MORAL REASON ESSAYS 1 Moral Reasoning: A Three Part Essay Gail D. Moskowitz Virginia Commonwealth University MORAL REASON ESSAYS 2 I often say that my job as a Clinical Social Worker in the role of psychotherapist is to sit with my clients in the depth of their pain without harsh judgment or the mongering of shame and criticism so that they can learn to sit with themselves and hear their problems anew. I am successful at this in a seamless way. I understand humanity and have long since given up the idea that there is much new under the sun when it comes to human behavior. Many of my clients act in ways that society would not approve of. While these individuals are in treatment and often also in twelve step recovery programs, it is not uncommon for a subset of those who I see to continue acting impulsively. Much of the behavior that clients display is self-destructive; they hurt themselves and those with who they are in relationships. Some of my clients’ behaviors are illegal (such as going to a prostitute) but not on the list of behaviors that I need to report. I have absolutely no difficulties continuing my work in the midst of this kind of client struggle even when a client is not making much progress. There have been times that I felt saddened or conflicted knowing that the spouse of a client was in the dark about awful, destructive, possibly dangerous acting out behavior. However, even this kind of conflict is surmountable when the only one in treatment is the acting out partner. It is when I am treating both partners and I come to know extremely disconcerting behavior that I have had difficulty with cognitive dissonance. It is precisely this kind of moral dilemma that I proffer for the purpose of this essay. I shall summarize the case and the moral dilemma it posed. The names will be changed and the facts altered for the sake of confidentiality. I will then analyze the conflict by identifying the deeply held moral values by which I live and practice my profession. The essay will then explicate that even as an individual who is crystal clear about the moral underpinnings from which I navigate life’s decisions, those values can come into conflict with one another and with the happenstance of life. By focusing on the value’s conflict generated from the moral dilemma described I will be able to offer an expanded view of possible solutions and what the effect or conflict each solution might engender. In order to take an even more rigorous look at the principles of my choices, the paper will take the reader through another evaluation of the material using the four framework approach of ethical decision making articulated by Starret (1991). The Dilemma In January of 2011 I began seeing Jacob, who was motivated to seek treatment after his wife, Dell, discovered that Jacob was having an affair with a friend who was also married. Jacob had been caught previously by Dell viewing pornography and engaging in other inappropriate behavior but the affair was her breaking point. Jacob moved out of the family home, broke off all contact with the affair partner and became active in a twelve step program for Sexual Addiction. Dell stated that Jacob could come home if he agreed to go to individual and couples’ therapy. Their couples’ counselor referred Jacob to me. I began working with Jacob on a weekly basis. The difficulties in his life were deeply rooted. The most significant of which was his having been pulled into a sex-game by a male babysitter when Jacob was nine years old after which the babysitter manipulated Jacob into pulling his younger brother in as well. Jacob worked in therapy with me in an effort to manage the panoply of sexual acting out behaviors that included men and women and long term and short lived contacts. He also struggled with internet pornography and anonymous hook-ups. Jacob was in treatment with me for one year and was getting better every week. He was taking responsibility for his actions and how they affected his loved ones. He became a more involved father and faithfully attended a 12 MORAL REASON ESSAYS 3 step program when he suddenly dropped out of treatment. One year later Jacob returned. He was involved in another long term affair. He was back to blaming everyone else for his problems. After several unproductive months of treatment, his refusal to return to a 12 step program or to enter an extended stay rehab we discussed the pain of the duality of his day to day life. We then collectively decided to ask Dell to enter into joint therapy with Jacob so he could use the time to get honest with her. She readily agreed. We began the first session confirming that the ultimate goal of the couple’s work was for Jacob to speak honestly to Dell. We agreed she deserved to know. She assured him she was in it for the long haul if they could reconnect and find a new way to be in a real relationship. He asked if we could spend some time just getting comfortable with Dell as a part of his sessions. This also was agreed to. Jacob and Dell came to see me nine times over a period of four months. Dell believed that Jacob was clean and sober. She believed that much of what he wanted to reveal was in the past. They had not at this time seen their couples’ counselor for more than a year. Jacob immediately began to use the time in our joint sessions to highlight the marital issues between himself and Dell. Dell was always willing to take her