kruczek, 2011). Some ethical issues

arise from situational operations and resource limitations that restrict the manner in which counselors and all re- sponders can conduct their work. It also is commonplace that political considerations at local, regional, state, and national levels, as well as media and communications enti- ties, become involved in shaping the situation and exerting pressures on the responders.

Counselors who deploy internationally and work in CHEs face unique challenges typically not found in domestic disasters. The unstable political, social, or economic ac- tivities that can exist in a CHE or mass trauma can create an environment of high security risks for counselors and relief workers (International Federation of Red Cross and Red Crescent Societies [IFRC], 2013; Stoddard, Harmer, & Huges, 2012). Aid workers, once considered quasi-neutral parties, have witnessed a significant growth in violence directed at them over the past few years (IFRC, 2013; Stod- dard et al., 2012). Counselors may be targeted for violence for various reasons, including being punished for actions considered “helping the opposition”; being terrorized to convince them to abandon operations; being robbed for their vehicles, possessions, money, or other items; being kidnapped for ransom or coercion or attacked in an effort to further destabilize conditions; or being caught in the crossfire because they provide aid in conditions that are precarious (IFRC, 2013; Stoddard, Harmer, & Ryou, 2014).

Ethical mass trauma responses occur in broader and particular social-practice contexts that are beyond those typically addressed in core professional ethical standards that govern more typical practices (IFRC, 2013; Stoddard et al., 2012, 2014). In mass trauma counseling, counselors often must confront clinical, interprofessional, institutional, and public policy forces that may have marked effects on their ethical judgments and boundaries. Mass trauma practice calls upon practitioners to solve complex ethical dilemmas, with multiple and diverse stakeholders, in chaotic circumstances that may strain the ethical decision-making capacity of practitioners. Such situations often go beyond those envisioned by traditional professional standards, that is, those that are delimited by more typical agency-bounded and relatively well-defined systems.

Recovery may not be successful unless attention is given to ethical responsibilities related to both the individual and col- lective trauma experienced in mass trauma (Lopes Cardoso et al., 2012). In his classic study of the Buffalo Creek, West Vir- ginia flood of 1972, sociologist Kai Erikson (1994) described two types of trauma, individual and collective, that occur jointly and continuously in most mass traumas. Mental health services must take both types of trauma into consideration in addressing community needs. Individual trauma is defined as a “blow to the psyche that breaks through one’s defenses so suddenly and with such brutal force that one cannot react to it effectively” (p. 233). Collective trauma is “a blow to the basic

Journal of Counseling & Development ■ July 2017 ■ Volume 95262

Tarvydas, Levers, & Teahen

tissues of social life that damages the bonds attaching people together and impairs the prevailing sense of community” (p. 233); it is often less visible to clinicians trained to work with individuals. Identifying and addressing collective trauma in mental health programs is essential, particularly when working with African American, Native American Indian/ First Nation, Latino, and some Asian American populations, with whom historical or transgenerational trauma has been an existing and unresolved issue, and for whom the experi- ence of current trauma may exacerbate or compound their experience of historical trauma (Hyatt-Burkhart & Levers, 2012; Levers, 2012b).

Another potential source of stress for mass trauma coun- selors may be the sense of humanitarian responsibility. Some individuals who have witnessed the experiences of those who survive mass trauma have a profound realization of the existential privilege most citizens and counselors have in not witnessing human trauma. The commendable, empathic impulse to respond to this sense of responsibility is powerful and motivates counselors to work in the area of mass trauma and CHE care. Paradoxically, this drive also can constitute a substantial risk factor that may predispose such counselors to be blind to some serious aspects of ethical risk in their work, especially prominent when counselors responding to mass traumas do not have prior experience, do not have adequate preincident training, or have not carefully evaluated their own motivations for undertaking this type of work (Trippany et al., 2004; Valent, 2002).

