Introduction We consider the ethical behavior of the caregiver to be absolutely fundamental in general and particularly to the relationship between the caregiver and the client. In our view, there are no excuses for violating basic ethical principles. As we will see, while, under the difficult circumstances under which some of the people taking this course are living and working, some ethical principles are slightly variable, the basics remain. We are extremely strict about this in our practice.
As always, we ask you to complete all of the activities given. It goes almost without saying, especially for this section, that you should not reveal any information that would lead anyone to be identified. That certainly would be unethical.
Your Responsibility The principles that we describe here are universal throughout the world among medical, psychological, social work, and other caring professionals. Whether or not you are formally educated in these fields and whether or not you have a formal license to practice, the principles expressed in this section form a basis that you may not violate, whatever the laws or customs of the region in which you are living and whatever the rules or practices of the governmental, inter-governmental, or non-governmental organization you work for.
In our view, and we hold this view very strongly, following orders is not an excuse for not working in an ethical manner and not following these principles. This also is a part of international law. Thus, YOU are responsible for your actions, not your boss or the judge or the prime minister. We understand that this may bring you into conflict with officials at various levels. We find it unfortunate that such officials frequently do not abide by these standards.
Do No Harm A basic ethical principle is to do no harm to a client. We find that no one may violate this principle. We will describe situations in the section on professionalism in which the question arises of doing nothing or doing something not wholly within your competence. Unfortunately, given the low numbers of trained and fully competent people in the field, this is not unusual. There are other situations in which there are questions as to the best course to take with a given client. We will discuss those specific situations later.
Here, we wish to state quite strongly that, whatever the laws of the entity in which you are working, we feel that cooperation with torture, “enhanced” interrogation, or any situation in which a client is put under physical or psychological pressure is completely and totally unethical. We feel the same about cooperation with the death penalty and about cooperation in any way with corporal punishment or any other measure that would harm a person physically or psychologically in any way. While governments state that this is “for the greater good” or for “national security”, we most strongly disagree.
Another point is work in prisons and with police officials and other official bodies. Sometimes, it is in the interests of the client to be examined by and/or to speak to a professional or a caregiver of another sort. Under such circumstances, any work that you do MUST be in the interest of the client and NOT primarily in the interest of the official body. Furthermore, the client must be informed clearly as to what is happening, what information will be transmitted, and to whom. To do otherwise is HIGHLY unethical in our view.
Another point which, unfortunately, is fairly common is that laws exist in some places and rules exist in some organizations that forbid working with certain groups of people, asylum seekers being just one example. We feel that it is not ethical for caregivers to obey such laws and rules. We see the right to care, including assistance with mental health and thus including reactions to trauma, as a fundamental human right.
Describe one or more situations in which you have been, if you have been in one, in which the principle of do no harm has been in question. Please do not put yourself or anyone else in danger if you answer this question.
Do you feel that the principle of do no harm does not apply in certain situations? Please describe.
Privacy According to virtually every international code, and according to our strong belief, the caregiver-client relationship is completely private. The only exception to this is if the client would hurt himself or herself or another person or an animal physically in the immediate future. The threat must be a real one. In such cases, the caregiver MUST take action and must inform the client that he or she is doing so. This exception does not include a situation in which there would be damage to property that would not do injury to another person or an animal. This exception also includes a situation in which a child is being abused in any way, that is, physically or psychologically.
We are aware that that governmental legal officials and people within inter-governmental and non-governmental organizations may attempt to extract material from the caregiver, sometimes under the threat of serious consequences to the caregiver. We believe that the release of material to such people without the written consent of the client is completely unethical, even if the caregiver is violating laws or rules.
In the same context, the caregiver must inform the client fully as to with whom he or she will discuss the situation of the client. Preferably, this will be on paper. Also, it must be clear to the client how this material will be used further, and who else will obtain the information. This also includes the use of client information with bosses, students, donors, and others. We feel that anyone else obtaining the information must have the same pledges of secrecy.
In a similar context, the client must be informed explicitly what notes will be made by the caregiver, who will see them, and how they will be stored. Again, preferably, this information to the client should be on paper.
When working with a group, it should be clear that the personal material discussed within the group may not be discussed with anyone outside the group including partners, friends, etc. Some groups have the rule that such material may not be discussed between group members outside of group sessions. Those sorts of rules are dependent on the specific circumstances of the group.
With regard to external people sitting in on individual or group sessions, we also have strict rules. In general, we do not allow it. When we do, it is with the explicit consent of all of the clients and caregivers involved. A condition of an external person sitting in is that any member of a group, or an individual client, or the caregiver may ask the external person to leave at any moment for any reason and that this will not be questioned. Furthermore, the external person must sign a written statement saying that any personal material will not be transmitted further.
