Ethical, Professional and Methodological Concerns about the Handling of COVID-19

What follows is not exhaustive but is a professional, critical examination of the current COVID-19 crisis in the United States.  It is known and noted by the author that there are numerous professional opinions outside of what is written here, and there are many more considerations beyond what can be written here.  This article is simply a critical examination of the current narrative in the United States through the lens of professional training and practice in the mental health field from a Licensed Professional Counselor with a Master's degree in Counseling Psychology with a very heavy emphasis on research methodology, epistemology, data interpretation, study formulation and treatment planning.  It is not intended to supplant or undermine public policy or directives, but simply to stimulate thought to the public from a professional perspective in addition to the ones in the media.

Introduction

As a mental health professional, a counselor, it is alarming to see how the COVID-19 pandemic is being presented in the American media and by medical professionals to the American public.  In the healthcare professions, methodology, ethics, consideration of impact, and a well-informed process are central to the practices in addition to the outcomes achieved.  As a citizen being affected alongside every other American regarding the COVID-19 virus, I am seeing many failures and lapses across the board in how this crisis is being addressed both by the media and politicians, but mostly with the healthcare professionals who are  the voice behind the decisions and directives that are affecting us all.  

It appears we are facing a near-total systems-failure in terms of the areas mentioned, that has caused harm to millions of Americans and will result even more significantly if this continues, far beyond what the virus can do.

What follows are some professional considerations as a mental healthcare professional of the issue as it is being presented to the public.

Primary Concern

For as contagious and deadly as this is being presented as being, and for as long as it appears the virus as been in the United States, the hospitals should already be full of the dead and dying.  The numbers, however, indicate that this has a survival rate of more than 97%, especially when factoring in that many who have it will be asymptomatic.  The numbers do not add up to indicate this is the crisis being presented.  However, this piece will be focused on methodology, ethics, presentation of data, and treatment planning.  Numbers will change, but when methodology and ethics are sound and consistent, the overall picture will be far more informative than numbers.

Language and Presentation

The use of vague language to inform the public regarding COVID-19 is especially disruptive.  There are repeated references to "cases" of COVID-19, not death rates or casualty rates, just "cases".   Cases and deaths are two different things.  Most people recover from COVID-19.  If they didn't, there would be far more deaths than there have been.

Maps presented on state and national websites combine data from different variables into one variable, the most recent being "cases and deaths" by county for the state of Idaho.  

Presenting this as a "case and death" is very inaccurate to say the least.  To present an issue in this fashion to a mental-health client, depending on their mental faculties and impressions of the world, this would constitute abuse because it is implying that simply having a condition will result in death.  And yet, this is what is being presented to the entire country and this is how data is being presented by agencies responsible for public health, by medical professionals who are educated to know better, and is being repeated by the media. 

Additionally, there is the concern that "cases" are being presented that anyone and everyone regardless of age or condition are equally susceptible to this virus.  There is definitely data indicating that the most susceptible are the elderly and those with pre-existing conditions. Some stay-at-home orders note that some people are more vulnerable than others including the elderly and those with pre-existing conditions - a tacit acknowledgement that not all are at the same risk, and therefore do not all require the same protections or to take the same actions to protect ourselves.

The word "pandemic" is applicable because this is, by definition, a pandemic - spread across continents and is infectious.  However, the word is being used in a way that sounds terrifying, yet it does not necessarily mean the virus is more lethal - just that it has spread further and infected more people.  So "pandemic" is accurate but not precise, and can be said the way it is being used and presented is not correct. 

It is a fine differentiation, but it is one that has a significant impact on all involved in terms of responses to it.

  

Data Measurement

The measurement and descriptions of variables is a central skill to mental health.  Both qualitative (descriptive - e.g. good, healthy, stressed) measurements, as well as quantitative (numerical - e.g. percent, total numbers, Likert scales etc.) are used in mental health.  But going back up to the language and presentation, the data being presented or the impression being communicated with the presentation is very misleading.  

The virus is being presented as "highly contagious" and yet, what does that mean?  What percent probability does any given individual have of dying or experiencing lifelong complications if they do contract it?   This is not being presented or talked about by the public. 

Now, many are saying "we don't know" a lot about this virus.  In order to make an informed assessment or plan treatment, professionals have to go off what is known, and  have to be accountable for how they came to know it, and be able to demonstrate that they did so.

