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Section Six: Advanced Leadership Issues in Ethics

Defining the Clinician/Client Relationship

In an earlier section, we talked about the competing interests involved in determining the "right" mission. Mental health clinicians, in their leadership role, will be at the focal point of decisions that will be made about what the mission is, and how best to fulfill that mission.

This position is the correct one for a leader to take, but it is a position that will involve a number of pressures from parties who have a stake in the outcome of decisions that are made. Before we move forward to further discussion, let's review the competing interests - once again in diagrammatic form.

Interests of the Client                                   Interests of the Clinician



                                       The Mission



Interests of the Broader                       Interests of the Profession

Society (Legal/Cultural/



We have already discussed some of the pressures that come from the client. The client's idea of the "right" mission may direct treatment towards things that are incompatible with good clinical practice, or that may ask the clinician to violate the integrity of the profession. 

The clinician's work in this case is to invite the client to come to a better definition of the mission. For this to happen, the clinician must project professional authority - based upon having expert skills and knowledge and commitment to the profession. He/she must also be able to define the mission in a way that creates buy-in for the client.

The ability to articulate the "right mission" clearly, with language and concepts that resonate with the client's values and sense of self-interest, is key to the creating this buy-in. The professional authority that creates this buy-in must be durable in nature, able to last through the ups and downs of treatment. This means it must be based upon true expert knowledge and skills, understood as such by the client over time. 

Furthermore, this combination of knowledge and skills must be brought into the treatment in a way that is directed by the right mission, not by any other considerations. The difficulty is that there are a number of other considerations that come into play in defining the right mission, not all of which are concerned with the patient's well-being.

Where does the definition of the right mission come from? As we have described earlier, it evolves out of a complex stew of input systems. At least some of the information about the mission - and how to serve the mission - is based upon 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 is in a state of continuous evolution. But the evolutionary process happens in two ways that are important for this discussion.

The first way that this evolution occurs is in the advancement of knowledge. 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 an illness requiring 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 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.

In this, there are pressures that come into play in deciding what the "right" mission is, and, therefore, in ethical decision making. Groups may advocate for  interpretations of what is right and what is normal - important determinants of setting the mission -  based upon what appeals to them emotionally, rather than upon a fair assessment of what the facts mean. 

This is very important to know for the clinician who wishes to operate at the highest level of leadership, and at the highest level of ethical behavior. In preparation for looking at this, it may be helpful to provide some background information on what values are and how they work in shaping definitions.

Values are deeply held cognitive and emotional constructs that help people define themselves, their lives and their actions. Values are tremendously important for people in terms of making complicated decisions quickly. Any situation in which a value is involved is one in which there is a lot of information with complex practical and emotional implications.

Without values, people would have to re-evaluate everything about any reasonably complex situation to predict both the practical and emotional effects on oneself. The amount of cognitive and emotional work in this would be overwhelming. Values organize important information in a sort of shorthand form that allows for integrated and self-consistent decision making to occur quickly in real time.

While the ability to have values is very useful in terms of forming a strong and consistent view of the world, values do have certain shortcomings. First, values are emotional, as well as cognitive, constructs. A person's emotional need to view things in a certain way may make it difficult to re-arrange his/her values - even when it may be more adaptive to do so.

When new information comes along that suggests the need to re-arrange one's values, it may be experienced as a burden for the person who must do the re-arranging. A great deal of resistance in treatment can come from this difficulty in re-arranging values (for clinicians, as well as for clients!). People can view the necessity to re-arrange values as very threatening.

This can be a source of considerable conflict. Because values are important in terms of having a consistent sense of yourself in an evolving world, it is easy to feel personally threatened when your values are challenged. A challenge to your values may be created by someone trying to force you to go along with their values, or it can be created simply by people having different values. Because they have different values, it can be seen as a refusal to acknowledge that your values are the right ones. 

People do not like to have their values threatened, and will therefore look for ways to reinforce and strengthen their values. They do this by encouraging others to adopt their values, by forming alliances with others who share their values, and by pressuring and challenging other people who do not share their values, sometimes resorting to force or violence. 

The real challenge for the clinician as a leader is in understanding and not being unduly influenced by the pressure that comes from the values of each of the parties with interests in shaping the mission - the client, the clinician, the profession, the broader society at large.

The values of each of these parties will provide inputs to the clinician about what the mission "should" be. At least some of these inputs may be somewhat antithetical to the fulfillment of the right mission. They will serve other agendas besides the long-term well-being of the client seeking help through treatment. The clinician's difficult job is to identify these pressures, and not allow them to undermine the correct work of the right mission.

This is because the primary mission of the treatment is to serve the well-being of the client who is seeking treatment. Other missions that are oriented towards forwarding the values of any of the other parties in this situation should be considered secondary.