share of the blame for the day to day discord. Jacob wanted to talk about their lack of passionate love making. Dell was earnest in her attempt to understand and address their collective issues. Individually Jacob indicated he was not ready to disclose the acting out in which he was engaged. In joint sessions Jacob would become angry or he would pull away and shut down every time Dell would attempt to get emotionally vulnerable with him. I knew that Jacob was continuing to act out sexually and I began to feel ethically and morally confused about what to do next! I struggled with the knowledge that Dell was earnestly in couples’ counseling with Jacob who was not willing to be honest with himself or his wife. He was doing morally unspeakable things. His behavior was putting his wife at risk physically and financially. I now also had a therapeutic relationship with Dell as well and I began to feel that I was in collusion with Jacob while we spent time working on mundane issues of married life. I knew I could not disclose Jacob’s behavior and I seemed to be unable to encourage Jacob to do so. I even met with Jacob individually to discuss his reticence at which time he stated he was no longer sure he wanted to be honest and if he did he was not sure how far he wanted to go. I did not want to abandon either Jacob or Dell but I sincerely wondered if I needed to end my joint work with them. I was at a crossroad; what would best serve my clients’ individual needs without sacrificing my ethical responsibility for confidentiality or sound mental health care? Analysis of Dilemma The Values in Conflict In my line of business confidentiality must head and always head the list of values from which I practice. It is fundamental to the therapeutic alliance. It almost always sets the stage for clients to be honest, which is the second most important value on my list. Confidentiality is needed to establish an environment of safety which in turn will promote honesty and hope for the MORAL REASON ESSAYS 4 client to sort out problems. Clients, especially those who suffer from addiction are routinely “bad reporters.” Again, this is not a dilemma for me. I believe deeply that we are all personally responsible for our lives and the decisions made. I hope that my clients will become more capable of honesty as they get less afraid of letting go of their current maladaptive modes of coping. Yet, when I am working with a couple I am accountable to both clients. Generally when I begin work with a couple I am upfront with them about secrets and how together we will handle the information. If I am working individually with a client who has a life of many hidden stories, even if I see their spouse collaterally during a few sessions, I am not stricken with any discomfort. The dilemma described was a unique; I allowed the situation to sneak up on me. This again brings me discomfort with another value I hold dear in my practice, working for continued competency. This leads me to the most explosive part of the value’s conflict. Honesty is fundamental to both healing from addictive behavior and making and maintaining emotional and physical intimacy in a couple’s relationship. I knew Jacob was withholding information and therefore lying. I could see Dell’s life plan was being based on a house of cards and I had tremendous empathy for her. I also felt Jacob’s pain and fear about disclosure. Is it just Values or something Deeper? Central to solving any problem is clarity about all aspects of the dilemma. So if honesty is an important value then I had to begin with self-examination. While I have trained myself to steadfastly accept that other people’s problems are their own, I was beginning to believe that I had inadvertently conspired with Jacob and I was upset with myself. I also had to admit that I was disappointed with Jacob; I thought he was ready to do the hard work to make change in his relationships and his life. Two other values etched in my moral code are sexual and financial MORAL REASON ESSAYS 5 fidelity. While he had broken off the affair I began to realize that he was now withholding his acting out behaviors from me as well because he knew I was also in a therapeutic relationship with Dell. I clearly was not feeling competent. The greatest conflict planted itself to grow in between my most important moral values. I was legally, ethically and interpersonally bound to keep Jacob’s behavior confidential and by doing so I was participating in lying to Dell. These lies kept her from having the information she deserved in order to develop a path for her future. In order for me to make good choices about helping Jacob and Dell, getting personally honest was a very important first step and managing my own emotional response was the second. Looking at All the Options As previously stated I could not tell Dell the information that Jacob was now withholding. One possible option would be to state to Jacob and Dell that Jacob’s original thoughts about disclosing to Dell was causing him much difficulty and perhaps it would be best to end the couple’s work and if Dell wanted to I could refer her to another therapist. I feared that the effects of this would be that Dell would feel tossed-out as she had already made a therapeutic alliance with me. Jacob might also feel negatively about this disruption. He, after all, was taking the opportunity each week to talk about his frustration with