It appears this virus has been in the United States well before January, 2020.  For as contagious as it is being said to be, and efforts to quarantine were not taken until March, 2020, and for all of the traffic and sociality in the United States we have, unless this is a virus that doesn't actually kill people for at least three months after contracting it, there should be a very high number of deaths at this point are not being seen.

Additionally, there is the need for context.  Death happens every day.  Death is a part of life.  Whether of COVID-19, a car accident, or other causes.  The numbers being presented on COVID-19 deaths that have happened, when put in context to all other causes of death are far less alarming.  For example, heart disease in the United States claims well over 600,000 deaths annually, and there are nearly 3,000,000 deaths annually in the United States.  A report on the radio yesterday (4/6/2020) stated there are over 300,000 "cases" of COVID-19 in the United States -  it would have to hit at least a 15% fatality rate or approximately 1:8 death rate to enter onto the top ten list of leading causes of death in the United States.  Given that it is said most of those who have it will not show symptoms, by the numbers, the death rate would have to be even higher, and current trends do not indicate this is going to happen or become the trend in the United States. 

Treatment Planning

Treatment plans are to be "evidence based" and should be as non-invasive and as least-disruptive as possible in order to achieve the greatest result.  The impact on all parties involved in any treatment plan is always to be considered, with an appropriate "cost/benefit" analysis as well as well as even an appropriate assessment of risk.  Treatment plans should encourage and foster as much autonomy as possible, respecting a client's unique circumstances, and ultimately need to be patient-centered - meaning, centered around their needs, well-being, safety and that of the community's and all others' involved.  

This being said, some treatment plans will be quite simple and of brief duration, and may only require a limited set of planned sessions for treatment with a specific outcome measure relatively easily accomplished for some people - such as an examination of beliefs surrounding a relationship that may be contradicted by the evidence.

Other treatment plans may be far more comprehensive in scope, require an interdisciplinary treatment team of multiple health professionals across a spectrum of services within an inpatient facility requiring a large number of support staff of an indefinite duration, with continuing evaluations of risk, wellness, and effectiveness being conducted in order to keep the individual and others' safe from harm.

But regardless of complexity, in no treatment plan are we to ever take the mentality that "the ends justify the means".  The process itself is as important - if not more - than the outcome.  Processes poorly done can render the outcome irrelevant if it causes more problems than it solves.  Being aware of the impacts of the processes are the responsibility and obligation of the clinical practitioner and the healthcare professional - it's what we're paid for, in short. When we fail to do this, we are no longer acting as a professional.

There is a lot of evidence as well as acknowledgement that the most vulnerable to COVID-19 are the sick and elderly.  This being said, in a treatment plan, the most ethical as well as effective thing to do is to tailor your treatment plan to target the vulnerable, put plans in place to help them stay safe, and let others retain as much autonomy as possible.

When the treatment plan impacts people who are not as vulnerable, in this case those who are young and healthy, but instead it cost them jobs, educations, increases stress, decreases productivity, threatens legal action, harms economic stability in the name of safety, it has not only undermined the very people supposedly being protected by cutting their support systems out from under them, but is doing far more significant collateral damage.

Perspective

In treatment planning and assessments there is a need to compare apples to apples - even if they are different types of apples, otherwise assessments or treatment planning will not be very effective. 

People frequently reference the number of deaths in Italy from COVID-19 as the basis of their fear in the United States.  Comparing Italy to the United States is useful ONLY IF acknowledging the differences between them.  Given that the United States is vast with entirely different customs, social histories, transportation systems, sanitation systems, climates, housing arrangements, medical systems and social services infrastructure, demographics, health histories, and much much more, using Italy as a predictor of outcomes within the United States would be a fallacy at the very least (unless you account for differences).  Every competent medical professional and healthcare professional knows to do this and why it is important, but it is not being done in the media.

Going back up to treatment planning, all healthcare professionals have an ethical obligation to protect their patients using the best information possible and to disclose that information so that patients can make informed decisions, except in cases where doing so would result in harm according to the best professional judgement of the practitioner.  In terms of treatment planning and the resulting fear and economic harm that has resulted in the United States, there are plenty of reason that these differences should be being discussed.

COVID-19 has been compared to the Spanish Influenza pandemic in which an estimated fifty million died with an estimated five-hundred million exposed (an estimated 10% fatality rate with other health complications to many others).  But what are the similarities to the Spanish Influenza, AND what are the differences?  What is different in the world between 2020 and when the Spanish Influenza occurred over a century ago?  Healthcare and sanitation have improved drastically in the United States, to say the least. In terms of informing the public, this is very relevant but is being left out.