Current Ethical Standards Despite the complexity of counseling in mass trauma prac- tice, there is limited specific attention to the application of ethical standards in the helping professions during extreme trauma conditions. Generally, disaster relief agencies such as the ARC, the IFRC, the National Organization for Victim Assistance, and the GCAT rely on eligibility criteria requiring professionals to possess independent practice level licensure for mental health professionals. They characteristically note that responders are expected to adhere to the ethical stan- dards of the licensures that they hold and the professions of which they are members. This requirement respects the credentialing and educational systems already in place in the professions, placing an additional onus on the professional credentialing bodies to provide proper standards and ethical knowledge and skills training that would allow the profes- sional to be prepared adequately to practice ethically under these conditions. To this point, the codes of ethics of the core mental health professional organizations such as ACA (2014), APA (2010), CRCC (2010), and the National Association of Social Workers (2008) have not provided specific standards that directly address various types of mass trauma. However, APA (2008) issued a statement on the role of psychologists in international emergencies that largely affirmed the Inter-

Agency Standing Committee’s (2007) Guidelines on Mental Health and Psychosocial Support in Emergency Settings, emphasizing the duty of psychologists to work within the boundaries of professional competencies as outlined in the APA (2010) ethics code.

Beyond admonishing responders to adhere to their profes- sional organizations’ codes of ethics, the major disaster relief agencies attempt to establish codes of conduct and provide some basic orientation to ethical conduct under disaster and crisis conditions. For example, GCAT (2015) requires adherence to the standards for traumatology and also has established self-care guidelines (GCAT, 2008). One of the most widely known such efforts in the United States is the disaster mental health (DMH) fundamentals training, which is required training for DMH counselors by the Red Cross. In providing an orientation to the DMH mission, values, and assumptions, a brief section of the manual emphasizes several ethical standards aimed at preserving public interest and maintaining the well-being of the client (ARC, 2012).

The provision of more elaborated and useful ethical stan- dards for practitioners is one of the major responsibilities of the helping professions’ organizations and credentialing bodies. This obligation can serve to improve the quality of ethical practice for clients and provide useful guidance to practitioners in the most difficult practice circumstances. In recent years, the professions have placed increasing emphasis on the knowledge and application of suitable ethical decision- making models to provide a sound basis for the application of ethical judgment and standards in addressing unusual or difficult circumstances. This step provides a strong underpin- ning for practitioner ethical practice but does not diminish the need for more specified and exacting consideration of issues that are likely to arise in high-stakes ethical practices such as those represented in mass trauma and CHE response settings. Sommers-Flanagan (2007) recommended that, particularly in crisis work, it is imperative to use an ethical decision- making model because of the direct and immediate clinical ramifications for the decisions reached. She recommended using Tarvydas’s (2012) Integrative Model of Ethical Deci- sion Making because it incorporates elements from a number of models, as well as the model’s constructivist orientation and incorporation of the many contextual factors present in trauma and crisis work. Specific ethical considerations should be addressed through the creation of ethical best practice guidelines, as proposed next.

Recommended Ethical Practices and Standards

In mass trauma practice, the nature of counselors’ activities and responsibilities is different and perhaps more challenging than that of counselors in more settled service settings. Mass trauma counseling is unique in a number of specific ways. Counselors

Journal of Counseling & Development ■ July 2017 ■ Volume 95 263

Ethics and Mass Trauma

are working under chaotic and difficult conditions, may have physical and stamina demands placed on them, and need to use nontraditional professional approaches in nontraditional conditions of various settings and locations; moreover, the actual conditions of the victims themselves may be extreme (Halpern & Tramontin, 2007; SAMHSA, 2013, 2014a, 2014b). Thus, caution must be taken to avoid or diminish instances of vicarious or secondary trauma, that is, introjections in which counselors vicariously experience the distress of their trauma- tized clients concerning the current disaster situation (Jankoski, 2012; Teahen, 2011; Trippany et al., 2004).

The challenges in the field are substantial and situation- ally changeable; at the same time, the guidance afforded in the literature concerning ethical principles and practices and the specific professional standards of counseling and related professions are insufficient to provide targeted assistance to practitioners. The need exists for specific ethical guidelines to enhance ethical practice in CHE and mass trauma response. In contrast to ethical standards, which are included within a mandatory code of ethics that has been adopted by and is enforceable on the members of a professional group, ethical guidelines are used to provide added expert suggestions or best practices to enhance and amplify practitioner interpreta- tions of the basic ethical standards.

