ETH5556 - Section 3: CULTURAL DIVERSITY, VALUE CONFLICT, AND ETHICAL DECISION MAKING: SETTING THE STAGE
What is the role of the mental health clinician, and what are the skills and beliefs that allow him or her to proceed in this very difficult profession in a professional and ethical way? At its heart, this work is based upon the ability to direct others towards fulfilling the visions, goals and mission that have been defined as right and important by the parties who are connected to that mission.
Said differently, our mission is to improve the mental health and overall well-being of the people who come to see us.
In his seminal work, Leadership without Easy Answers, Ronald Heifitz, (Director of the Leadership Program at Harvard University's Kennedy School of Government and a trained psychiatrist) describes this mission as "adaptive work", defining it as "developing the . . . capacity to meet problems successfully, according to (defined values and purposes)". (13)
When there are conflicts over values and purposes, the adaptive work will usually include engaging in the process of clarifying and integrating or merging the competing values. (13)
In the field of mental health,
"people adapt more successfully to their environments, given their purposes and values, by facing painful circumstances and developing new attitudes and behaviors. They learn to distinguish reality from fantasy, resolve internal conflicts, and put harsh events into perspective. They learn to live with things that cannot be changed and take responsibility for those that can. By improving their ability to reflect, strengthening their tolerance for frustration, and understanding their own blind spots and patterns of resistance to facing problems, they improve their general adaptive capacity for future challenge." (13)
As experts, we are charged with leading our clients from a physical, emotional, mental (and, perhaps, spiritual) place that is "worse" to a place that is "better". We help them change in ways that have better adaptive results.
This is an excellent representation of the work we do in the field of mental health. It is also deeply infused with a variety of modes of Western thought. Dr. Heifetz is very clear about this. He says that if his ideas are relevant for people from non-democratic societies, "it would be fortuitous." (13)
Other cultures do not honor "personal growth" or "individuation" with the same kind of certitude that we do. In fact, many other cultures view the American obsession with personal freedom as pathological and destructive. Other cultures view the needs of the collective or the community as being primary, and individuals are expected to relinquish their individuality rights and needs – and sometimes even give their lives - for the greater good of their culture, community or country.
As we will see when we examine the many different elements that are viewed as having value and importance to different cultures, there are many ways of approaching some of these fundamental concepts. This is a knowledge point that is integral to maintaining a high level of cultural awareness.
As leaders, we are supposed to utilize our higher degree of knowledge and skills - as well as our capacity to view a client's situation from an objective perspective - to direct our clients towards a fulfillment of the defined adaptive mission. This is leadership, and our professional authority is derived from a willingness to operate within the boundaries set by these leadership demands.
Mental health clinicians who are willing to work from a position of leadership must have a great deal of clarity on several subjects when confronting complicated ethical situations. First, they must be able to differentiate three separate - but connected - arenas that professionals must consider when they are engaged in complex decision making.
These three arenas are the legal, the moral, and the ethical. Let's look at these three areas in diagrammatic form. We will later look at how these three areas operate when in interaction with different cultures.
Pertaining to personal behavior as measured by prevailing standards of behavior as defined by a specified (usually spiritual) group.
Consequences for moral lapses are generally the domain of individual and group conscience.
Pertaining to accepted principles of right and wrong as defined by a specified (usually professional) group.
Consequences for ethical lapses are generally the domain of the profession and keepers of the profession.
Pertaining to accepted principles of right and wrong as defined by the law, rather than by equity (fairness, justice impartiality).
Consequences for legal lapses are generally the domain of the legal system.
It is possible for a clinician to act in a manner that is legal, but not ethical; or ethical, but not moral; or moral, but not legal or ethical.
Since, these three different dimensions in decision making are mentioned in codes of ethics for mental health clinicians - sometimes on the same page, within the space of a few paragraphs, it may be helpful to examine the differences.
Let's start with the Legal dimension of decision making. Laws are defined by people in legislative positions, and courts (and/or juries) that interpret and issue rulings based upon their understanding of what those laws mean. The laws are not necessarily written by those persons who are most knowledgeable about a subject, nor necessarily by people who are even interested in being either fair or equitable in writing the law.
As we know from the history of the civil rights movement, in fact, laws can be written and enforced in ways that are unfair and inequitable. Conversely, some very moral and ethical people have expressed their deep moral and ethical convictions by breaking the law.
Almost by definition, laws tend to express – more or less - the defined beliefs and values of the dominant culture. Laws attempt to create a certain measure of conformity to the standards that are deemed by the dominant culture (or at least, the people in charge of the legislative processes at any point in time) as being right and wrong. They define the standards, values and viewpoints held by the dominant culture as "right", thereby often defining any group who differs from this as "wrong" or "deviant".
The law is designed to be fluid and changing over time, but fixed and certain at any specific point in time. The law, in fact, oftentimes struggles to keep up with (and sometimes even fights back against) cultural changes in ethics and morals. Leaders who are involved in helping ethics and morals to progress forward sometimes find themselves pushing the boundaries of the law until the law can be rewritten to reflect the changes in understanding - until society does its adaptive work on a larger scale.