In any treatment planning it is essential to collaborate and make sure all points of view are examined.  When the view is unanimous and no alternative considerations are presented or acknowledged between professionals, the saying "when everyone is thinking the same thing, someone isn't thinking" becomes relevant.  Recently a media outlet accused President Trump of not listening to medical experts on COVID-19, but there was not any acknowledgement that not all "medical experts" agree with each other on this.  It is presented as if there is one single solution, there is no collateral information outside the current narrative, the president is ignoring it and we are all going to recklessly die.  This is where it begins to look like this is not a medical issue so much as a political or media issue, which is touched on more a little later in the piece. 

Impact 

"Social Distancing" is its own stressor.  Creating lines at the store, marks all over the floors showing how far to stand from each other, having senior citizens shop at a very early hour can be extremely difficult in that those who are medically fragile may require more sleep, more rest and instead have to exert even more energy to go out earlier, paying attention to how close you are to others at all times to an abnormal degree for weeks on end, all increase stress which impacts ability to resist diseases.  Lines at the store, reports of police being called for people being too close or arrests for "assault by coughing" with the accompanying fear seem to make the actual virus a distant secondary danger.  While social distancing may leave people feeling less crowded in the checkout line, many are more stressed about being in public; the negative effects of social distancing are going to be felt long after this ends and some people will still be afraid to get close together long after this is over. 

Additionally, going out to the store or leaving the house is necessary to reduce stress, buying toys with children, grabbing a fun snack, going to work gives our minds a rest, shift our focuses to enable us to feel better and even make ourselves healthier.  

Locking people up at home while their jobs are lost, stressing about money, fearing being arrested or being ordered back to their homes for a curfew, and signs and interventions everywhere for a virus that is now seen to have a very high survival rate is not healthy on an individual or a national scale.  

The suggestions that people wear masks to the store or while out for a walk: is this an informed, evidence-based directive, or is this being overly cautious and in consequence doing more harm than good by causing more stress and fear? 

For those who are mandated to treatment for violent crimes, being isolated with their families at homes by stay-at-home orders, losing their jobs, being unable to schedule doctors appointments for several weeks while hospitals lay otherwise empty waiting for an influx of the sick that has not come, and stopping therapy in person as many clinics have done, increases risk of harm to others as well as the risk of relapse and other complications to them, and further stokes fear.  

Law enforcement releasing those who are violent from jails and prison and ceasing making arrests on the fears of a virus that has not been demonstrated to be as deadly as it is portrayed increases further risk to both past victims and future victims.  There are far more domestic violence victims than there are COVID-19 deaths, and government orders in this case are increasing the danger to the public rather than decreasing it.  

Further, some presentations by educators to school-children are also unethical and unnecessarily cause fear and distress by their explanations of government officials' decisions to shut schools down.   Going back to the fact that they are our future generations, in terms of education it has to be asked: what are they being taught when this is the response?  They certainly aren't learning best-possible-practice, but more the-ends-justifies-the-means-regardless-of-cost, as well as their formal educations are being impacted.  Families may be growing closer together where parents suddenly find themselves home-schooling their children, on the other hand, but this is one of the very few positives I have seen from the current handling of this issue.  

Scope of Practice

Elected officials are just that: elected officials.  They are not doctors or psychiatrists or surgeons in most cases.  Elected officials have a few jobs, among which are to keep the public safe, as well as get re-elected or run for election so they can keep the public safe.  When healthcare takes on a political tone or has democratic motives, especially with an uninformed media that is not familiar with the nuances of healthcare, the best practices of healthcare stop being done.  Doing too much can be even more dangerous than not enough.  

It has been said that we will not know if we did too much, but we will know if we did too little.  

This is a fallacy. 

The fallout from doing too much can and will most certainly be seen.  There is not only current data, but there will be more data, that when ethically collected and interpreted accounting for and acknowledging limitations, will allow it to be seen in hindsight whether the response was too much or too little. 

Further there is the fallacy that the only choices are to do either too much or not enough.   The question is, how much is too much, and what is prudent as well as effective?  Doing too much in the name of caution is not the same as being prudent and effective, and when it comes to healthcare, does more harm.  

