ETH8585 - SECTION 6: LEADERSHIP DEMANDS IN ETHICAL DECISION MAKING
The position of a mental health clinician is one that requires its practitioners to take a leadership position and operate from a position of authority. The mental health clinician who does not will inevitably run into ethical problems. There are two connected reasons why this is so.
1) The position of mental health clinician is one in which expertise is expected. From this expertise, certain kinds of authority are generated, in ways that we will look at later in this training; 2) The nature of the work is such that only experts should do it, and can do it ethically. This fact is actually written into the code of ethics for each mental health clinician in sections that are concerned with the idea of operating within one's area of competence.
As an expert, you will find yourself in a position that tests your understanding of ethical decision making almost every day. Because of the complexity of the work, a factor that is created by the very nature of the work itself, you will be presented with situations whose ethical implications are not easily covered by the codes of ethics that each of the several mental health professions puts forth as guidelines.
The codes of ethics we see and read are fixed and general. The situations mental health clinicians deal with are specific and organic in nature – they change, they mutate, they respond to interventions and become different before one's eyes.
Codes of ethics state as much. The social work code of ethics, for instance, states, “The code offers a set of values, principles, and standards to guide decision making and conduct when ethical issues arise. It does not provide a set of rules that prescribe how social workers should act in all situations.”
It goes on in a later section, "Reasonable differences of opinion can and do exist among social workers with respect to the ways in which values, ethical principles, and ethical standards should be rank ordered when they conflict. Ethical decision making in a given situation must apply the informed judgment of the individual social worker. . . "
As we shall see, when really difficult ethical situations arise, one discovers the limitations of a professional code. One must rely on a deeper understanding of the nature of ethical decision making, as well as a willingness to draw from the wisdom of your colleagues.
In plain English, this means that the mental health clinician is expected to have a degree of individual responsibility for making complex ethical decisions. This is the difficult responsibility of a leader. People expect experts to have the capacity to make good decisions, even when the ground is difficult and complex.
In entering this section of the training program, we need to begin with a definition. What is leadership?
Leadership is the ability of persons in positions of authority and responsibility to direct a defined system (consisting of people, values and culture, boundaries, and other systemic elements) towards fulfilling the vision, goals and purposes that have been defined as essential, important and right.
This ability to direct others towards fulfilling the right visions, goals and missions is at the heart of the work done by mental health clinicians. At its core, our mission is to improve the mental health and overall well-being of the people who come to see us.
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 are 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 this admirable mission. This is leadership.
There are some complications to being a good and ethical leader in this field. The first complication is that we must actually be experts. In other words, we must really have the skills to pull off the fulfillment of this mission. These include leadership characteristics, some of which are shown below.
- The ability to create buy-in to the mission
- The ability to effectively communicate and champion the vision and core values of the treatment process
- The ability to build motivation for the treatment and change process
- The ability to shape the therapeutic culture in which the changes are to occur
This also includes some skills that work in the clinical arena, including those clinical skills that are useful for people in all leadership positions. These include:
- The ability to manage oneself and one's emotions
- The ability to project integrity, create credibility and build trust
- The ability to project a clear and coherent sense of meaning about what is being done and why it is being done
- The ability to manage problems and work towards positive change
- The ability to resolve conflict and negotiate differences
- The ability to transfer tools and skills to the other parties involved in the change process
This requirement to actually be an expert is the reason why a high level of education, many hours of experience, and many hours of continuing education are required for practitioners in this field.
There is, however, another requirement that is, in many ways, even more important for the purposes of this training.
You must have leaders who are pursuing the right mission.
This is the concept that will pull together some of the complexities of the topic we have been studying to this point. The process of defining what is the "right" mission is one that takes place in a complex system. In this complex system, many parties have a stake in the outcomes of what the "right" mission is, and therefore are going to try to advocate for the mission to work towards their interests.
Let's look at this in diagrammatic form below. Explanation will be provided on the pages that follow.
Interests of the Client Interests of the Clinician
Interests of the Broader Society (Legal/Cultural/Socio-Political)
Interests of the Profession
The client has the most personal interest in deciding what the "right" mission is. The client also has some very important rights in determining what the mission will be. These rights are acknowledged and formalized in the ethical codes in sections that discuss client autonomy.
The client wants the mission to include things that improve his/her life in ways that are in keeping with his/her values, standards, perceptions and beliefs, not ours. If the clinician is very satisfied with changes that the client makes in his/her life, but the client is unhappy with those same changes, then the mission - from the client's perspective - has not been accomplished.