Ethical guidelines are aspirational and provide more spe- cific ideas about ethical best practices that are tailored to the specialized practice experienced in that area. As such, although they may not be mandatory standards for counselors, these guidelines can provide substantial assistance in understanding how the core ethical principles and standards may “look” as they are applied to a particular set of practice circumstances. In the following section, we present ethical guidelines for mass trauma counseling practice and summarize some of the more critical points from the literature, professional standards (e.g., ACA, 2014; CRCC, 2010), and our clinical experiences as seasoned responders. The guidelines are intended to provide more specific ethical suggestions to counselors who work with mass trauma; they also aim to engender further discussion in the counseling profession about the issues raised by actual practice in this important area of counselor functioning. These guide- lines are select ethical directives, specific to unique aspects of mass trauma practice, and are not intended to be exhaustive; they are derived from and aimed at supplementing and eluci- dating the content of the ACA Code of Ethics (ACA, 2014). A substantial amount of the material included in the guidelines provided below is adapted from the 2014 ACA Code of Ethics, and this source is specifically acknowledged.

Mass Trauma Counseling Guidelines Counselors who provide services to clients in situations of mass trauma, whether they are volunteer counselors with a relief agency or employed by agencies and response entities, must abide by the mandatory professional code of ethics of

their counseling organizations and licensure boards. Coun- selors also should understand that advanced ethical knowl- edge and skill must be cultivated to meet the unpredictable and often highly complex ethical challenges represented in trauma work (Cook et al., 2014; Levers, 2012b). Specifically, counselors should understand the obligations dictated by the core ethical principles of autonomy, justice, beneficence, nonmaleficence, fidelity, and veracity, as weighted and ana- lyzed through the process of principle analysis; understand and apply a specific, credible ethical decision-making model to the process of selecting an ethical course of action when responding to mass trauma situations; and be aware that seek- ing consultation or supervision is an important part of ethical decision making. The following guidelines are presented as aspirational statements of more specific mass-trauma-related obligations. These basic tenets of ethical behavior are reflected in the following mass trauma counseling guidelines that are recommended in this article.

A. Definition of client and primary responsibility Because mass trauma care frequently is provided in

nontraditional and even chaotic conditions outside of normal agency contexts, counselors clarify that their primary responsibility is to respect the dignity and promote the welfare of clients, who are defined as the survivors of the trauma event(s) and their families (Levers & Buck, 2012). Mass trauma victims include persons directly and indirectly affected by the event. Additionally, counselors’ duty for promotion of wel- fare extends to the trauma responders and their family members (ARC, 2012).

B. Refraining from diagnosis Counselors providing services in the initial stages of

mass trauma refrain from premature diagnosis of the survivor, recognizing the risks of overpathologizing reactions or prematurely diagnosing normal reactions to severely abnormal circumstances (ARC, 2012). Coun- selors provide assistance, support, or referral for those who are experiencing the most extreme reactions and support strength-based interventions that emphasize resilient trauma responses (Saul, 2013).

C. Confidentiality and consent for services Counselors may be required to offer services in chaotic,

public, or semipublic situations that make provision of strictly private or confidential conditions impossible. Interactions in the field may not be structured and oc- cur on demand. Where counselors are not able to offer proper conditions and adhere to full requirements for confidentiality and consent, they can, at a minimum, honor the need for as much confidentiality and consent as possible by taking such measures as (a) identifying themselves clearly as a mental health professional, (b) providing a practical and abbreviated form of informed consent, (c) looking for and using as private a space as

Journal of Counseling & Development ■ July 2017 ■ Volume 95264

Tarvydas, Levers, & Teahen

possible given the available surroundings, and (d) em- phasizing and modeling keeping survivor information confidential with other workers and staff (Tarvydas & Ng, 2012, p. 523).

D. Client autonomy 1. Avoiding long-term harm. Counselors take mea-

sures that enable clients to exercise the highest de- gree of self-determination possible. They are aware that a common reaction of clients to mass trauma is an initial reaction of feeling a lack of control over their circumstances. However, counselors avoid assuming unnecessary responsibility for clients’ decisions or speaking on clients’ behalf to avoid long-term harm through prolonging or deepening clients’ sense of dependency and vulnerability (GCAT, 2008).