Dell and making it emotionally difficult for Dell to do much of anything except accommodate. Another consideration was to ask Dell directly how she felt about Jacob avoiding the work he started out to do. I did not think that Jacob could handle this. In a subtle way I knew he would feel abandoned by me. I felt responsible to both of them. An additional possibility was to continue my work with the couple trying to minimize his aggression and help her to find her voice. If Dell encouraged more transparency and Jacob was unwilling to provide it then it was really her responsibility to decide how she wanted to proceed MORAL REASON ESSAYS 6 in her own life. If he believed that honesty was going to drive her away, even though she stated many times that it wouldn’t, then perhaps he would begin to see that withholding honesty would actually be the wedge between them. I wholeheartedly believe in forgiveness but I think it is difficult to forgive someone who does not acknowledge the wrong doing. I had been his support for so long and now it appeared that this work would be the undoing of their marriage and if Jacob perceived my divided loyalties it could very well unbalance his already tenuous mental health. I felt compassion for both. I could consider asking Jacob to meet with me individually again. I would help him articulate his current frustration and inability to follow through on his plan. I would also want to ask him how he intended to proceed. The difficulty in my meeting him and asking these questions would be that Dell was also my client and it seemed unfair to allow Jacob to have the driver’s seat. I knew that Jacob would not tolerate my meeting individually with Dell as well. Since fairness was another of my values solving this dilemma seemed to have an unending effect on my sense of moral justice. Therefore I knew that if I did not choose to change the status quo of work I was doing with Jacob and Dell, I would only be prolonging the problem and perhaps causing harm. A Choice to Make and to Live By After carefully weighing the options about how to continue with this couple I knew I had to be 100% honest with myself. My current work with this couple was no longer helping. My sense of obligation may have been misplaced as I began to work with Dell and knew what Jacob was withholding. I had to have a frank talk with myself, and consultation with my ongoing supervision group. Dell is married to Jacob who is a very broken man and I had to go back to my deeply held belief that she is responsible for her own life and her own decisions. I also had to admit to myself that in my hope of providing real and lasting change for this couple I allowed the MORAL REASON ESSAYS 7 joint sessions to linger way past the point at which it was therapeutic. Jacob’s behavior was devolving. He continued to put up an angry shield at any mention of his part of their difficulties. I knew he was regressing and I had made a mistake. My choice is to begin to explain and then discuss with Jacob and Dell that Jacob did not at this time have the psychological health to follow through on his proposed idea about disclosing to Dell. Further I will be honest about my own misjudgment. I will strongly encourage Dell to seek individual treatment and continue working in her own twelve step support group. I will invite Jacob to come back to work with me individually. I will allow them both to express their feelings to me and I will manage my own disappointments through the healthy mechanisms I have established in order to do the work of therapy. Moral Rule and Moral Judgment I am happy with this conclusion while it may not be easy to pick up the pieces. My moral rule is that I am responsible to model emotional honesty in my relationships with my loved ones and my clients. My moral judgment is that continuing to collude with Jacob’s lying was destructive. One Page Attachment Statement of dilemma: I was at a crossroad; what would best serve my clients’ individual needs without sacrificing my ethical responsibility for confidentiality or sound mental health care? A. 1. 2. 3. 4. List of values discussed in my paper: Confidentiality Honesty Safety Accountability-clearly if I am accountable to each I feel a deep sense of conflict as he acted as if he were going to be honest by he is withholding information. This makes him the most powerful and ultimately destructive person in the room. 5. Acting ethically-The NASW code of ethics and the Virginia Board of Social Work would consider it a serious breach of ethics for me to reveal confidential information even from one spouse to another. 6. Responsibility-Yet, I am 100% responsible to both. MORAL REASON ESSAYS 8 7. Secrets are destructive 8. Protecting the rights of others 9. Empathy 10. Self-respect 11. Work for continued competency 12. Relationships 13. Respect the rights of others 14. Compassion 15. Fairness 16. Sexual and financial fidelity 17. Forgiveness 18. Approval B. My moral rule: I am responsible to model emotional honesty in my relationships with my loved ones and my clients. C. My moral judgment: Continuing to collude with Jacob’s lying was destructive. Ethical Analysis Hopefully it can be said that each day in everything we do and in every decision we make, consciously or not, we proceed from an ethical standard. Probably most actions are undertaken intuitively as the majority of adults have surely integrated appropriate ways