On the other hand, clients, at times, may not have a clear sense of what changes will ultimately prove to be the most productive over the long course of time. Children, for instance, often lack the life experience to understand how long-term improvements require short-term sacrifices. Adult clients, of course, may have similar problems with this understanding.
This is where the clinician's leadership responsibilities enter into this dynamic process of defining the mission. From a position of knowledge, experience and wisdom, the clinician can direct the mission towards the goals that will best serve the needs of the client - even when the client doesn't fully see or understand the importance of the goals.
Part of the clinician's responsibility is to raise the client's level of awareness in this area, so that the client's understanding becomes aligned with the greater knowledge and wisdom of the clinician. This, of course, presupposes that the clinician actually possesses that greater knowledge and wisdom.
Where the client is unable to grasp this higher level of awareness, the clinician may utilize his/her professional authority to advocate for a more therapeutic mission, even where that mission deviates from a client's short-term (or short-sighted) interests. A failure to invoke this professional authority when it is appropriate to do so will generally represent an ethical lapse on the part of the clinician.
In other words, the clinician should not simply defer to client autonomy, and avoid the difficult leadership work of shaping the right mission. The ethical demands related to professional authority are quite clear in this area.
This understanding, of course, does require that the clinician be right when he/she outlines what the mission should be. This requires a very high level of awareness of the profession, as well as an awareness of oneself, and one's own blind spots and biases. As mentioned previously, it also requires a willingness to be humble and accept one's limitations in this area. Seeking the professional advice of one's colleagues is a useful way to respond to these limitations.
Very importantly, it requires that the clinician be very cautious when values are addressed, and take care not to impose his/her values upon the client. Values are not the "right" values simply because they are the ones held by the clinician.
This is particularly important when cultural and religious content is raised in the course of the clinical work. No matter how deeply the clinician feels that his/her values are right in terms of cultural or religious beliefs, the client must be approached from the context of the client's values. Otherwise, the clinician becomes involved in proselytizing, not therapy. This departs from the primary mission of the mental health professions.
All of the mental health professions assist in the process of defining the correct mission to be followed. They do this by describing guidelines and standards to follow in many of the most important areas. They also describe in some detail approved approaches towards fulfilling this mission.
In this way, the mental health professions seek to provide both support and limits to their practitioners. They support by showing what aspects of the mission are in keeping with professional standards.
They limit by explaining what behaviors are not allowed, and by confronting practitioners who engage in those proscribed behaviors, and applying consequences to them.
This limit setting capacity works positively to encourage and enforce a measure of humility for those practitioners who exceed the limits of their professional authority. Ultimately, it also creates a situation in which the responsibility for decision making in difficult ethical situations is at least partially shared by the whole profession.
The profession, through its official representative bodies (NASW, LPCA, AAMFT, APA), also acts as an intermediary between the individual practitioner and the society at large.
As advocates for the professions and the people who practice them, these representative bodies try to help shape law so it better corresponds with the realities of the profession. Furthermore, they try to stay abreast of changes in the legal, ethical, and moral climate, shape modifications in professional standards, and communicate the changes in thinking to the practitioners.
The definition of the mission will be created in the interaction of all these involved parties, each of whom will have a variety of complicated interests. We have already described one of the complications. The client has interests that may involve an orientation towards short-term needs and instant gratification. These can conflict with long-terms interests, such as growth and emotional development, which require delayed gratification.
There are other areas in which there are conflicts of interest. To do justice to this study of leadership, we must look at two in particular.
The representative bodies for each profession involving mental health have several tasks to accomplish, only some of which are oriented towards taking care of the mission on behalf of the client.
In addition to looking after the well-being of the clients being served, the representative bodies also look out for the well-being of the practitioners who are at work, and the well-being of the profession itself. This means that these representative bodies will sometimes take positions that seem to work contrary to the well-being of clients being served.
An example of this is the advocacy work for higher fees for practitioners. The net effect of higher fees for clinicians is a better standard of living for the clinicians. A secondary effect of this position, however, is that counseling ends up being more expensive for, and less available to, clients.
This is not altogether an act of selfishness on the part of each profession. In order to bring highly qualified people into the field of mental health, and keep them engaged in the difficult work involved, there must be a sufficient level of reward for the practitioners. Otherwise, practitioners will ultimately choose to take their talents to other fields, reducing the quality of service available to clients.
This balancing principle also works at the level of the individual clinician, who is always attempting to resolve this conflict at a personal level. This is even more important for understanding leadership at a very deep level.
Each mental health clinician, in each situation at work, struggles to find some workable balance between the demands of taking care of a very demanding mission, and taking care of one's own interests and purposes.
