The question of
how and where psychologists draw the lines of ethical conduct has flourished in
the news recently. Revelations of the American Psychological Association’s (APA)
connections with the CIA interrogation-torture have surfaced both inside the
Washington DC beltway (with the US
Senate Select Committee’s report) and out (e.g., James Risen’s Pay
and Price: Greed, Power, and Endless War, which inspired the APA to
re-open their investigation).
Although the
torture of detainees is very different from the treatment and supervision of
people who have sexually abused, some points are worth noting as we consider
the effects of our actions on our clients and society. CIA detainees and sexual
offenders are often more vulnerable populations than they appear. It can be
easy to feel an urgent need to use whatever means are necessary to reduce risks
as quickly as possible. It can be easy for professionals to lose sight of just
how much power they hold over the people in their charge. Finally, it can be
easy to believe that one is not capable of causing harm to people in our care
or custody. As one extreme example, CIA psychologist Kirk M. Hubbard stated in
a journal article titled Psychologists and interrogations: What’s
torture got to do with it?:
Constanzo (et al.) argue that ‘psychologists should not be involved
in interrogations that make use of torture or other forms of cruel, inhumane, or
degrading treatment’ . . . Their statement is ironic for torture is illegal in
the United States. But even more importantly, it seems to come from and apply
to a world that no longer exists. . . . We no
longer live in a world where people agree on what is ethical or even
acceptable, and where concern for other humans transcends familial ties.
This statement does
indeed contain ironies (e.g., it seems that no one is disputing that torture
took place outside the US, or the belief that whatever happened could not be
torture because that would be illegal, or that because it took place outside
the US it was somehow less unethical). This
statement also illustrates how people in the helping professions can find or imagine
exceptions to standards of professional conduct (e.g., behavior that would be
unethical under other circumstances is ethical when the world is changing and
we believe that old rules don’t apply). Certainly, the behavior of nations in
wartime is beyond the scope of this blog and the expertise of this author.
However, professionals at the intersection of mental health and the law will
want to consider factors that influence our understanding of ethical conduct,
as well as how these same factors may appear to change over time. Lost in the
current media discussion are other discussions about the involvement of mental
health professionals in interrogations (e.g., Chaffin, 2010).
A new article
appeared in the Journal of the American
Academy of Psychiatry and the Law, this time by psychiatrist and retired Brigadier
General Stephen Xenakis, titled, The role and responsibilities of psychiatry in 21st century
warfare. In it, he states:
When
I first worked with detainees at Guantanamo Bay, I was troubled by a peculiar
and unsettling awareness . . . Here I was, focusing on torture and cruel,
inhuman, and degrading treatment of prisoners and yet, these were the very men
who were the “enemy.” As a career Army officer, I pledged to protect our nation
against all enemies, foreign and domestic. As a physician, I pledged to care
for all who were hurting and needed help. Facing some detainees who were
tortured because they were our enemies, sometimes with the aid of military
physicians, I felt I had entered a domain in which the old paradigms ceased to
apply. Perhaps that is one of the fundamental problems with Guantanamo. . . . I
have always believed that doctors are champions of human rights, no matter what
role or assignment we accept. After all, every society endows their doctors and
healers with special trust and confidence. We symbolically wear the white coat
at all times, even as psychiatric experts for the prosecution or in military
uniform.
What does this
have to do with the treatment of sexual violence?
In 2010, the
late psychiatrist Bill Glaser wrote (among other things) that in its current
state, sex
offender treatment is punishment and that professionals should not kid
themselves about this. Jill Levenson and
I wrote a reply
in which we argued that this is simply not the case, and that licensed professionals
are bound by ethical codes that make it unlikely for treatment to be entirely punitive.
Just the same, Glaser’s point was well-taken, in that our clients don’t always
view their treatment to be as helpful as their therapists do (Beech and Fordham,
1997), even though consumer-satisfaction surveys of sex offenders have
often produced positive results (e.g., Levenson,
Prescott, & Jumper, 2013).
In 2011, Steve
Sawyer and I published an article on boundaries and ethics
in sex offender treatment. We observed that:
The
licensed therapist treating sexual offenders has an ethical responsibility to the
client, a legal
responsibility
to the court, and an ethical/moral responsibility to the community.
Specifically, the therapist’s primary responsibility to the client’s welfare is
checked in part by the standard of practice to share information with
county/state corrections and/or the community as required by law or by
contractual obligations or as needed to protect the community. This is done
with informed consent from the client or as needed by law. Within these limits
of confidentiality, however, the therapist’s focus is on the sexual offender
client. This situation recognizes that the client is best served—and the public
is best served—when the therapist and the client develop a therapist–client
relationship that is separate from the sexual offender’s relationship with the
probation officer and the court.
This seems clear
enough; professionals in our field are almost always involved in balancing the
rights and welfare of others and develop specific practice skills for doing so.
