Exploring Ethical Dilemmas in Art Therapy

50 Clinicians From 20 Countries Share Their Stories

Audrey Di Maria, Audrey Di Maria

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781134814268
• Edition: 1
• Topic: Medizin
• Subtopic: Psychiatrie & geistige Gesundheit

Exploring Ethical Dilemmas in Art Therapy: 50 Clinicians From 20 Countries Share Their Stories presents a global collection of first-person accounts detailing the ethical issues that arise during art therapists' work. Grouped according to themes such as discrimination and inclusion, confidentiality, and scope of practice, chapters by experienced art therapists from 20 different countries explore difficult situations across a variety of practitioner roles, client diagnoses, and cultural contexts. In reflecting upon their own courses of action when faced with these issues, the authors acknowledge missteps as well as successes, allowing readers to learn from their mistakes. Offering a unique presentation centered on diverse vignettes with important lessons and ethical takeaways highlighted throughout, this exciting new volume will be an invaluable resource to all future and current art therapists, as well as to other mental health professionals.

PART I

Looking Beneath the Surface

Brenda Barthell (see color insert)

1

FACTORS THAT CAN INFLUENCE THE ETHICAL DECISION-MAKING PROCESS

Audrey Di Maria

Rummaging through the attic of my childhood home recently, I pried open a trunk to find a stack of 40-year-old graduate school notebooks. As I flipped through their pages, my mind drifted back to a course I had taken as a first-year student: “Art as Therapy with Children.”

All eyes were riveted upon our professor, Edith Kramer, as—her hand slicing the air, her long gray braid bouncing on her back as she moved from one side of the room to the other—she described one of the earliest and most challenging experiences she had had while working at a residential treatment facility for boys who, at that time, were referred to as “disturbed.” Ten-year-old Martin—whose relationship with his mother was characterized by provocation (on Martin’s part), punishment (by his mother), and reconciliation—was energetically painting an unflattering picture of the school administrators, when suddenly he obliterated the image, destroying his work. Edith told us that the excitement that she had felt while Martin was painting was immediately replaced by a surge of anger toward him. As she explained in the section on transference and counter-transference in her classic book, Art as Therapy with Children:

I had identified with Martin. By painting the caricatures, Martin had expressed for me my own hostility against the school’s directors, and on a deeper level he had expressed my childhood rebellion against parental authority. As long as his caricatures were good, he had gratified my aggressive desires in a way that was acceptable to me. I had indulged in more vicarious gratification than is permitted to the therapist and so I was doubly hurt when Martin reverted to raw destructiveness. I was not only attacked in my role as Martin’s teacher who had helped him to make the picture, but I was much more deeply hurt because identification with Martin made me experience his regression as my own. Since breakdown of sublimation was to me the most serious menace to my integrity as an artist, I experienced Martin’s attack on his painting as an attack on me, and I reacted with panic, regression, and counterattack.

Kramer 1971, pp. 41–42

In an instant, Edith conveyed to us how easily our own feelings could become intertwined in the work that we would do as art therapists. Her generosity in sharing this experience gave us a glimpse of Edith, the person (rather than Edith, the theoretician, Edith, the author, Edith, the artist) as she went about her work. She made it OK to talk about mistakes. In allowing us to see the motivations underlying her action, she challenged us to become more aware of our own.

When confronting ethical dilemmas, we neglect a big part of the picture if we fail to take into consideration what we, as individuals, are bringing to the decision-making process. As much as we might strive to be, we are not objective observers, nor should we be. Our internal responses can inform our understanding of the work, but we must factor our own values, sensitivities, and blind spots into the equation if we are not to be inadvertently led by them.

What, specifically, do we take into consideration when faced with dilemmas that might involve or impact our clients? The informed consent document they signed upon beginning treatment might seem to be a blueprint for treatment, outlining the roles and responsibilities of both parties, but what about aspects of our clients that do not wend their way onto a sheet of paper or into a computer file, such as their belief systems, their cultural traditions, their religious convictions?

The Graphic

The graphic (Figure 1.1) does not present a sequence of steps, but a mandala of variables that can (knowingly or unknowingly) influence our ethical decision-making process. At the center of it all is our client. The phrase at the top of each ring (e.g., Laws, Ethics Codes, Policies and Procedures, Job Descriptions, and Professional Training, Experience, and Skills) references material that is easier to codify than that which is represented by the phrase on the bottom of each ring. Even “Professional Training, Experience, and Skills”—which might seem to be less discrete or to have boundaries that are more elastic than, say, the Law—can be embodied by graduate course syllabi and grades, descriptions of jobs held, credentials indicating the meeting of licensure or certification requirements, or Continuing Education certificates confirming the completion of skill-based instruction. Not so with the descriptors at the bottom of the rings and the central circle. Thus, our client’s goals, expectations, concerns, values, and culture are inherently more difficult to define or delineate than the terms of the informed consent document that the client has signed. The outermost ring has been left blank in order to accommodate other factors that might affect our own ethical decision-making process, such as our personal traits and tendencies.

FIGURE 1.1 Factors that can influence the ethical decision-making process.