Many people from non-dominant cultural groups have experienced prejudice from the law as it has been written, as well as conflict with the parties who set and enforce the law. Mental health clinicians will frequently find themselves caught in the middle of this sociological conflict. It is a tension that will be present during attempts to find the best ethical outcomes. We will see in a very clear way some of these tensions as we analyze our scenarios.
The second dimension we will look at is the Moral dimension. The moral dimension is deeply involved in helping to shape both the legal and the ethical dimensions. Both laws and ethical codes, in fact, represent some attempt to codify and enforce commonly accepted moral understandings.
Ethical standards, like laws, are also at least partially derived from commonly accepted moral ideas about what is right and wrong behavior, but typically within areas relevant to specific professions.
The important distinguishing feature of the Moral dimension, however, is that it is personal in nature. Both legal and ethical lapses can set in motion the external imposition of consequences. Moral lapses that do not also break the law or violate ethical standards will not provoke any externally imposed consequences. The consequences for moral violations will play out between the person and his/her individual conscience.
This does not mean the moral dimension is less significant. In fact, the moral dimension is usually the dimension out of which leadership and change emerge. It is usually a single person or forward thinking group of persons whose moral thought and principles lead the legal and the ethical dimensions to more evolved or adaptive states of being.
The difficulty, of course, is that the moral dimension is personal in nature in negative ways, as well. When a person's own personal moral standards are less evolved than the prevailing legal and ethical standards, then this moral dimension works to sabotage the establishment of better legal and ethical standards, instead of helping to lead law and ethics towards a better place.
The proponents of segregation earlier in this century, for instance, based many of their positions upon a moral code that lagged behind changes in the prevailing social norms and standards. They did not want to adapt their values to changes in cultural norms, but instead wanted the parties being oppressed to continue to do the greater part of the adaptive work by tolerating the oppression.
This issue leads, of course, to very tricky ground. Most persons who have deeply held Moral standards feel that these standards are held for the right reasons, not the wrong ones. When they are right, the society at large benefits from their unwillingness to bend; when they are wrong, society is damaged by their inflexible attitude towards change or adaptation.
The essential question in this issue, of course, is - what is right? This is not an inconsequential question for the mental health profession. It is deeply involved in the decisions that are made about the last of our three dimensions - the Ethical dimension.
In general terms, each profession wrestles with the question of what is right on an ongoing basis. The governing bodies in each of the mental health professions attempt to work with their members in an evolving society to create workable definitions of right and wrong behaviors in important areas related to the profession.
When individuals depart from the standards set by the profession - even if the departures are based upon deeply felt moral reasons - the profession may choose to implement sanctions against that individual. The individual must evaluate this potential risk when a moral decision is made that is in conflict with the ethical standards set forth by the profession.
Each profession, of course, attempts to make their difficult judgments about which behaviors are right or wrong in well-reasoned ways. It is a complicated process which may involve dialogue and seeking consensus from members of the profession, guidance from core groups of wise and experienced leaders, and input from relevant outside parties who have a stake in the outcomes of these decisions.
In this process, the governing bodies are balancing many things. The core defining values of the profession are included in the mix. Knowledge about prevailing social standards will generally be factored in, including where those social standards differ among diverse populations of clients served. The need to protect the legal status of the profession is also considered, meaning that the core values and beliefs may need to be tempered by what the law will allow.
It is neither a perfect nor an easy process, and the conclusions that are reached are often neither clear nor fixed. Ethical practice aims at a constantly moving target, changing all the time in response to new understandings or new laws - while each profession as a profession engages in its own adaptive work to try to keep up. There is a fundamentally dialectical aspect to this process – complex systems trying to incorporate at times mutually incompatible components as the system changes and evolves over time.
This leaves individual clinicians room for both flexibility . . . and uncertainty in their choices of how to handle ethical dilemmas.
It can be frustrating for professionals to try to practice ethically without clearer and more concrete guidance from their professions. However, the lack of concrete answers is more a reflection of the difficulties of corralling an evolving and adaptive process than it is a failure of the professional bodies to do their adaptive work.
This evolutionary process defines at least two other items that need to be mentioned in this section. Both have to do with the ways in which determinations are made concerning what is "right" and what is "wrong".
The first way we will sometimes determine whether something is right or wrong is through knowledge drawn from scientific examination - latest research about what is effective, what is harmful, what is normal. This helps to define both what is possible, and what is right to aim for in clinical practice.
The information that is gathered in this process is in a state of continuous evolution. As time moves forward, an increasing amount of information is gathered and distributed. As experts, mental health clinicians are expected to do a reasonable job of keeping up with advances in this information.
But there is another evolutionary process that occurs in tandem with this increase in available information. The increased knowledge changes our understanding in areas that are not simply cognitive in nature. It is concerned with something else altogether. Let's bring in some examples of this to demonstrate.
In the not so distant past of the mental health field, pre-frontal lobotomies were considered a valid treatment approach - the reservations of the client notwithstanding! In terms of the thinking of the day, doctors determined that patients would be "better off" with a severed corpus callosum, in line with the mission of improving the well-being of the patient.
