Ethics Rounds

Caffe Coco, on the island of Kauai, in the town of Kapaa, seats about 20 people on the inside. If you choose to dine outside in the back, you'll be joined by curious geckos and perhaps a rooster or two wandering by your table. Under a straw covering to protect from the sun, as a guest of the Hawaii Psychological Association, I had the opportunity to discuss ethics with a dozen or so psychologists who serve the Kauai population, just under 70,000.

Caffe Coco was the setting for one of five ethics workshops we held on four of the Hawaiian islands over the course of a week this spring. I would like to take this column as an opportunity to thank the Hawaii Psychological Association for extending such a warm welcome, and the psychologists whom I met across the state for sharing with me the ethical challenges they face in their practices. What I feel most grateful for is the education I received by virtue of the open and honest discussions we had regarding how APA may not always entirely appreciate or fully understand the unique settings in which these psychologists practice.

The discussions in Hawaii highlighted a series of dialectics, tensions between two opposing positions that might pull a psychologist in different directions. What I found most interesting was how the psychologists with whom I met worked creatively with these tensions in their search to reach an ethically reasonable and appropriate point of view or response. Three examples of these dialectics include the psychologist as "insider" or "outsider"; the ethical mandate of competence and the importance of making services available to those in need; and the perspective of the island culture vis-à-vis the perspective of APA as the professional association.

Native or outsider?

Discussions of the "insider/outsider" phenomenon in the island communities showed the centrality of this distinction in Hawaiian culture. One comment began our discussion at Caffe Coco: "Some places have six degrees of separation; here, we have zero degrees of separation." Reflecting on the comment, another member of our group looked at me and observed, "On the island, you would be a nobody." Smiling (with a bit of a strain), I asked why, and the group responded that my manner of dress-my shoes and that I was wearing a tie-would immediately signal that I was from "off island." Identity on the island, it was explained to me, arises from one's relationships-to a rich network of people, places and institutions. My attire would signal that I do not belong to any social network on the island, hence my status as a "nobody." Laughing, one of the group remarked that things weren't all that dire; since I was wearing a lei, people would conclude that I must have at least one friend in Kauai. That remark brought home to me the centrality of relationships in the culture.

Those comments began an interesting discussion about the meaning of being an "insider" or an "outsider" in an island community. Both perspectives were represented, since in our group we had psychologists who had come to Kauai following their psychology training, as well as a psychologist who had lived her entire life on the island.

A complexity of the insider/outsider distinction is that each position is simultaneously valued and devalued. The value of being in insider arises in large part from the strength of a close-knit community, where in the words of one workshop participant, "People literally grew up in one another's houses." Disclosures of information-where information is the coin of the realm-may deepen a feeling of intimacy and enhance the experience of connectedness, and coming from the inside one has ready access to information that an outsider will gain only with great time and effort, if at all. One member of our group remarked, "There are wonderful things about this culture and wonderful advantages to knowing it from the inside." Said another, "Living on an island means that you're all in it together; relationships have to exist, and you have to find a way to make it work."

Other aspects of being an insider are more complicated. A native islander pointed out that coming from the island, rather than from the outside, may mean less respect for one's expertise, a bit like the biblical aphorism that a prophet is never respected in his or her own land. Adding to the complexity are pressures that an insider may feel when certain professional issues, such as mandatory reporting, arise. Filing a mandatory report may engender feelings that an intimacy has been shared and then betrayed, and may affect an entire social network where there are multiple connections with the psychologist's own familial and social ties. A concept that captures the connectivity of life in these communities is that of the "coconut wireless," where information about one's activities quickly reaches an entire community that is far from disinterested or dispassionate about one's doings. One of our group, acknowledging the complexity of the coconut wireless, remarked that such scrutiny could also have its benefits insofar as it can "make you a better person."

Boundaries of competence

A second dialectic that emerged was the ethical dilemma that arises when a community's mental health needs stretch the bounds of one's competence and other resources are not readily--or not at all--available. This dilemma, like the insider/outsider dialectic, seemed quite familiar to nearly all the psychologists with whom I spoke. There were ample examples of psychologists facing a choice: work outside of one's area of usual practice or deny services. Our discussions of Ethical Standard 2.01, Boundaries of Competence, explored the ways the Ethics Code sets forth for achieving competence, such as supervision, consultation and additional training or education. Listening to our discussions, I again found myself interested as much in the way these psychologists were thinking about the dilemma as I was in hearing their resolutions to it.

An idea that surfaced in more than one discussion was a resistance to taking the easy way out. As one psychologist remarked, "To make myself comfortable, I could deny treatment," with the clear implication that doing so was not an adequate response. This psychologist's way of thinking about the dilemma has a certain courage, a willingness to take a risk to provide treatment to someone in need. There is a natural and understandable disposition in our highly regulated era to avoid situations of ethical complexity in order to minimize exposure to legal and ethical liability. I am impressed and humbled when psychologists actively and explicitly resist an impulse to yield unreflectively to this disposition.

Unique ethical challenges

A third dialectic, the perspective of the island culture vis-à-vis the perspective of the professional association, emerged as we discussed ways in which APA may not fully understand or appreciate the unique ethical challenges of island practice. One psychologist remarked that when a Hawaii psychologist describes a case involving multiple layers of relationships, not unusual for practice on the islands, APA may well say, "You need to exit the situation." She then continued with a twinkle in her eye, "But leaving is not an option-we live on an island!" This aspect of the workshop emphasized how discussions at APA about ethics may not always take island circumstances and culture into sufficient consideration in fashioning ethical standards and guidelines. The Hawaii Psychological Association was identified as a particularly helpful resource in providing guidance.

As this discussion unfolded, another theme emerged: the value of an outside perspective. In this regard, APA was identified as bringing something of value precisely by virtue of its distance. The group elaborated the concept of achieving a balance between two extremes, something like Aristotle's golden mean, where one avoids going too far in either direction. In this case, the balance lies between making either the island culture or APA the defining touchstone; the challenge is to allow a dialectic to emerge in which each perspective is valued and present in finding the right path in resolving ethical dilemmas.

Perhaps what impressed me most in our Hawaii workshops was the degree of ethical self-reflection among the psychologists. Very much present in our meetings was a conscious and explicit awareness of how practice in this unique setting requires special consideration of our Ethics Code. I will seek to foster and encourage this voice with the hope that, in APA's work on ethics, we appreciate and embrace the entire range of what psychologists do across the settings in which we work and that we learn to listen in a respectful, open and supportive way when colleagues share their professional challenges and struggles.

Stephen Behnke, PhD, JD, directs APA's Ethics Office.