regarding issues of enormous complexity and potentially life-and-death implications can push even the most resourceful therapists to and beyond their limits.
Fearing that formal review agencies will hold us accountable, after the fact, scares, stresses, and distresses some of us. Some agencies focus specifically on the ethical aspects of our work. Others, such as state licensing boards and the civil courts, enforce professional standards of care that may reflect ethical responsibilities. The prospect of review agencies second-guessing us—and perhaps falling prey to both outcome bias and hindsight bias—can make difficult judgments a nightmare for some therapists. They may suffer debilitating performance anxiety, dread going to work, and discover that the focus of their work has changed from helping people to avoiding a malpractice suit.
Managed care stresses some therapists. For example, capitation contracts provide a limited sum of money to cover all services for a group of patients (e.g., a business that has contracted coverage for its employees with an agency). The agency providing services, having estimated the average number of sessions needed for each patient, must limit the total number of sessions to make a profit. Strict guidelines may limit how many sessions a therapist can provide. Therapists may feel pressure to terminate before the limit, even if they think services are still needed. Even if clinicians follow agency procedures, they may face charges before an ethics committee, licensing board, or malpractice court for patient abandonment, improper denial of treatment, or similar issues. Therapists may fear not only that a formal review agency will sanction them but also that the limited sessions fall far short of what their clients need.
Teaching or learning therapy is practiced on the living—this can stress us. As supervisors, we may grow uncomfortable with how the supervisee responds to the client differently from how we would, with our responsibility to evaluate the supervisee’s work, and with the demands of our role as teacher, mentor, and gatekeeper. As supervisees, we may doubt our ability to carry out clinical responsibilities (especially when they involve suicidal or homicidal risks), dread making mistakes, feel uneasy about differences in values or theoretical orientation between ourselves and our supervisor, wonder if racial (or gender or sexual orientation or religious or political, or, or, or) differences between us and our supervisor are causing us to be viewed in a negative light, and figure that if we are completely honest in describing to our supervisor what we actually thought, felt, and did with our clients, we might be advised to look for another line of work.
Learning to work competently with clients from various identity groups can be challenging. Understanding and integrating racial and cultural issues and context is fundamental to our professional responsibilities. We can complete workshops, read, get supervision, take continuing education courses, but the challenge in gaining knowledge about various social groups will be an ongoing task. Knowledge about the various social identities that our clients represent will be necessary in assessing the degree to which we integrate various values, behaviors, and expectations in the course of treatment. Those potential identities include but are not limited to race, ethnicity, generation, gender, ability status, sexual orientation, gender identity, caste, religion, spirituality, immigration, employment, and the like. Working competently requires awareness, knowledge, and skills about people’s identities and the ways in which overlapping forms of oppression (e.g., gendered-racism, gendered anti-Semitism) impact people’s lives (for further reading on the theory of intersectionality as originally created by Black Women see Combahee River Collective, 1995; Crenshaw, 1991; for intersectionality in clinical practice see Adames et al., 2018; Chavez-Dueñas et al., 2019).
WHAT DO I DO NOW?
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,