If you stray too far from looking out for one's own personal interests, you begin to have "boundary issues" or a problem with being "co-dependent" with the profession. On the other hand, if you stray too far from looking out for the goals and demands of the profession, you start to exploit the client for your own needs, thereby forfeiting your professional authority and incurring ethical problems.
This balance has a very central position in this complicated drama of defining the mission. The clinician's personal interests - his/her personal needs, goals, and especially values - are going to be in play as part of the balance that is being sought at each point in time.
Any leader who takes seriously the responsibilities involved in shaping the "right" mission will struggle with the implications of this understanding. Is the mission being undertaken to protect the well-being of the client, or is it being undertaken to take care of the self-centered interests of the clinician?
Am I, as a mental health clinician directing a client towards a mission based upon my need to have others affirm my values and perceptions, or based upon a clear assessment that the values and perceptions shaping my actions and choices will be more constructive for them?
The level of self-awareness required to answer that question is very high. Those clinicians who are familiar with 12-step programs will be aware of the concept of a "fearless moral inventory". Each clinician who wishes to take on the responsibilities of being a true leader is going to be faced with engaging in just such a process on a continuous and ongoing basis.
This aspect of leadership is one of the most difficult and demanding aspects of professional practice. It is also absolutely essential to ethical practice. The willingness to commit oneself to a soul wrenching search for the right mission - with absolute clarity about one's own selfish purposes and motives - has profound implications for the level of professional authority that is generated in the clinical work.
This is important. Professional authority is what persuades clients to follow the lead of the mental health clinician. It determines the level of trust that is generated. And the directive and persuasive power of professional authority comes from the client believing that the clinician knows the right mission and follows it with commitment and skill.
If the mission is the right one, it carries behind it the backing of the entire profession. This encourages the client to have trust in such a mission, and to have trust in the leader.
A clinician whose primary purpose is concerned with taking care of his/her personal needs and interests will not possess this professional authority. It must be the mission, not the personal beliefs, values, ideas, or goals that guide the direction of the mission. This is the most important and compelling core issue in any understanding of real leadership.
Because professional authority emanates from the mission, it will be deeply impersonal. It will have no personal feelings directing it. It will not become angry at clients for any of their actions. It will not become frustrated or even frightened.
Instead, professional authority will always be impassive and purposeful, engaged in a conscious and constant search for the most successful actions, approaches and solutions to reach the optimal fulfillment of the mission: furthering the well-being of the client.
Professional authority is also impersonal in the sense that it is not to be directed towards protecting or enhancing in any way the personal feelings or well-being of the person using it. In other words, this kind of authority is not to be used in the service of - in layman's terms - the clinician's "ego trip".
In fact, the use of professional authority makes specific demands upon the clinician to remain in control of his/her personal feelings, wants, needs, drives, and values, and to make those factors secondary to the pursuit of the mission. This includes the obligation to control countertransference, as we mentioned earlier in this training.
Professional authority, in other words, imposes restrictions and burdens on the mental health clinician in return for the backing of the profession, and the trust of the client.
Some of the worst ethical breaches occur when clinicians exploit their professional authority for personal purposes. Sexual, financial or other exploitation of clients makes professional authority a tool for the personal gain of the clinician, instead of a tool for the well-being of the client. This is the worst kind of violation of the ideals of leadership.
Other kinds of problems with the ethical obligations of leadership are less active in nature. As a leader, the mental health clinician is expected to withstand pressures - directed at the clinician from many fronts - that are designed to sway the clinician from pursuing the right mission.
This is another aspect of the personal-professional balance that warrants discussion. However, this whole arena is complicated enough that we will devote an entire section to it later in this training, when we look at advanced issues in leadership. We will therefore delay further discussion of this issue for now.
While the focus of this training is upon ethical issues, and not clinical issues, the understandings we are presenting about striking the balance between the personal and the professional are also deeply connected to the clinical aspects of practice. Leadership, authority, and a commitment to ethical practice are vital components at the foundation of a successful therapeutic relationship.
The therapeutic relationship, which works at a very deep level to engage the client in the process of change, is the great constant factor in successful treatment. Research studies on the efficacy of psychotherapy have consistently demonstrated that it is the relationship itself which is most consistently responsible for positive outcomes in treatment.
There are many different approaches to treatment, involving many different skills for creating change, but none has been shown to be as important in determining outcomes as the willingness to create a successful therapeutic relationship. It is for this reason that so much care must be put into establishing the right kind of therapeutic relationship.