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ETH5556 - SECTION 7: ADVANCED ETHICAL DECISION MAKING TOOLS

Two Models

We are going to begin this section with two models from the literature: Gerard and Teurfs's Dialogic Thinking (11)and Brown's Diversity Ethics Process Model. (5) However, first it may be helpful to spend a little time explaining the nature of dialogue as a mode of action.

Dialogue differs from discussion or debate in important ways. Discussion has as its root the Latin word for things banging together in conflict. Debate has as its root the Latin word "to fight". Discussion and debate are primarily about competition, with both sides presenting their points of view in order to force concessions and be allowed to avoid the adaptive work that is required with change.

Laws are primarily discussion-driven: if you don’t operate in accordance with our idea of right and wrong, there will be consequences. Do what we want – or else – as we impose our idea of right and wrong on the society. Codes of ethics are less fully discussion-driven, but still retain the sense of value definition residing in the hands of the powers that be.

Dialogue is an exploration for common ground and mutually beneficial adaptive solutions. Whereas discussion is conservative of pre-existing positions, dialogue is fundamentally transformational. It does not look for solutions that may maintain the positions necessarily held by any single party in the interaction; the solutions from dialogue may involve fundamentally changing the beliefs, values, positions, and behaviors of all parties involved.
Like therapy, dialogue is an organic process. It embraces and seeks interaction and change. It asks questions, instead of looking to force compliance with pre-determined values, beliefs, and ideals.

Gerard and Teurfs describe the four building blocks for this process of dialogue to move forward constructively. These building blocks are:

- Surfacing and suspending judgments and assumptions
- Identifying the assumptions of the parties in dialogue
- Listening
- Shared inquiry and reflection (11)

Each of these four building blocks should be familiar to and comfortable for mental health clinicians. The shared inquiry and reflection pre-supposes a willingness to come at the inquiry from multiple value orientations, and the skills to create an atmosphere of safety and trust for the client to engage in this process with the clinician.

Brown's Diversity Ethics Process Model is more directly connected to this training program and our goals for understanding the ethical decision making process. It proposes the following clearly defined stages of how to approach ethical dilemmas when a diversity of values is present. Here are those stages.

1. Make a proposal (What should we do?)
2. Identify observation (Why should we do it?)
3. State values (Why is this the right thing to do?)
4. Align personal, client, professional, societal values
5. Explore the alternative views (with the participation of the client)
6. Uncover the assumptions (for the client's values, the clinician’s values, the profession’s values and society's values)
7. Find the best option (in concert with the client)
8. Perform a consequence analysis (in concert with the client) (5)

Please note the transformed role of the clinician in this process - from a role that places the clinician as the expert, towards a role as a participant in the process of uncovering the shape and direction of the decision or solution. This is Heifetz's Type III adaptive solution in action.

The key distinction in this way of operating as an expert is that the context and key definitions are not supplied exclusively by the dominant culture. This is a shared adaptive process, and it is expected that the client’s cultural elements will be accorded enormous respect in terms of the power to shape the definitions - based upon the client’s systems of beliefs and values.

The advantages of this approach are important in terms of avoiding extreme (i.e., less adaptive) positions. The values and biases of the dominant culture are not automatically imposed on the client, with no room for discussion and interaction. The client's position is not labeled as deviant.

However, the extreme position on the other side is not taken, either. This is to say that the clinician is allowed to invite the client to examine his or her value orientations, beliefs, ideals and perceptions. The client is not given an automatic pass to avoid the dialogue through taking the position that any questioning or examination of his or her position is culturally disrespectful.

The responsibility for the clinician in terms of respecting the client's right to autonomy does not constitute permission for the client to refuse to engage in any process in which adaptation might be required. The client may still say, in essence, "this is my culture and I decline to change anything about it".

However, the clinician is not ethically required to respect cultural diversity and difference to the point of being unable to enter into dialogue about the intersection of the client's culture and the larger culture in which the counseling is taking place. At the very least, the client's autonomous decision to participate in the larger system that is the United States – and the fact that therapy is occurring - is an implicit and explicit acceptance of the reality of interaction and cultural interplay.

Brown's Diversity Ethics Process Model, performed correctly, seeks to create a process through which these thorny cultural collisions are led towards resolution to the satisfaction and adaptation of all the interacting parties. Before we attempt to use this as a template to address our introductory scenario, let's add one final tool to the armament of the clinician.

If we begin with the proposition that culture is a mechanism for mutually interested groups of people to cope with its problems of external adaptation and internal integration – an adaptive tool – is there any way to determine which components are more adaptive than others? Will this help us to work with the client to facilitate making decisions about what adaptations might be most effective in handling any given situation?

This is where it might be helpful to put forth some information about the different dimensions of values and other cultural components, and the relationship of these dimensions to the adaptive work of cultures over time.

Any time a value enters the mainstream of a culture, it is first evaluated based upon how well it performs the tasks that a value is supposed to perform. This is to say, is it functional? If the value is something like, "Hard work and group cohesiveness are important virtues," and the value has positive adaptive effects by allowing the group to prosper, then the value is a Functional Value.

If the value has a maladaptive effect, it will generally be discarded and disgraced within the community, and the community will quickly try to eradicate it.

As the community encourages the adoption of the value as a community standard, it applies its reinforcing resources to firm up the value's place in the community. It rewards the value, gives praise for those who hold the value. The value begins to assume emotional value for the people who hold it.

Or the value may be something that resonates naturally within the emotional life of the members of the community, because the value has intrinsically rewarding qualities. "We are the chosen people" is a value that resonates easily within communities from an emotional standpoint.