in which to act. It is also important that individuals in any ongoing professional endeavor pause and reflect and evaluate whether their actions are effective and made from a moral and ethical framework. Robert J. Starratt (1991) suggests just such a structure in configuring how leaders in a school setting can establish standards for ethical decision making. He proposes that we assess our moral decision making and our actions through the ethics of critique, justice, care and the profession. Critique refers to the importance of asking all the questions, not just the easy ones; keeping a keen eye on where power lies and who it impacts. The framework of justice entreats a leader to know the rights of the institution and the individual and to evaluate whether these rules protect and serve all constituencies. The ethic of care asks us to understand that each person in a system MORAL REASON ESSAYS 9 has individual needs to be addressed. The last framework, the profession, is essential in sorting out the larger picture. It encourages the leader to look within the context of the profession and institutional expectations, as one must have a professional focus, when evaluating ethical decision making. These four clear and powerful frameworks can certainly be used in any setting. In the third section of this assignment, Moral Reasoning Essays, I will use these ethical frameworks to justify and evaluate the analysis and choices made in solving the moral dilemma illustrated in essays one and two. Framework 1- Ethic of Critique Socrates was correct in helping us to understand that conflict is best solved by daring to ask all the questions! This should also be true when the conflict is internal. The ethic of critique demands comprehensive and critical thinking. It suggests that one take a hard look at who has the power to direct the flow, who benefits from how things are currently going and who chooses the values from which to work and in turn colors the arena? Ultimately, I identified honesty as a fundamentally important value to the work of a therapist. It is synthesized into my moral rule, I am responsible to model emotional honesty in my relationships with my loved ones and my clients, and my moral judgment, that continuing to collude with Jacob’s lying was destructive. I believe I was able to do this because I was not afraid to look critically at every aspect of my work and particularly because problems were noted. I asked every question in regard to all the solutions so I could identify how any action would affect every player. I was able to see that Jacob’s anger, obstinacy and fragility gave ultimate power to the one person who was incapable of empathy. I also saw my collusion was self-protection, that would be tantamount to abusing my power. I knew that if I were also to stay true to my other deeply held values of keeping clients safe, being accountable and responsible to MORAL REASON ESSAYS 10 all with whom I work and maintaining my professional ethics I would have to change course and bear the brunt of any emotional fallout. Framework 2-The Ethic of Justice Even when outcome is correct it is not always pleasant. Once I was clearly able to assess the problem continuing the status quo became abuse and not merely a mistake. Often we want to look for a cookbook of direction to make an assessment about how to proceed yet the nuance of leadership does not come with a list of do’s and don’ts. Johnson (2012) highlights the work of the 18th century philosopher, Immanuel Kant, who believed that there is only one morally correct action and it incumbent upon all to follow that directive. Starratt in his (1991) article explains that Kant taught that we were all individually obligated to act on the ethical imperative. Starratt’s ethic of justice directs us to think beyond the rules and laws in an effort to ascertain if the written guidelines are fair and if they protect the few against the many. It is essential to evaluate whether rules are just and if they take each person into account and not just the institution or the power holders. The rules governing my ethical dilemma are dictated by the ethics of my profession. As stated they include both confidentiality and the responsibility of competent service to all clients. It was not possible to serve both of these masters from a morally grounded structure. Further, Jacob knew that he had the rule of confidentiality on his side and he was using it to hold everyone hostage. Another rule as a therapist is that I must be the one with the objectivity and stay out of the emotional fracas. I cannot be effective any other way. Yet, all the rules published never account for human behavior. I needed to regain my objectivity as this directive is paramount. My empathy for Dell was clouding my recognition of the problem we were being lured into. I do believe that I have an obligation for morally correct action; I just don’t think that the answers are MORAL REASON ESSAYS 11 always completely clear. I was able to review the rules and mandates in an effort to make a decision that took everyone into account. The truth was that no one was being served well and change was needed. Framework 3-The Ethic of Care Johnson (2012) describes care as fundamental to moral decision making. He references Carol Gilligan, a feminist psychologist and writer, in contrasting this ethic from what she considered the male dominated view of, “justice