Читать книгу Ethics in Psychotherapy and Counseling - Kenneth S. Pope - Страница 16

A fundamental stress that confronts therapists is the urgent, complex, inescapable question: “What do I do now?” Consider these scenarios:

 I’m staring at this insurance form, wondering if I should get creative with the diagnosis. They won’t cover this new patient’s condition, but they can’t get the help they desperately need without the coverage.

 Thought I’d hit the jackpot when my new grad school therapy supervisor turned out to be nationally known and her recommendation to be key to the rest of my career, but she’s telling me to do things that are ethically shifty.

 She’s sitting here in front of me, crying and telling me I’m her last hope because her husband beats her, but there are no shelter beds open and she can’t go to the police because her husband is a decorated police captain.

 The physician down the hall is a quack, but as long as I refer my patients to him, he sends me enough referrals to pay my bills.

 My immigrant client is struggling to obtain a green card (residence card), and has been waiting a much longer than average time period. I have contacts in the agency. Should I intervene to help facilitate the process? Is this an act of appropriate social justice?

 A pregnant teenage client is considering having an abortion. She has not shared the news with her parents and wants me to keep her pregnancy a secret. She fears being kicked out of the house if her parents find out about her pregnancy.

Doing psychotherapy confronts us with constant challenges. Each ethical challenge, large or small, subtle or staring us in the face, brings a tangle of questions. Is there a “right” thing to do? If so, how do I find out what it is? How do I actually go about doing it? What makes it right? Who says so? If I do it, what will happen to the patient? to me? to innocent—and not-so-innocent—bystanders?

We wrestle with personal questions that are hard to admit to ourselves or others. What am I tempted to do? What could I get away with? Would doing the right thing cost too much? make people mad at me? get me sued? get me fired? Would doing the wrong thing be all that bad? Would anyone find out? What would happen to me if they did? What if I’m not strong enough, not “good” enough to do the right thing? Can I duck this one and stick someone else with it?

These stinging questions always lead back to the basic question: What do I do now?

Strong, deep, informed ethical awareness helps us answer that question. It brings into focus how our choices affect the lives of our patients, our colleagues, and the public. It frees us from the sticky webs of habit, fatigue, fallacy, dogma, carelessness, hurry, and stress. It wakes us to new possibilities.

If this book helps you to strengthen, deepen, and inform your ethical awareness, it will help you find better answers to that basic question: What do I do now? This book will disappoint those looking for an ethics cookbook, an authority pointing out the right answer for every scenario, a substitute for ethical consideration, decision-making, and personal responsibility. We believe that approach fails in the real world, leading us to blunder with confidence.

Each of us must bring our own ethical awareness to the challenges, pitfalls, and opportunities that we face in each unique, constantly changing situation, to make the best choices. We emphasize eight basic assumptions about ethical awareness.

1. Ethical awareness is a continuous and active process that involves constant questioning and personal responsibility.

Our work requires constant alertness and mindful awareness of the ethical implications of what we choose to do and not do. Ethical awareness helps us to shoulder personal responsibility for our ethical choices, for what we choose to do and not do. We face the consequences for what we choose or not choose to do.

Ethical awareness helps us avoid quick certainties that shut down further questioning. It prompts us to rethink what seems to be a “given,” to continuously look for more creative, more ethical, more effective solutions to problems.

Ethical awareness means setting aside arrogance and complacency. All of us have weaknesses, vulnerabilities, and blind spots—it comes with being human. The stark differences are not so much between those with many flaws and those with few but between those who are freely open to themselves and others about how their own shortcomings affect their work and those who tend to hide such shortcomings and see others as their inferiors.

Ethical awareness depends on our ability to take care of ourselves, to recognize when exhaustion, personal problems, or feelings like fear, anger, boredom, resentment, sadness, hopelessness, or anxiety hurt our work, and to do something about it.

2. Awareness of ethical codes is crucial, but formal codes cannot take the place of an active, thoughtful, creative approach to our ethical responsibilities.

Ethical awareness is strengthened and informed by pouring over the ethics codes that bear on our work. But formal standards and guidelines¹ are no substitute for an active, deliberative, and creative approach to our ethical responsibilities. Codes prompt, guide, and inform our ethical considerations; they do not shut it down or take its place.

Ethical awareness never allows us to follow a code in a rote, thoughtless manner. Each new client, whatever their similarities to previous clients, is unique. Each situation is unique and constantly changing—time and events never stand still. Our theoretical orientation, our community and the client’s community, our race and culture and the client’s race, culture, and so many other contexts and factors shape what we see and how we make sense of what we see. Each ethical choice must take these complexities and contexts into account.

Codes can steer us away from clearly unethical approaches. They can shine a light on key values and concerns. But they cannot tell us what form these values and concerns will take. Standards and guidelines can set forth essential tasks or point to aspirational goals but they never show us the best way to carry out those tasks and realize those goals with a unique client facing unique problems in a specific time and place with limited resources. Ethical decision-making is a process and codes are only one part of that process.

