Multiconstruct

As a long time social services provider, clinical manager/trainer and administrator I have been doing my own trainings to maintain my Co-occurring Disorders certification for a long time. I have a strong interest in philosophy and have spent some time with a lot of primary texts.

The ethics trainings I have attended have not been very informative or helpful and have been focused a lot more on CYA (Cover Your Ass) and agency policies than actual training on ethics or even morals. Discussing scenarios is not as engaging as the real ethical scenarios that come up on almost a daily basis doing the work and managing those delivering services.

Since COVID raised it’s bumpy little head I have not been at an agency that has staff that need 6 hours of ethics training or wanted to gather up folks who need the training as a consultant. Last time I did self study and read and reflected on Stoic ethics. I had planned to work my way through some of Epictetus’s Discourses but I left it at home while I’m away from the office getting my van repaired.

I thought instead I would distill some of my ethical thinking in an extended blog post. My post career plans are to write a book “A Practical Guide on Building a Better World” distilling my lessons learned in social services, activism, politics, policy making and living an ethical life. A section on ethics will be a must.

My thinking on ethics is rooted in a big handful of thinkers, writers and doers. In no particular order I want to acknowledge Lou Marinoff author of “Plato Not Prozac” whose chapter on ethics I found transformative and made me a Multi-Ethic Relativist. I was fortunate enough to work with another PhD philosopher Brian Bowles who taught me the difference between boundary crossings and boundary violations.

My brother John Trapp has been an invaluable collaborator. He followed MLK to Gandhi to Tolstoy to the ancient Greeks. As a true Epicurean he nonetheless turned me on to the Stoics, most importantly my man Epictetus and the inimitable Marcus Aurelius. Of course I couldn’t leave ethics without acknowledging Jesus, primarily the Sermon on the Mount Jesus who launched me on a path with his simple admonition to “love your enemies and pray for those who persecute you”.

Since you’ve read this far, you deserve a photo. Here is the aforementioned John Trapp in front of Turkey Creek on last week’s hike.

The first question to ask is why ethics? With a myriad of ongoing training needs why is ethics the only one required by name? The reason ethics is required is so that professionals don’t have sex with their clients. It is perennially the most common reason professionals lose their license or certification. I’ve seen it again and again throughout my career. To say it plain, never have sex with a client.

When we elicit feelings in clients we call it transference. Freud identified it as the driver of the therapeutic change process. Counseling, if you do it right is almost all listening with total attention. What is sexier than that? But it’s not real. As a helping professional you are not presenting your unadulterated authentic self but you are being paid to provide a service which involves activating the best part of yourself to help another primarily through supportive listening and empathy. Your client is not in love with you. They are in love with an illusion.

When clients elicit feelings in us that is called countertransference. It is normal and should be expected and needs to be managed. Clients will stir up all kinds of feelings in us from frustration, anger, sympathy, admiration and even love. No feeling is wrong, only actions based on those feelings. Having good supervision or peer support is essential to navigate the tricky waters of countertransference.

Now that the most essential point is made we can move on to defining our terms. Ethics is a system of thought that determines how to make moral judgements. Ethics is the system and morals are what we do. The powers that be should really mandate morals training instead of ethics training. As clinicians, supervisors, administrators and policy makers and even just as humans we are constantly using moral reasoning to navigate ethical dilemmas.

One of my favorite John Trapp quotes is “Most ethical dilemmas are choosing between the right thing and the easy thing”. This point helps us to make the distinction between justification of our choices and actions and rationalizations of our choices and actions. We all have a strong bias for the path of least resistance. Lou Marinoff points out the root of justification is in justice. That is why we need to have intelligible ethical systems. Lost people wander downhill.

There are lots of ethical systems and they all have some value and they all have weaknesses, blindspots and contradictions. Lou Marinoff recommends using multiple systems for moral reasoning. Some fit better in some situations and sometimes looking at issues from multiple perspectives. He calls this approach Multiethical Relativism. Let’s look at some systems and what they offer.

Most folks get their ethical system from their religious background. That is fine and works for most people most of the time. The golden rule appears with slight variation in a large number of religious traditions.