This is important, because decisions that are made in the course of treatment are often made under considerable pressure from other parties to forward other agendas or promote other values in ways that may be more concerned with furthering political agendas than to fulfilling the mission that has been defined in the treatment setting.

This places a very heavy burden upon the clinician in his/her role as an expert. While trying to forward the well-being of the client in the clinical work, there will also be a relatively constant need to investigate and evaluate a wide variety of value elements thrust into the clinical relationship.

As he/she tries to bring the best information forward about techniques and approaches to further the well-being of the client, the expert clinician must work to keep this information free from cultural or value bias put forth - sometimes with great pressure - by parties who are threatened by interpretations of the information that do not conform to their agendas or values. 

There are many areas in clinical treatment in which these complex values questions play out in difficult ways. The treatment of issues related to sexual identity and sexual orientation is an arena that cannot be discussed without generating conflict from groups with competing and conflicting value positions that generate enormous political energy.

Questions of the role of spirituality in clinical treatment are given meaning and power by values issues. The rights of clients to choose the time of their own death raises questions that test the values of the society as a whole.

Information and ideas that are involved in shaping the course of clinical treatment play out against this highly charged backdrop - in which various groups apply pressure to promote their perceptions and values.

The clinician's leadership position necessarily puts him/her at the vortex of this particular storm.  He/she is placed in the position of needing to sort through all of the facts and all of the values - factoring in whatever value biases might be present - to see if he/she can find the right mission.

At the same time, the clinician must also sort out his/her own value biases, and take great care not to impose those value biases on clients who may come from a different cultural context. The clinician's job, after all, is to improve the client's well-being as much as possible within the client's own cultural context and value system. This idea is contained within the concept of client autonomy. 

Yet there are also situations in which the problems for which the client is seeking help are - to some extent - caused by their values. Sometimes it is the cultural elements that create the problems from which the client suffers. In such instances, to respect the values means to be unable to help the client. 

This aspect of ethical decision making may appear to be quite abstract or esoteric. It is, however, very real, and at the heart of some of the thorniest ethical dilemmas. The clinician, in his/her leadership role, is almost asked to play God in picking and choosing which value elements to forward and which to submerge.

There are ways to approach these complex decisions, if not to fully resolve them. In the course of this training on ethical decision making, which is designed to explore issues at the intermediate level, we will not have the opportunity to fully develop a system of resolving some of the complex value conflicts that arise in ethical decision making. 

That will be a subject for a later training, covering complex value conflict, examining these difficult issues at the most advanced level of ethical decision making.

For now, our goal will be more limited. We will want to make the more advanced clinician fully aware of this process when it is occurring. This is important, because many values issues contain subtle value biases that are at least partially obscured from view.

This is because the values issues are often embedded in value systems that are so familiar and comfortable for the clinician that they are almost invisible. In reviewing a couple of our ethical scenarios, we will try to shake some of the more difficult values biases free from their embedded place to allow the trainee to see them more clearly. In so doing, we may raise more questions than we answer. This, however, is an important step in a difficult process. 

Where possible, we will also try to put in place some pieces of a framework for a system of approaching more complex ethical situations. This will create some preparation for the later, more advanced training that will examine complex situations of values conflict. 

As a starting point for this, let's ask a trick question. What is the best way for an experienced and skilled clinician to treat an extraordinarily difficult and demanding client?

In order to protect the client's interests, the best way to proceed is for the clinician to put his/her heart and soul into providing the best help possible, and hope that the efforts will be sufficient to allow the client to grow and improve. In order to protect the clinician's interests, the best way to proceed is to transfer the client to some other unlucky clinician and let him/her deal with the hassle of treating the client. 

In each situation in which there are complicated ethical issues at stake, there will be interests held by parties connected to that situation. Some of these interests may be very transparent and easy to see, other interests may be more hidden and difficult to see.

The first task of the clinician in this complex process will be to see through the veil of values to the deeper issues below and behind. When the clinician can uncover the interests held by the various parties, it will then be easier to begin to examine who has the more compelling interests at stake in the situation.

This uncovering of the veils of values in a variety of extremely difficult ethical scenarios will be at the heart of the most advanced level of ethical decision making. Fortunately for the trainee of this course, we will not proceed to this here. Instead, we will bring this section to an end and move forward to our analysis of the scenarios.

At this point in the training, the trainee should be able to answer the following questions:

What is the fundamental nature of values and why are they so important to an understanding of ethical decision making? 

What is the primary mission of treatment and why is this so important to the process of ethical decision making?

How do values and the advancement of knowledge come into conflict in the ethical decision making process? How are these two items connected to the leadership principle of humility?