As mental health professionals, we are bound by a professional code of ethics. We likely had to read this code at some point in graduate school and then study it again carefully in preparation for our licensing exams. At the time, it probably seemed simple and straightforward. Specific guidelines for each helping profession may differ slightly, but they are intended to help keep us all at our best.
Once we get caught up in the emotional work of psychotherapy, which can be as challenging as it is rewarding, it is valuable to reconsider these ethics in light of our roles within the systems we are now part of. Doing so can help us be sure we are not indirectly contributing to the concerns of those we work with. It is likely we now perceive things a little differently than we did as idealistic grad students awaiting our capes and permission to go out and save the world!
Challenges that May Arise in Practice
While I have had the freedom of working in private practice for the past 9 years, as a new professional I was reared in the trenches of inner city social work. I worked in a number of fields—higher education, child welfare, community mental health, and psychiatric settings—and found each well-intentioned organization to have their own unique culture. At the heart of all of them was deference to a larger implicit system. Whether this system is a school administrative board, a requirement of “making your numbers” to cover the costs of your agency, or the way we routinely apply the diagnostic medical model itself, it is important to take a step back in order to gain perspective on how we (employees who want to help those we work with as much as we want to keep our jobs) may unknowingly be complicit with systems that create major ethical questions and potentially even more risk for people in therapy.
I am licensed as a clinical social worker. According to my professional organization, the National Association of Social Workers (NASW), social workers are driven by a mission grounded in the following core values:
- Being of service
- Promoting social justice
- Respecting the dignity and worth of each person
- Focusing on the importance of human relationships
- Maintaining integrity
- Ongoing development of competence
While we want to always prioritize the safety and well-being of people in therapy, we also must bear in mind the complications we may impose on an individual when, in the interest of protecting them, we turn them over to systems that, once an individual is part of, may be difficult to leave without further trauma.
While all people and professionals who endeavor to abide by guiding principles may have moments that challenge their judgment, mental health professionals are likely to be frequently challenged in multiple complex ways—some more subtle than others. Often these ethical questions will overtly arise when providing direct service to a person in therapy.
As mandated reporters, for example, mental health professionals are often conflicted over concerns like how to ensure the safety of a child when dealing with the dynamics of the larger family system. Just as commonly, we may struggle with how to protect a person we are working with from self-harm as they negotiate the darkness of suicidal thoughts. Whether or not a person is employed directly within a system, these are the current ethical protocols, and decisions like these are heavy burdens to bear.
Only once have I had to make a formal report to child welfare services in the interest of protecting a minor from being a victim of, or bearing witness to, violence in the home. I have only had to call an ambulance to escort a person experiencing an episode of decompensation from my office a handful of times. These are some of the hardest decisions we, as mental health professionals, have to make because there is so much at stake for both you and the person you are working with.
Prioritizing Well-Being and Best Interests
While we want to always prioritize the safety and well-being of people in therapy, we also must bear in mind the complications we may impose on an individual when, in the interest of protecting them, we turn them over to systems that, once an individual is part of, may be difficult to leave without further trauma. In New York City, for example, once a child welfare case is opened for investigation, that person’s name will always show up in the system, even if it is determined any allegations are unfounded. Thus, it can be difficult to balance our well-meaning and/or mandated actions with what serves the both the short-term and long-term best interest of people seeking our help.
Similarly, once someone is admitted for a psychiatric evaluation, they are likely to be kept on a locked inpatient unit for at least three days with other people who may be experiencing various forms of mood issues and psychosis. Is this really the best setting for a person to find peace? Our system prescribes this as a way to first and foremost assure their safety. But we also know the mainstream medical model’s first response to managing psychiatric episodes is to administer (often large) doses of psychotropic medication in order to suppress the symptoms manifesting outside of the range of what we consider normal. This might also give us pause to consider whether this really is the best course of action?
How many times have we asked ourselves more philosophical questions in service of the people we are working with?
- What if these symptoms are not evidence of disease as the medical model would have us assume, but are in fact presenting to offer us information?
- Have we considered that, for some, “symptoms” of mental health concerns are in fact a part of a larger spiritual transformational process that necessitates disintegration in order for a shift to a higher level of functioning to occur?
These are not questions mainstream models tend to entertain, although I have seen these cases in my own academic research and practice.
Asking the Bigger Questions
Our short-term, reductionist mainstream systems are products of our Western culture of comfort, materialism, and immediate gratification. Our culture rarely seeks to understand the causes of our ailments, whether they arise physically or emotionally, and instead generally responds by trying to suppress them. How do these assumptions impact us all?
For the past few months I have been involved with a developing community at The Institute for The Development of Human Arts (IDHA) in New York City that is asking these bigger questions. This community of mental health workers, clinicians, psychiatrists, current and prior users of mental health services, advocates, artists, and survivors of trauma and adversity draws from the expertise of the multi-disciplined professionals involved as much as it does from those with lived experience.
The project, a collaborative think tank, has come together to refocus on the values at the heart of human healing. Their first eight-week course, “Rethinking Crisis,” creates a framework for exploring and understanding the challenges in our current mainstream systems while laying the groundwork to co-create a new paradigm that can better reflect the ethical codes that guide our professions.
Being in classes with diverse professionals and experiencers with backgrounds that clearly demonstrate how many of our systems have unintentionally created harm in the interest of healing has given me the opportunity to learn and further sensitize myself to the ways I engage with the people I work with.
All of us have available to us, at any given time, new opportunities to consider perspectives outside of our own, especially from those who have had the experience of being oppressed by systems created to assist them. We may know big system change takes time, but it only takes a few moments to revisit our codes of ethics and consider an expanded perception that may continue to inspire us toward conscious action in all aspects of our work.
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