2. Supported decision making and providing informed choice. Counselors seek to assist clients in rees- tablishing a sense of control through facilitating or assisting in the clients’ decision-making processes. Where it is necessary, counselors provide limited assistance to support decision making through such measures as providing assistance to address practi- cal needs (e.g., helping to locate family members), ensuring accurate and timely information and resources, taking sufficient time to process the information, offering support and encouragement, and facilitating a proper environment to allow for consideration of the decision. These conditions are provided to allow clients maximal opportunity to regain their ability to respond and to engage in informed decision making and consent (ACA, 2014; ARC, 2012; GCAT, 2008).

E. Managing and maintaining boundaries in noncounsel- ing relationships

1. Counselor–victim or counselor–survivor relation- ships. Counselors are aware that victims and survi- vors of mass trauma events are highly susceptible to fraud, exploitation, and emotional vulnerability. The nature of the trauma situation often involves unusually intense physical and emotional experi- ences and environments without any traditional contextual structures to reinforce professional–cli- ent boundaries. Because of these vulnerabilities, and the extreme nature of the counselor–client power differential, counselors who provide mass trauma and CHE services must avoid romantic or other intimate relationships with victims (ACA, 2014). They also should avoid such relationships with other disaster responders during the period of deployment. Additionally, counselors need to be intentional and vigilant in their restraint concern- ing potential boundary issues related to secondary

traumatization; this is a difficult and delicate aspect of the boundary issues involved with the cost of caring (Jankoski, 2012).

2. Relationships with media and other nonresponder figures. Journalistic coverage of news-making mass traumas and involvement of government authorities and dignitaries are common and potentially con- structive activities. However, counselors must be sensitive to and cautious of engaging with media and other public figures in a manner that could sen- sationalize an already emotionally charged situation in ways that might negatively affect survivors (ARC, 2012). This is of special concern if the request is to identify an affected person or persons, thus violating confidentiality and subjecting vulnerable survivors to public exposure that the survivors may regret at a later time. As far as conditions permit, counselors protect survivors’ confidentiality and assure that proper survivor consent to any contact with media or public authorities or dignitaries is obtained, thus preserving survivors’ dignity and choice during such interactions.

F. Time-limited services and continuum of care 1. Time limitations and services. Counselors are aware

of the time limitations and resource constraints that govern the scope of the services they may provide to clients. They adjust the scope and type of services accordingly and provide accurate information to clients regarding the scope, duration, and nature of care they will be providing (GCAT, 2008).

2. Transition to continued care. Counselors understand that initial mass trauma mental health counseling ser- vices are short term by nature and focused on initially establishing the basic security and emotional stability of their clients (SAMHSA, 2013, 2014b). They do not promise or engage clients in types of counseling interventions that cannot reasonably be provided under these constraints. They assist clients in identifying their ongoing counseling needs and transition their clients from short-term crisis care to long-term supports and services as needed. They provide information to clients about the stages and long-term nature of mass trauma recovery and possible individual challenges confronting their clients (GCAT, 2008). They provide realistic referral and transition services to respond to clients’ ongoing individualized needs for counseling and recovery services.

G. Professional competence 1. Specialty practice. Knowing the personal, existen-

tial, and competence issues related to mass trauma work, counselors recognize that this is a specialty area of practice and seek to prepare themselves for this practice through appropriate predeployment

Journal of Counseling & Development ■ July 2017 ■ Volume 95 265

Ethics and Mass Trauma

or preservice education, training, and supervised experience (ARC, 2012). Even in crisis care, coun- selors do not provide services outside their scopes of practice, unless conditions fit those described in Standard G.2.

2. Emergency care and limited competency. Coun- selors cannot control the conditions to which they may be required to respond. If the counselor has not been prepared adequately for these circumstances, the counselor may provide emergency care where no other care is available and will do so until the incident has concluded or more skilled providers become available (American Psychiatric Associa- tion, 2013). Counselors will work to the utmost capacity of their applicable skills and training, seek consultation from more experienced responders where available, and take care to do no harm.

3. Multicultural competency. Given that various types of mass trauma events may disproportionately af- fect the most vulnerable segments of populations, counselors gain knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to the specific environments in which they work (CRCC, 2010). They consider factors that may be unique to the culture of the survivors so as to offer effective and ethical services (ACA, 2014). They actively involve and consult with persons from the host com- munities in whi

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.