Give your experience with guaranteeing the privacy of clients, good and bad. Again, we ask you not to put yourself or a client in danger if you post this material.
The Relationship Between the Caregiver and the Client Outside of the Caregiving Situation In general, we find any relationship between a client and a caregiver outside of the sessions between the caregiver and the client to be unethical. Such external contact and involvement compromise the caregiver’s objectivity. Furthermore, the caregiver knows a great deal about the client and can use that information, usually unconsciously, to manipulate the client. Maintenance of this distance is the responsibility of the caregiver.
We realize that this is difficult in areas where there are few caregivers, in situations in which the caregiver and the client are in the same social and/or professional circles, and under a number of other circumstances. Under such circumstances, the caregiver and the client must avoid one another to the greatest possible extent. This is the responsibility of the caregiver.
Certainly, the mixing of roles can cause severe problems. For example, we have seen the negative effects of mixing friendship and caregiving and of situations in which the caregiver also is the employer. With very rare exceptions, these situations of mixing of roles do not work.
Obviously, no sexual relationship or close personal relationship may be allowed to occur between a client and a caregiver.
In general, we maintain a rule that a caregiver may not have any other relationship with a client for at least one year after the caregiver-client relationship has ended.
Describe a situation in which you have been involved in a mixture of roles or a situation in which you have observed that kind of mixture of roles. What happened?
What is your view on what we have said here? Are there circumstances in which a client and a caregiver may have a relationship outside the caregiving situation? Give your experience.
Professionalism In our view, what you may and may not do is a question of the circumstances under which you are working and the location in which you are working.
It is obvious that, in a place in which there are well-trained, well-supervised professionals and health care is available to all who need it, it is not ethical to work if you are not so trained and supervised, except under the supervision of someone who is.
Yet, under the conditions that many who will be taking this course are working, such universal, competent care is not available, particularly for vulnerable groups. We then return to the questions raised in the part of this section called do no harm earlier. Do you let the client go without care? Do you carry out work that you are somewhat unsure of? These are very difficult decisions when people are suffering. Certainly, there are some partial answers if you do decide to act. There is a great deal of information and some training available without charge on the Internet. Also, there are organizations such as the CWWPP and the Global Psychosocial Network of Psychologists for Social Responsibility that offer training and supervision without charge. We urge you to look for local organizations and individuals who can supply such training and supervision.
Another point is that, frequently, there are traditional methods of care. Very frequently, we find these equivalent and at very least complementary to northern/western methods and frequently much more appropriate to working in local situations.
Whether or not you are formally trained, we find it unethical to offer care without obtaining regular and comprehensive supervision. Unfortunately, we know all too many professionals who should know better who do not have it. We will discuss supervision in detail in the section of this course on self-care.
Describe the situation in your region with regard to well-trained and well-supervised people.
Are there people in your region who are competent but do not have formal training in your region? How do they work and what is your opinion of them?
Are there local and/or traditional methods used in your region? Please describe them, so as to educate us about them. How well do they function?
Do you have regular supervision? If you do, how does it work and how do you feel about it? If you don’t have it, what are your plans to get it?
What other comments about professionalism do you have?
Payment and Gifts With regard to payment for services, we feel very strongly that health, including mental health, is a basic human right. We do not believe that anyone should be making profits because of the suffering of other people. This also applies to drugs. Yet, the other side of this is that caregivers and their organizations must eat, pay rent for facilities, pay for Internet use, etc. Yet, we do not believe that it is ethical for anyone to be refused care because of the inability to pay. Unfortunately, this occurs in quite a number of places, even in regions that are quite rich.
The next question is that of gifts. In virtually all codes of ethics, gifts to practitioners are considered to be unethical, however well meaning. There is a difference between such gifts to individuals and contributions to the organization as a whole. There also is a difference as to whether the gift is more or less expected or whether it is completely voluntary. This can be a very thin line. Our position is that we do not accept gifts except those clearly within the ability of the client to pay, and then as contributions to the organization.
Describe the situation with regard to payments in your region. Is there health insurance? Does it cover mental health services? If so, which and for how long?
What are the policies with regard to payment within your organization?
How do you work with clients who cannot pay?
What are the practices with regard to gifts within your organization?
What is your personal policy with regard to gifts?
Conventions and Codes The principles that we have given in this section mirror the codes of ethics of a number of organizations. We give a few links here. There are many others. We strongly urge you to look at these as part of your education.
Final Remarks We believe ethics to be one of the cornerstones of practice and of the relationship between the caregiver and the client. As we said at the beginning of this section, without ethics there is nothing.