In Buddhism they identify a concept called Ahimsa which means do no harm. It’s the first part of the Socratic Oath. As I learned from Brian Bowles both the left and the right hold a do no harm ethical basis, it’s truly a universal ethical principle. Where the right and the left diverge is the right holds a purity ethic as well. From borders, language and culture; to defined gender roles, and a respect for “life” folks in the right sometimes see the purity ideal trumping the limiting harm ethos.

Ahimsa is a great foundational ethical principle. There are other systems. Utilitarianism holds the most good for the most people. It has some moral value though it can easily be taken to perverse extremes with simple thought experiments. Here’s a nice comic illustrating it’s downside. https://existentialcomics.com/comic/494

Utilitarianism does have some good practical applications especially in group living situations. Sometimes the ethical choice is not in a particular client’s best interest. For the good of the group, the integrity of the program or for the safety of other participants and staff it can be ethical to discharge someone for example even if it’s not best for them.

When I was a young clinician I always gave my best effort for the person in the room and didn’t hold back. I was proud when I had successful outcomes in difficult cases and was not afraid to go the extra mile. I also didn’t pace myself well and would burn out. I saved my ducats though and so I would resign with notice and go backpacking or hitchhiking around the country until I healed up a bit and then throw myself back into the grind. Had I not been in a place to do that it would have been ethical to do a little less, better project my energy and personal well being and stuck it out for the long haul.

Another example is thinking about the clients you are going to serve in the future. I remember in my first social work job I was working with a sweet little old grandma who had her 2 grandkids (a boy and a girl) placed with her in a dilapidated one bedroom apartment. She had moved into the living room but Protective Services had issues with a bit and a girl sharing a room.

I worked the local housing authority to get them fast tracked and vouched for her without completing my due diligence. Turned out Gramma had a felony for operating drug house. Not only did I not get her in public housing I never got anyone in public housing ever again. On a positive note I had helped clean and paint the apartment did some other minor repairs and ran a curtain across the bedroom as a Plan B and it passed inspection and she kept the kids.

Even more than utilitarianism I find value in virtue ethics. As a student of sociology I learned about roles, status, and master status, the role that singularly defines us. Most women take their master status from relationships, wife and/or mother are common. Most men from their employment. I have never wanted to be defined by job or career or relationship and chose my master status as, a good person. So I naturally turned to virtue ethics that hold that virtue is the only good.

When faced with situations that challenge our equanimity we need only ask which virtue do I need to call on. When you can say, “thank goodness I ran into that really annoying person because it gave me the opportunity to practice patience” nothing bad can ever happen to you.

Virtue ethics requires us to define what is good. Fortunately Marcus Aurelius has done that for us. I’m going to share a larger meditation because it is a good one.

“Begin the morning by saying to yourself, I shall meet with the busybody, the ungrateful, arrogant, deceitful, envious, unsocial. All these things happen to them by reason of their ignorance of what is good and evil. But I, who have seen the nature of the good that it is beautiful, and of the bad that it is ugly…”

For Marcus Good, Truth and Beauty are all synonyms. As a policy maker my moral framework of decision making was whenever possible we should move forward in the most just, beautiful, sustainable and equitable way. When that option is not on the table, and the utopian ideal rarely is, I would then factor all the possible options including doing nothing and support whichever was the least terrible and that set the stage for better choices in the future. Time for another picture.

Few clinicians and direct service workers are philosophers. We just need to have a few perspectives down in order to have highly functional moral reasoning. The work gets most interesting and the most dangerous not when we are choosing between the right thing and the easy thing, that is simple even if hard. Moral reasoning is most fruitful when our ethical principles are in conflict. When there are no easy choices but carefully balancing competing interests and moral precepts.

It’s less important to definitely answer the great questions, like is morality absolute or is it relative to the culture and times that you live in. In the helping professions we are not engaged in an intellectual exercise but making choices that can literally be life and death.

One important ethical consideration is boundary crossings versus boundary violations. Boundary violations are moral failings that are always wrong no matter what the circumstances. Exploiting clients financially or sexually or using them to meet your own emotional needs are all examples of boundary violations.