In another example, homosexuality was redefined in the 1970s - at least by the field of mental health - as a variation of human experience and sexual expression, not as a deviation or illness requiring either re-socialization or a cure. It was decided at that time that the cultural inclination to view homosexuality as a form of deviance did not align with the facts discovered in researching variations in sexuality.
The ramification of this is as follows: people who followed standard medical practice - or morally or legally acceptable positions - at one point in time would find those same positions wrong and morally reprehensible at later points in time. Conversely, the deviants – those persons who acted outside of the law or standard practice – would find their positions vindicated from a retrospective point of view.
This is a humbling understanding that must be considered very closely as we attempt to determine what is right and wrong in this period of cultural transformation.
The list of evolving ideas and understandings is very long. This re-examination of ideas takes place in a particular context, or - perhaps better said - contexts. In this evolutionary process, different people - and different groups of people - do not just evaluate new information based upon their cognitive perceptual abilities. The ideas are not just evaluated based upon what people think of them. They are also evaluated based upon what people feel about them. This is the domain of values.
In some cases, the values of the people evaluating the information will be more important in determining how evolving ideas will be received and perceived than will the facts that are presented. This is one of the domains in which culture operates.
The United States is currently in the midst of a major transitional period in the history of its shared values. This is what some in the political arena have labeled a "culture war", but it is really more properly viewed as an extension and intensification of historical forces that have always been at work in this country.
The United States, more than ever before, is struggling with its own adaptive challenges related to the integration and assimilation of ever increasing numbers of new citizens from different cultures. This has occurred in conjunction with a partial - but steadily increasing - diminishment of the hold on power traditionally held by the White (and primarily male) members of American society.
This has disrupted and challenged the predominate model of assimilation and diversity that has been held as the ideal since America came into being. Let's look at this model and also examine what are the possible future replacements for this model. This will be derived from the work of Leah Wing (32).
The model forwarded by the most conservative forces in American politics is usually described as the "white bread assimilation model". It is presented in a formula that reads like this:
A+b+c = A
This formula states that the non-dominant groups are expected to integrate into the culture that is both held and defined by the dominant group. The final culture will retain those ideals and values that the dominant culture views as important, and extinguish anything from the non-dominant groups that doesn't fit with the dominant group’s ideals. The non-dominant groups are submerged completely within the dominant group, with their cultural material lost.
This model has never been fully realized in the United States, although there are groups who have attempted to make it so. The more frequently referenced variation of this model, however, has been the "melting pot" model, which looks something like this:
A+b+c = A'
The dominant culture still retains the greatest influence over the ideals of the culture, but the inclusion of new ideas and influences changes the dominant culture in ways that allow for better integration of the non-dominant cultures' material. This melting pot theory has traditionally been viewed as the social covenant for assimilation. (32)
What does this model mean for the dominant and non-dominant groups in terms of adaptive work? It means that the dominant group has traditionally been required to do less adaptive work within this system while the non-dominant groups have been required to do more adaptive work. It's a better deal for the dominant group – which is why the dominant group tries to forward this as an ideal. It allows them to put the burden of more adaptive work on others.
This process of "passing off the adaptive work on others" is a very common phenomenon in situations of cultural clashes and challenges in the assimilation of competing values systems. Clinicians see this regularly in miniature during couples counseling, where partners blame each other for not adhering to the "right" values and beliefs about how partners "should" behave.
The values used to make these determinations are derived from each partners' own personal cultural value systems. Couples counseling, in many ways, is essentially a dialogue of cultural reformation.
The period of transition in America that is occurring at the present time is reshaping the predominate model of assimilation in a fundamental way, and it is going to affect all aspects of American culture – including mental health practice – for some time to come. However, as the traditional melting pot model loosens its grip, it creates a period of uncertainty and confusion. Consensus on a new and better model has not been reached.
The other models that have been described in the literature are possible options. Let's look at them here, although we won't go into them in any great detail.
The "quasi assimilation" model A+b+c = A'(a'b'c')
The dominant culture provides the general framework for the workable social structure, but all cultures associate with it equally and retain elements of their own cultural ideals. (32)
The "transitive" model A+b+c = A+b+c
All groups remain unassimilated in the ratio in which they exist in the society, with degree of influence proportionate to this ratio. This still leaves the dominant group with the greatest degree of influence, since they have the highest proportion of people. (32)
The "reconstructionist" model A+b+c = A'B'C'
The core culture is transformed through its interactions with other cultures – as are the other cultures through their interactions with the dominant and other cultures - and the non-dominant cultures are accorded equal influence in the definition of cultural ideals. (32)
The "pseudo assimilation" model A+b+c = X'a'b'c'
The dominant group and the non-dominant groups work together to define a workable social structure – not based upon the historical ideals of the dominant group or any other group, but based upon the definition of a new structure created through the shared adaptive work engaged in by all parties. When the structure is formed, each group associates with it, but also retains elements of their own cultural ideals. (32)
It is still uncertain which of these models – if any - will assume a prominent position over the next part of this century. What is clear is that the old models – where the dominant culture largely dictated the terms of development – will be altered.
This will lead us to our next section, in which we study the relationship between values and culture, as well as the other elements of which culture is composed.