3. Awareness of laws is crucial, but legal standards should not be confused with ethical responsibilities.

A risk in the emphasis on legal standards is that meeting legal standards, which for some can mean finding ways around those standards (e.g., looking for loopholes), can start to replace ethical behavior. This practice is a high art in the political arena. Caught betraying the public trust, politicians often insist they did nothing wrong because no law was broken. When it turns out that a law was broken, politicians admit that their enemies are harping on a mere “technical violation of the law.” Ethical awareness avoids the comfortable trap of aiming low, of striving only to get by without breaking any law.

Ethical awareness stays alert to possible conflicts between our ethical and our legal duties.

An overly exclusive focus on legal standards discourages ethical responsibility. Practicing “defensive therapy”—making risk management our main focus—can cause us to lose sight of our ethical responsibilities and the ethical consequences of what we say and do. When we originally discussed this tendency to confuse legal and ethical issues over 30 years ago in this book’s first edition, the tendency had already begun to spread widely. It shows no signs of slowing down.

4. We believe that the overwhelming majority of therapists and counselors are conscientious, dedicated, caring individuals, committed to ethical behavior. But none of us is infallible.

All of us can—and do—make mistakes, overlook something important, work from a limited perspective, reach conclusions that are wrong, hold tight to cherished beliefs that are misguided or biased. We’re aware of many barriers between us and our best work, but we may underestimate or overlook some of those barriers. Part of our responsibility is to question ourselves: What if I’m wrong about this? Is there something I’m overlooking? Could there be another way of understanding this situation? Are there other possibilities? Can I come up with a more creative, more effective, better way of responding?

5. Many of us find it easier to question the ethics of others than to question what we ourselves value, believe, and do. It is worth noticing if we often find ourselves stewing over just how ethically weak, dense, or shady others are while sparing ourselves from critical self-assessment.

It is a red flag if we spend more time trying to point out other people’s weaknesses, flaws, mistakes, ethical blindness, destructive actions, or hopeless stupidity than we spend questioning and challenging ourselves in positive, effective, and productive ways that awaken us to new perspectives and possibilities. Questioning ourselves is at least as important as questioning others.

6. Most of us find it easier to question ourselves on those intriguing topics we know we don’t understand, that we stumble onto with confusion, uncertainty, and doubt. The harder but more helpful work is to question ourselves about our casual certainties. What have we taken for granted and accepted without challenge? Nothing can be placed off limits for this questioning.

Certainties are hard to give up, especially when they feel like they are part of who we are. They become landmarks, helping us make sense of the world, guiding our steps. But perhaps an always-reliable theoretical orientation begins distorting our view of a new patient, leading us to interventions that make things worse. Or having always prided ourselves on the soundness of our psychological evaluations, we keep rereading our draft report in a case in which an unbiased description of our findings may bring about a tragic injustice, harming many innocent people, and begin to wonder if our feelings for the client led us to shade the truth. Or the heart of our internship has been the supervision, and we’ve made it a point to tell the supervisor everything important about every patient, except about getting so turned on with that one patient, the one who is not very vulnerable at all and does not really need therapy, the one we keep having fantasies of asking out after waiting a reasonable time after termination and then, if all goes well, proposing to.

Questioning our certainties means actively and repeatedly seeking out and listening respectfully to those who disagree with us and engaging them in openly exchanging views. It means actively searching out articles and books that challenge—and sometime attack—our assumptions, beliefs, and practices.

We must follow this questioning wherever it leads, even if we venture into territories that some might view as politically incorrect or—much harder for most of us—“psychologically incorrect” (Pope et al., 2006).

7. We often encounter ethical dilemmas without clear and easy answers.

As we try to help people who come to us because they are hurting and in need, we confront overwhelming needs unmatched by adequate resources, conflicting responsibilities that seem impossible to reconcile, systems that work against the best interests of our clients, frustrating limits to our understanding and interventions, and countless other challenges. We may be the only person a desperate client can turn to, and we may be jerked every which way by values, events, limited time, and limited options. Our best efforts to sort through such challenges may lead us to a thoughtful, informed conclusion about the most ethical path that is in stark contradiction to the thoughtful, informed conclusions of a best friend, a formal consultant, our attorney, or the professional groups we belong to.

In the midst of these limitations, conflicts, disagreements, and complexities, we must make the best choices we can. We must each struggle to answer the question: What do I do now? And each of us must take responsibility for the decisions we ultimately make. We cannot shift personal responsibility for what we decide and what we do to another person, group, law, code, or custom. There is no escape from these struggles. They are part of our work.

8. We and our clients do not live in a vacuum. We live and develop in sociocultural contexts.

We are called to act in accordance with an ethic of human rights and social justice. We open our eyes and hearts to how discrimination, hatred, injustice, beatings, xenophobia, slavery, jail, starvation, torture, or genocide—based on factors like race, religion, immigration, culture, gender, sexual orientation, disability, politics—affect us, our clients, their families and communities, our supervisees, and the world we live and work in. We search for the most ethical response to social injustice. We don’t shrug our shoulders and turn away. We face these issues with courage, honesty, caring, and a sense of personal responsibility to respond ethically.