Yet the recent events involving large agencies and organizations (the APA, CIA,
etc.) should still make us wonder if there aren’t other concerns to bear in
mind. In what ways might we go wrong? What should we look out for in order to
prevent harm to clients? How can we maintain the highest level of professional
conduct? Anecdotally, it seems to the
author that the most common forms of grievances and ethics complaints (when
they occur) are in the areas of misuse of evaluation measures, and coercive
treatment experiences.
Readers may be
aware of an ongoing class-action suit in Minnesota. After 20 years of
operation, only three people of a current census of over 700 have ever received
provisional discharges (one within the past few days), raising inevitable questions
of constitutionality of the program. The federal judge in the case established
an expert panel to examine the program; their report
was published recently. This expert panel consisted of four experts, three of
whom have served as directors of civil commitment programs. After nearly a year
of reviewing the program, they released a 108-page report with 44 broad
recommendations. Within their (at times devastating) conclusions, the panel comments
on the apparent failure of many clients to advance in treatment, although they note
efforts to expand a pre-release portion of the program:
This
delay appears to be a result of a pervasive belief on the part of MSOP
administration and staff that it is not their responsibility to proactively
petition and rigorously advocate for clients to advance in phases and to CPS.
There is a shared belief of having no control because the structure of the law
and its processes have created the inability to release clients. . . Clinical
staff and clinical supervisors do not appear to be supported or encouraged to
appropriately modify the treatment offered in order to appropriately respond to
the individual and complex needs of these clients. From a clinical point of
view, this population seems to be administratively unrecognized, misunderstood,
and inappropriately served (or underserved). It was clear to the Panel that
staff who work with these clients have genuine and compassionate concern for
the wellbeing and future aspirations of their clients, in spite of feeling
unsupported in their attempts to advocate for programmatic changes.
Although there is always more to any
story, two themes emerge for purposes of this
discussion:
·
One is the theme (often heard
in discussions as diverse as CIA abuses and good programs that fall on hard
times) of good, decent staff at the front lines feeling powerless and helpless
(apparently, a parallel process to the experiences of the clients in the
program).
·
Another is the theme that apparently
no one was advocating for the rights or wellbeing of the clients.
In my view,
there may be two areas of focus for professionals that might be helpful and
that are often outside strict interpretations of ethical codes.
The first is advocacy
of quaternary prevention,
as described in our field by Geral
Blanchard and others. While primary, secondary, and tertiary efforts focus
on preventing sexual violence among specific populations, quaternary prevention
focuses on the prevention of harm being caused by these same efforts. Most, if
not all professionals who enter our field want to practice ethically. Yet, many providers and
treatments have caused harm under the mantle of helping others.
The second is
that all people in our field should re-visit the idea of advocacy, alluded to
recently in an article titled Where has all the psychology gone? by Gannon and Ward. Where our field
once advocated for community safety to the point of placing clients’ needs
second to community safety, it may be time to consider just how far back that
second place is. For example, the
Texas Department of State Health Services defines sexual offender treatment, in
part, as: “Sex offender treatment is different than traditional psychotherapy
in that treatment is mandated, structured, victim centered, and the treatment
provider imposes values and limits. Providers cannot remain neutral because of
the risk of colluding with, adding to, and/or contributing to the offender’s
denial” (Texas Department of State Health Services, 2012).
As an example of
context of advocacy elsewhere, consider this section of the preamble of the NASW Code of Ethics:
Social workers promote social justice
and social change with and on behalf of clients. “Clients” is used inclusively
to refer to individuals, families, groups, organizations, and communities.
Social workers are sensitive to cultural and ethnic diversity and strive to end
discrimination, oppression, poverty, and other forms of social injustice. These
activities may be in the form of direct practice, community organizing,
supervision, consultation administration, advocacy, social and political
action, policy development and implementation, education, and research and
evaluation. Social workers seek to enhance the capacity of people to address
their own needs. Social workers also seek to promote the responsiveness of
organizations, communities, and other social institutions to individuals’ needs
and social problems.
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
The preamble to
the APA Code of Ethics is more
succinct: “Psychologists respect and protect civil and human
rights.”
Perhaps our next
step as professionals is to ask ourselves:
·
Even though our clients provide
informed consent to our treatments, how much duress must they be under to do so
before it is not meaningful consent to treatment (e.g., “I am only consenting
because if I don’t it’s four years added to my sentence”)
·
To what extent are we
advocating for both our clients’ needs as well as community safety?
·
At what point is it acceptable
for a mental health professional to induce suffering, whether directly or
indirectly?
·
At what point do mental health
providers in large institutions (such as civil commitment programs) have an
ethical obligation to advocate for their clients over and above what the
administration is (or is not) doing?
And in the
shorter term, and against the backdrop of the axiom that the only thing necessary for the triumph of
evil is that good men do nothing,
how can professionals best discuss these topics publicly while maintaining
the highest standards of professional conduct?
