Ethical Clinical Social Work
When you’re a writer, you have a lot more liberties to express yourself. That’s why I love writing fiction. I can go places I can’t do as a therapist and a professor. Writing allows for pushing the boundaries and limits.
My day time job is very different. There are limits that are guided by ethic. Being a therapist requires an ethical commitment to providing services that are in the best interest of the client, allow for self-determination, and do no harm to the client. In many ways this is pretty easy to stick to when it comes to most situations. For example, revealing the best treatment strategies for someone struggling with bipolar I disorder – the positives, negatives and the possible outcomes of both action and inaction – is difficult but within the realm of clinical social work. Many times clients will take a course that we disagree with; there are other times we wish they would comply with treatment, such as taking medication. There are times when it is important to admit that there might not be a viable treatment or that there are limits to cognitive behavioral treatment, psychiatric medication, exercise and/or meditation and good nutrition.
Being an ethical therapist may involve making the tough decision to notify child and family services of harm to children, even though doing so will affect the client-clinician relationship. Maybe elder services will have to be notified, even though your client is well intentioned yet overwhelmed with taking care of his or her parent suffering from a major neurocognitive disorder such as dementia. Sometimes, though fortunately not often, you will have to notify the authorities of someone who is a danger to self or others. Failure to warn the authorities, the intended victim, and your team will result in sanctions, possible dismissal and worse – harm to the client or someone else.
Being ethical in anything, clinical social work included, means making educated guesses based on what is observed and said and what has been demonstrated by past behaviors. It’s a good thing we’re trained for this eventuality.
If I am home and see a person – a stranger – forcibly entering my neighbor’s home, would it be alright for me to simply say “too bad for Roger,” and then go upstairs and prepare for sleep? It could. Nothing is compelling me to do anything. It could just be a prank in poor taste or maybe even law enforcement activities. It could be anything other than something bad. Sadly, there are multiple examples of “not getting involved” and passing the responsibility to someone else because “It’s not me.”
The thing is, if I saw something like that, I would call 911. Intrusive? Nosey? Yes to both – but in keeping with the slogan “See something, say something,” I would feel I need to have someone who knows about this kind of thing step in. This is where I would defer to law enforcement to come in, assess the situation, and apply their professional judgment. If my suspicions were wrong and what I saw was not a danger, then all is safe and the world goes on. If it was a bad situation and now the police are involved and Roger is safer with their assistance, then a difficult situation is being properly dealt with and for better or worse, I have done my civic duty.
Additionally, if I am a licensed gun owner and am confronted in my domicile, depending on where one lives, then I can defend myself and family if I feel in danger. While this might be extreme, this is another example of how the judicious use of lethal force might fall under civic responsibility.
The Dilemma of Speaking Out
In these interesting times of deep-seated divisions, I can’t help but think of Martin Niemöller’s (1892-1984) quote about speaking out:
First they came for the Socialists, and I did not speak out—
Because I was not a Socialist.
Then they came for the Trade Unionists, and I did not speak out—
Because I was not a Trade Unionist.
Then they came for the Jews, and I did not speak out—
Because I was not a Jew.
Then they came for me—and there was no one left to speak for me.
Keep in mind that Martin Niemöller was a Protestant pastor who was critical of Adolf Hitler’s polices and found himself in a concentration camp for years for his speaking out. As a United States citizen, I am blessed with freedom of speech. There are limits, of course. If what I say deprives someone of their safety, then we have another issue. There’s a price to pay for what you say and write.
But what if I have training, knowledge and experience to assess someone as potentially dangerous but then do nothing? What if I know someone who has a history of being volatile, impulsive, and unpredictable, someone whose mental status is unclear? What if there were dozens of first-hand examples to draw from as it was a matter of public record? And while this person has made bold statements – pejorative and paranoid – and has access to weapons, am I obligated to do something, especially if I’m a trained clinician? Massachusetts social workers have the ability to have someone involuntarily transported for psychiatric evaluation if the person is deemed to be a danger to self and/or others. This could be construed as an endorsement of the potential for harm.
Now what if the person I see as a danger to others is a public figure? What if there are clear signs of a personality disorder and/or mental illness clearly laid out in the Diagnostic Statistical Manual for Mental Illness – 5th Edition of a public figure who controls arsenals of weapons in the last remaining superpower on the planet?
There is an ethical issue with this – it is unethical for trained clinicians to assess people they have not met. We can’t diagnose them nor provide treatment ideas as we have not interviewed them directly. So even if I could state my observations based on my training and experience, I would not be able to invoke Section 12 for immediate transport to a local emergency room for evaluation.
While I could make dark parallels to similar leaders in Germany and Italy in the earlier part of the 20th century, I am not as brave as Martin Niemöller, even if I am protected by the First Amendment. And it is not the immigrants I fear as much as I would be concerned with the long-time residents of the United States.
A Possible Plan
So what can be done? Although there is presently no personality testing for all public leaders to measure disposition, mental status and how they handle stress, maybe there should be. For now, if there are clinical specialists to psychiatrically assess our public leaders on a regular basis with the powers to deem competency, I would make sure they are well credentialed and on-call 24/7.
I think if we had the above two measures in place, I would sleep better. We know what happens when those who should know say nothing. History has a way of repeatedly giving us opportunities to change it, alter its course by modifying our actions. As Winston Churchill said after watching the rise of the nationalist socialist party in Germany and fascism in Italy – “Those that fail to learn from history are doomed to repeat it.”
Maybe it’s time for clinicians to re-think making a diagnosis without meeting the person themselves. Maybe it should be requalified to be a requirement in terms of ongoing psychiatric assessment for public figures. Maybe when there’s plenty of evidence that something is wrong in the public record, there could be an exception.
If you see something, say something.