Conclusion

While I am not a virologist or an immunologist or even a biologist, my profession requires me to work with interdisciplinary treatment teams and to not just look at the numbers, but look at how we are thinking and approaching an issue, look at numbers and graphs and be able to derive probabilities in multiple ways as well as be able to identify weaknesses within studies and data.  The current COVID-19 scare appears to be causing more harm than it is preventing.  It is costing people emotionally, mentally, socially, physically, spiritually, professionally, intergenerationally, medically - far more than any deaths.

While this entry is not exhaustive in scope, and it is not being suggested that COVID-19 requires no intervention at all or that it is not harmful, there remain a great many more questions to be asked and perspectives to be examined.  We need to be making informed decisions.  

In the end, when healthcare ethics and evidence-based practice are followed, issues will be identified far more quickly and effectively, with far lower numbers of those harmed and those impacted by unintentional collateral damage, and overall wellness will increase. 

Why Domestic Violence Offenders Should Not Be Allowed to Participate in Domestic Battery Treatment Prior to Sentencing

One of the things domestic violence treatment providers need to screen for is people who have been charged but not yet sentenced for domestic violence. 

Abusers often have a history of manipulating others, both inter-personally as well as using systems such as employment, mediation services, courts, religious organizations or legal systems to do so.

When people are arrested for domestic violence, their defense attorney will often suggest they enroll in a domestic violence treatment class to make themselves look good before the judge and to show sincerity and earnestness in getting help for their problems as a means to have their sentence reduced.

If they do enroll in treatment at this point in order to manipulate the system they are actually not being treated - the therapist is tacitly endorsing the manipulation, taking money for it as well as sending messages to the victim that the abuser is once-again getting away with manipulating others - all sorts of ethical issues here on the parts of therapists and treatment providers.

The problem with power and control issues/abusive behaviors is that these are a part of a larger pattern and are ingrained behaviors.  There is a significant difference between developing accountability, insight, empathy and understanding of one's issues, and simply admitting them.

Admitting an offender "has a problem" may happen in the courtroom, or upon being confronted with evidence that they had committed a crime/were abusive or even upon being arrested.  Admittance however does not instantly give anyone the insight, skills or tools necessary to navigate life's difficulties or pursue healthy parenting or relationships. Admittance is unfortunately simply a step in the cycle of violence and abuse and often does not have a lasting impact. Abusers will say "I'm sorry" and "I messed up" and buy themselves time from the victim until they resume their abusive behaviors and the victim is hurt all over again. 

Conversely interpersonal skills, Insight and accountability, however are gained over a period of months and years, depending on the individual and the effectiveness of the treatment.

While awaiting sentencing, offenders will attend their treatment with the mentality that they only have to go through the motions for a short time to escape their consequences, so the commitment to change, developing insight and lasting behavior simply is not going to be present.  Often the judge may then assess the abuser as truly penitent, leave them to attend their treatment on their own, give them a reduced sentence and once again the abuser manages to con a system without being forced to make any lasting changes.  If the judge does require them to attend treatment, they may allow the treatment that was participated in (with a manipulative mentality) for the previous several-months/weeks to count as a part of their sentence.  At this point the treatment has lost a lot of it's edge and the therapist has lost credibility and effectiveness to help the offender make lasting changes and ultimately help protect victims.  The abuser returns eventually to their relationship or starts a new one without having made meaningful changes, and as we know the cycle of violence escalates over time, and the risk to the victim has increased. 

Admitting offenders into treatment in this manner is going to have a negative impact on the other members of the group as well.  They are now attending treatment that is supposedly about taking responsibility, gaining accountability and making personal change through insights gained; yet the therapist is taking money from people who they are now helping to escape consequences and to con the legal system, completely undermining the lessons of "treatment."

Under the current rules (as of the writing of this article) of the Idaho Council on Domestic Violence and Victim Assistance, once sentenced to treatment, abusers are not allowed to attend couples/conjoint counseling as a part of their treatment - it increases the risk to the victim because the victim will be sharing personal things that will be exploited by the abuser later, the therapist is seldom specifically trained in the treatment of power and control relationships and will often miss power and control tactics being used right in the middle of session and unwittingly endorse abusive behavior against the victim, and abusive behavior is not a shared problem as it is solely the responsibility of the abuser.

It is my opinion, that once charged with domestic violence or any abusive crime, treatment providers should not provide mandated-type treatment for that abusive behavior until after their sentence is given; or at the least, judges and juries should be prohibited from taking into consideration whether the abuser entered treatment before the sentencing in the formulation of the sentence, and any treatment received at that point should not count towards fulfilling their sentencing requirements.