In which we ride off into the sunset

This is my tenth and final blog entry, and it is about considering our ability to be ethical when working with the constraints of our workplaces. My ninth post was about acknowledging ugly feelings and P.T. Anderson movies. My eighth post was about trusting our clients and empathy. The seventh was about the ethical challenges of assessing for functioning. Post number six was about ethical differences and new Southern Rock. Post number five was about imaginary devil worship. Number four was about Public Enemy and my contrary ways. Number three was about the blues, number two was about feorabros, and number one was about Scandinavian heavy metal.

We have, at last, reached the end of this semester’s blogging assignment (and we are but a few weeks from the end of the semester). One of the biggest challenges that this semester has presented for me, and two that have come up a few times in the discussions of ethical dilemmas my peers have experienced, is that we must work within logistical realities and we must work in the uncertain terrain of human behavior.  

I think back to some of the stories my peers have told about working in hospitals. They have encountered several situations where other people, and people with more power, have behaved in ways that are ethically suspect or have put my peers in situations that strain at the limits of their roles as medical family therapists.

I also think about the financial challenges that our clients might face. At Mercer, we use a sliding scale, and so cost is no barrier, but in our futures we will be working in situations where non-abandonment might become a real challenges. I know that we have some clients in the clinic who were referred by faculty members who could no longer see them because of insurance issues. In these cases our faculty were able to stay involved, at least peripherally (or even as a co-therapist) because the client could be shifted from the therapists own caseload to the clinic’s. What to do when you are not a supervisor at a sliding scale clinic (that shares the same office space as your own practice)?

I also think about the challenges of risk assessment and safety contracting. We have been given instruction and provocation to think about our duties to prevent people from inflicting physical harm on anyone in at least four different classes, but the details of safety remain murky and scary. I have done suicide assessments and safety contracting already, and I feel that I did fine, but those conversations always have a twinge of uncertainty. (I, or course, got backup from the on call therapists to make sure I had done everything right.)

Certainly, when faced with an inherently difficult ethical situation (not a dilemma exactly, but a situation where living up to our responsibilities is difficult) want to live up to the standard of CYA, but any therapist worth his or her salt should take those responsibilities much more seriously than merely to understand them as mechanical obligations. The “correct” courses of action for the three circumstances mentioned above are fairly obvious, but the nuances of carrying out those duties in ways that honor the spirit rather than merely the letter of our responsibilities are difficult.

Of course, the even thornier problems of self as therapist come into play whenever we encounter a difficult to carry out ethical obligation. Do we want to face the challenges of dealing with someone with more authority who is not cognizant of his or her responsibilities? Do we have the confidence to make difficult judgments about client safety? Do we have the patience and concern to make sure our clients are being taken care of when they are not in our therapy rooms?

As we reach the end of the semester, the intersections of personal and logistical issues has become increasingly clear. A psychosocialspiritual perspective applies not just to the presenting issues our clients struggle with, but to our own ethical reasoning, and we must be vigilant to find the connections between where we work and who we are if we are to carry out our duties responsibly.