These kinds of values are Emotional Values.
As values remain a part of a community, and are passed down from older generations or more senior members of the community, they begin to acquire the value of tradition or habit. They may even have value of this sort past the point at which the value has present functional value for the adaptation of the community, and past the point where they resonate emotionally with the culture's members. These are Residual Values.

Adaptive challenges often occur when the Emotional Values or the Residual Values are no longer able to serve functional adaptive purposes. Community members can be constrained from moving to more functional positions by the pull of the emotional or residual components of their values, beliefs and perceptions.

Values and other cultural elements can also have purposes related to creating affiliation between members. This is to say that the values and other shared elements of a culture can serve as a mechanism for drawing people together or defining them as members of that group or community – even if the values are not particularly functional or emotionally pleasant. These are Affiliative Values.

Gangs will often develop affiliative values to build group cohesion and separate the group from other communities that might compete for its members. The affiliative values may be emotionally unpleasant for the group members, but the stress of adapting to them emotionally may be one of the features used to create more group cohesion.

Finally, groups are also drawn to Transcendent Values. These are the elements of the culture that attempt to grasp the larger meanings and purposes of the world and incorporate them into values that help the culture adapt to the most difficult and unanswerable questions and anxieties that challenge humankind.

There are cultures in which all actions have spiritual significance and the most powerful values will always be transcendent values. Because the secular and scientific aspects of Western culture are so different from this orientation, it can be difficult at times for less spiritually inclined clinicians to appreciate the deep effects of spiritual material and to understand the frame of reference defining the actions of clients whose goals and purposes are driven by spiritual material.

Emotional, Residual, Affiliative or Transcendent Values can have great power and meaning for the people that hold them – even when the values are not particularly functional in real time, or when they hinder attempts at adapting to changed circumstances. Every clinician has bumped up against these different value elements when working with clients, and we often see them as a source of resistance to change.

There are occasions where all of a client's value and other cultural elements will have a great deal of alignment. This is to say that the culture's values will be very functional, they will resonate deeply from an emotional perspective, they will have powerful connections to a long and successful cultural history, they will bind people together in deep and powerful ways, and they will align with the deeper spiritual longings and meanings for that culture.

This kind of alignment will contribute to the strength of that culture's value elements. It will create some difficulties when the culture has a challenge of adaptation that may require restructuring of some of the cultural elements.

When the clinician leads the dialogue towards the sixth step of Brown's Diversity Ethics process, these different dimensions of cultural material can help to uncover the assumptions and evaluate the best way to create adaptive change. Often the work of the clinician in creating better adaptations lies in attempts to reconfigure the Emotional, Residual, Affiliative or Transcendent Values in ways that allows these cultural elements to be more functional or adaptive to the client's current circumstances.

Very strong cultures – and cultures that operate as extremely closed systems – may put up strong resistance to changes in their value elements. This is particularly the case when the system of values, beliefs and perceptions held by a group is structured in a way that it can only operate and survive as a cohesive whole. If any element is removed or changed, then the whole value system might collapse – with profound consequences for the community that holds the system of values.

There are innumerable cases in the literature of the disastrous consequences to native cultures when the value elements of conquering cultures are imposed onto systems of values that have their own, internally consistent logic and integrity. If the new values from the dominant culture undermine certain key organizing cultural elements, the rest of the structure for the culture can sometimes crumble and fall apart.

Mental health clinicians must do a careful examination of the fragility or resilience of the cultural system with which they are interacting prior to entering into the adaptive dialogue. If the cultural system is at risk for damage and harm through the insertion of foreign value elements, then the adaptive work must proceed slowly, respectfully and carefully.

Whenever possible, it must also be done in ways that accord the client appropriate measures of autonomy in terms of how and when the client engages in the process. However, as we have mentioned, it may not be avoided entirely. The leadership work of the clinician lies in successful application of the proper skills and timing.

Dialogic work also assumes one additional thing. It assumes that all the parties who enter into the dialogue will be willing to be changed or transformed through the interaction with the other parties. Said differently, instead of each party entering the interaction with the idea of dominating or convincing the other party to change their fundamental moral or value-based position, the transaction will be concerned with a joint effort at creating adaptive solutions to the conflict.

The solutions can utilize elements from either or any of the parties' original frameworks, or can create new and innovative positions wholly apart from what can be found in any of the original moral, value, or perceptual positions of the parties.

The nature of this kind of work has been explored by a number of authors in a number of arenas. Pearce and Littlejohn have developed a model of discourse designed specifically to address the kinds of intractable moral and value based conflicts that we are studying here. They call their model Transcendent Discourse. (20) They describe the strengths and purposes of their model in the following ways:

1) Transcendent discourse goes beyond simplicity to explore the complexities of the lived experiences of the participants;
2) Transcendent discourse goes beyond obstruction to engage in genuine dialogue;
3) Transcendent discourse goes beyond blame to identify and critique the basic beliefs and assumptions of faith;
4) Transcendent discourse moves forward into new ways of understanding and acting. (20)

In describing process, they present a model similar to the processes we have looked at earlier in this chapter. They propose the following five-step process for resolving intractable moral conflicts:

1. Uncover the communities' basic assumptions
2. Develop categories to compare incommensurate differences
3. Seek to explore rather than convince
4. Assess the strengths and weaknesses of both worldviews
5. Seek to reframe the conflict into more productive terms (20)

The leader's role in moving this process forward includes securing the willingness of the involved parties to engage in this sort of process, explaining and teaching the model sufficiently to allow the process to move forward, and facilitating the exchanges and interactions in accordance with the principles and tools of the model. This model is very compatible with the ideals of cultural competence in clinical practice.

In our analysis of the scenarios, we will try to incorporate the philosophy and strategies of these modes of dialogue and discourse in striving for adaptive solutions. Let's move in that direction now, beginning with a wrap-up of our introductory scenario.





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