Boundary crossings are different. They are a step across clearly delineated lines of separation between staff and people being served. It might be socializing, accepting a gift, taking someone to a holiday gathering or a support group meeting which you might attend anyway. Going to funerals or weddings or other celebrations. The myriads of things we do with our friends and family that we don’t do with our clients.

Boundaries are an important part of professional life as dual relationships are frought with peril and ambiguity. A good boundary crossing is done for a therapeutic reason and is discussed with your supervisor or peer accountability partner. Having that second set of eyes is an important safeguard.

Here is an example in case I’m not being clear. I had a long-term counseling relationship with a fellow I’ll call Mark. Mark was old school,of Irish descent, and a larger than life character. He made a lot of breakthroughs in our work together after struggling with drugs and alcohol for a long time. As our work progressed he started mentioning and then insisting that we share a meal together. For Mark us sharing a meal was an acknowledgement of our equality and a recognition of our common humanity. So towards the end of our work I checked in with a peer manager  and took Mark to lunch. It was an important thing for him and helped him be OK with moving from our formal supports to relying on the informal supports of the recovery community.

After he was out of services he connected with me on social media. My policy is not to solicit online relationships with former clients but to accept them if I’m comfortable with it after they have completed services with me. Mark stayed in touch and I saw him continue to do well. Many years later he invited me to lunch at the restaurant he worked at. I was serving on City Council at the time and he wanted to show off his important friend and show me that he had made it.

After giving Mark a ride or two to the store I briefly became his paid caregiver when he developed a terminal illness. Throughout our post therapeutic relationship I was cognizant that the therapeutic relationship goes on forever but nonetheless a more reciprocal friendship type relationship developed. To do nothing else would have been to label Mark a second class citizen forever.

When we conflate boundary violations with boundary crossings we close the door to activities that can enhance the therapeutic relationship and add meaning and depth to our own lives as well as a greater sense of community. Many agencies and supervisors preach so hard against dual relationships out of an excess of caution and a lack of recognition of the full humanity of those served.

I developed a diagram to make this point. We have two axes, one is bond intensity (the strength of the staff-client relationship) and the other is bond integrity (the morality of the staff-client relationship). With high bond strength and a high moral compass you have engagement. Engagement comes from mechanical engineering, you engage a clutch for example. Even though the gears are separate they interlock and movement happens.

With a high bond intensity without equally high integrity we get enmeshment. The clinicians feelings are wrapped up in the client, there is an unhealthy connection that leads to poor outcomes and increased risk to the client and/or the agency. It is fear of enmeshment that drives most ethics trainings and policy manuals which unilaterally ban innocuous or even beneficial boundary crossings.

With high bond integrity but low bond strength we get a lot safer for staff and agencies but at a cost to efficacy and really helping people. I call this Arms Length Professionalism. Some people are going to get better but they probably would have gotten better without your help as well. With neither bond integrity or bond intensity you most likely get case failure. People quit showing up or get discharged from the program. Here is a poorly drawn chart to illustrate the 4 quadrants:

My final advice is engaging and acting your moral reasoning is also based on where you are in your career. If you are new in the helping professions stick close to agency policies and procedures and written ethical guidelines. Make your mistakes in the “Arms Length Professionalism” quadrant. Ask questions, seek advice.

As you grow in the work you gain greater ability to bring nuance and flexibility to issues. To seeing beyond the immediate to long-term issues and more effective ways to successfully engage clients to create a climate of better outcomes while avoiding the pitfalls of enmeshment.

There are bright lines though that should never be crossed regardless of how long you have been in the field. I worked on a psychiatric unit right after I got my BS degree. There was a 16 y/o girl who had been sexually assaulted who did not want to visit her father. She escalated and the charge nurse told me to take her to the “quiet room”.

I deescalated the situation and she agreed to stay calm. The charge nurse insisted, I resisted and she threatened to write me up for insubordination. I drug that poor girl to the “quiet room” and still feel the shame 30+ years later. I should have stood my ground and let the chips fall where they lay.

Your moral reasoning and your identity as a good person are some of the most sacred things you have. Protect them, grow them, teach them and let them carry you into a place of peace and efficacy.