Ethical dilemmas can easily arise when there is tension or conflict between the rings (e.g., when a therapist’s values are in opposition to an administrator’s actions) or within the rings (e.g., when the norms of a workplace do not reflect that institution’s policies and procedures). Even more important are the dilemmas that are generated by friction between factors represented by the concentric circles and the rights, preferences, and needs of the individual who is at the very core of our work (e.g., when our blind spots include an appreciation of the important role played by our client’s culture).

Laws, Ethics Codes, and Informed Consent

It is our responsibility to know the laws and the ethical principles that govern our work, but are they as definitive as they appear to be? What happens when international, national, provincial, or municipal laws conflict with one another or with the ethics codes of our profession (Di Maria, 2013a)? How judiciously are laws constructed and how equitably are they applied?

State laws in the US (e.g., regarding the age of consent, the duty to warn, the statute of limitations for prosecuting the sexual abuse of children) vary widely. Those governing the licensure of art therapists are no exception (e.g., with regard to title protection, reimbursement by insurance companies). Some state laws (e.g., regarding the privacy of client records) have stricter provisions than federal laws. Anne Patrick’s book, Liberating Conscience, (1997) written from the perspective of a Catholic feminist, makes the point that rules can be used to justify behavior that is unethical or immoral. As I write this, the federal government appears to be chipping away at home rule here in the District of Columbia (The Washington Post, July 24, 2018); our city council’s decision to declare Washington a “sanctuary city” might have repercussions in terms of the allocation of federal funds; and District residents are still not represented in Congress by a voting member.

Imagine that you are an art therapist who works in DC, San Francisco, or one of the other sanctuary cities. You have been seeing the child of a parent who is an undocumented immigrant, and one day that child arrives at a session with visible bruises. The child wants to draw, and both the content of that drawing and the comments made by the child regarding the artwork indicate that the bruises might have been inflicted in the home. Art therapists are mandated reporters. Is your course of action clear? Does the context make a difference?

Some of us live in places where there are no regulations governing the practice of art therapy, in particular, or mental health treatment, in general. For guidance, we might turn to the ethics code of a certification body (such as the Art Therapy Credentials Board in the US) or a professional membership organization (such as the American Art Therapy Association). Aspirational values, such as autonomy, nonmaleficence, beneficence, fidelity, and justice (which—along with creativity—are included in the Preamble to AATA’s Ethical Principles for Art Therapists, 2013) can help to clarify what is at stake when we are confronting situations that are ethically challenging. (Although I refer here to AATA and the ATCB, due to my greater familiarity with the provisions of their codes, many other countries have professional art therapy membership organizations and credentialing bodies, several of which are referenced in the chapters that follow.)

In the absence of an art therapy association, credentialing procedure, or training program, we might turn to the policies and procedures of the agency in which we work or to the cultural norms and traditions of the workplace—as well as the description of the position we hold. Most importantly, there is the agreement that the client and therapist have made with each other; whether it is called an informed consent document or goes by another name, it forms the basis of our contract with the client, outlining what the client has given us permission to do.

The Clientele, the Setting, and the Mode of Treatment

Are some ethical challenges more likely to arise in specific types of settings or when we are working with clients who have particular mental health conditions? How might our response to an ethical issue (such as one involving the use of non-erotic touch, gift giving and/or receiving, self-disclosure, or the creation of artwork with, or alongside, a client) vary in settings as diverse as an early intervention program for preschoolers, an assisted living facility, a detention center for adolescents, a private practice, a community-based studio, an inpatient hospital for members of the armed services, a camp set up for those displaced by a natural disaster? What is the effect upon our decision-making process of our mode of treatment, be it individual or group, couples, family, or community-based work)?

Our Theoretical Orientation, Training, and Experience

How often do we automatically rely upon tenets that we absorbed during art therapy classes or internships? To what extent does our current theoretical orientation reflect that of our training program, our supervisors, our co-workers, our therapists? Whose example do we endeavor to emulate—or did we vow never to replicate? To what extent did these early experiences become professional preferences that might narrow our focus when we’re facing ethical dilemmas?

Our Values, Traits, and Tendencies

In an engaging workshop, Catherine M. Iacuzzi, PsyD, MLADC, introduced us to the set of wonderfully provocative questions that comprise Michael Taleff’s (2010, p. 30) Ethical Self-Exam:

• Do you live via or through a certain set of ethical (moral) standards?
• If you do, could you easily spell them out if asked, or would you find yourself having trouble coming to an answer?
• If you do have standards, essentially what are they? (Write out a list.)
• Do you assess different ethical situations by the same standards or do you use different standards for different ethical situations?
• If you do assess different situations by different standards, what reasons can you cite for this action?
• Do you ever cheat on your standards? If so, on what particular circumstances do you usually or most often cheat?
• Do you judge others with one set of standards and judge your actions by a different set?
• If so, can you recall the last time you did this, and on what did you cheat?

Might taking this “quiz” highlight areas that could have an undue influence upon us when we are endeavoring to make a decision that is ethical?

On my first day of work as an art therapist, 40 years ago, ...