as fairness (p. 172).” Gilligan encourages us to remember that connection to others ought to trump the notion that only one truth exists. Starratt (1991) wants us to view each human being’s needs as central to moral reasoning. He cautions us that every relationship cannot be have deep familiarity but each person is worthy of fully being cared for. This ethic is close to my heart. It is clearly what motivates me to do the work I have chosen. Caring for this couple and wanting them to have a chance to heal, grow up and keep their family intact was the original motivation to invite Dell to work with Jacob in session. Caring also ultimately informed my decision to stop the course of the treatment I was offering to Jacob and Dell. I believe that both of them deserved a chance to get what they needed. In the short term we all had to manage our discomfort. I had to admit my short-sightedness and risk Jacob’s wrath and Dell’s disappointment. Jacob had to admit that he was not able to follow through with his original goal to disclose his behavior and begin a course of refocusing on his own internal struggles. Dell was going to be left without a therapist. I trusted that the good news would be that she needed a better advocate than I could be at the time; I knew I was doing the right thing. Caring, and recognizing that most dilemmas are not solved, as Kant would have us believe, from a black and white list of moral rules, moved me to make my choice. MORAL REASON ESSAYS 12 Frame 4-The Ethic of Profession I have noted over the years that when some people are asked what their profession is, they answer with what they “do.” For example they may say, “I teach,” or “I work at the Schwartz and McDonald Law firm.” Others answer with who they are and say, “I am a first grade teacher or I am a tax attorney.” When I am asked what I do, I say without hesitation, “I am a clinical social worker.” I feel tremendous pride in my association with the profession of social work. The preamble to the code of ethics established by The National Association or Social Workers (2008) (NASW) is shown below. The mission of the social work profession is rooted in a set of core values. These core values, embraced by social workers throughout the profession’s history, are the foundation of social work’s unique purpose and perspective: service social justice dignity and worth of the person importance of human relationships integrity competence This constellation of core values reflects what is unique to the social work profession. Core values, and the principles that flow from them, must be balanced within the context and complexity of the human experience. Essentially my own value stance is mirrored in the associations. The above statement not only captures the individual value beliefs explicated in this essay, it also reminds us that humanity is infinitely complex and all work must be predicated on taking real human beings in to account. Social Workers cannot rest only on theory or philosophy alone. Further, NASW calls for continued competence best sought by ongoing self and case evaluation. I fully believe that my work in this case satisfied this imperative. MORAL REASON ESSAYS 13 Concluding Thoughts Mistakes Made Perhaps it can be noted that when Jacob agreed to invite his wife to enter into couple’s work I needed to be reestablish the boundaries I had with Jacob to include the dynamics that would arise from integrating Dell into our work. From this it could be concluded that somewhere along the way I lost my objectivity that is surely a part of continued competence; I would not disagree. I do, however, try to remember that we are ALL human and vulnerable to err, not just my clients. I know that the only way to fix a mistake is to move from it with a new plan. One other comment can be made of the moral decision making explicated in this essay and that is whether I compromised confidentiality by using case material. I had to think deeply about this. I use case material when I teach and before I do so I get permission from the client. I always change names, identifying information and content. In doing so I have to do a little creative writing and this is true in writing up this case as well. I, as always, sought permission from the clients modeled in this essay. To that end I feel that this exercise is scholarly and only adds to my continued quest for excellence. Worth the Effort Starratt’s (1991) frameworks provide a new template to look at the ethics that inform everyday work life. Using his writing as a tool encourages professionals to examine their actions from a new perspective. His philosophical ideas about ethics are beautifully nuanced and articulated. He asks the practitioner to remember what is ultimately important (in his case educating children) when entering into the environment of politics, policy, economics and personality. For me, Starratt’s outlook offers an opportunity to look at circumstances with a fresh pair of eyes; surely for all of us this enhances objectively. MORAL REASON ESSAYS 14 References Johnson, Craig (2012). Meeting the Ethical Challenges of Leadership: Casting Light or Shadow. 4th ed.Los Angelos: Sage Publications, 2012. Print. Starratt, R.J.(1991).Building an ethical school: A theory for practice in educational. Educational Administration Quarterly, 27, 185-202 The National Association of Social Workers. Code of Ethics, 2014. Web. 7 March 2014.