For many years now, the youth in residence at Children’s Bureau, Inc. Retreat Program have participated in a conscience sensitive group therapy with Dr. Galvin, the consulting psychiatrist and this therapist. Originally, what we called Conscience Group had been conducted every week spanning the months of fall and winter. In brief, the developers of the original curriculum envisioned interactive conscience tasks that would afford opportunities for group participants to explore each of the five domains of conscience in turn. In our work with children and adolescents, we have called the five domains: moral imagination, moral connections, moral emotional responsiveness, moral values and moral choosing. [A full description of the original curriculum for this therapeutic modality is contained in Galvin, M., Gaffney, M. and Stilwell, B. (2005): Preliminary observations and reflections on conscience sensitive group therapy. In Conscience Works, an On-line Periodical, Theory, Research and Clinical Application, 2(2): 1-23., which can be readily accessed on the website Conscience Works at http://shaw.iupui.medlib.edu.]
While I really liked what we accomplished with the original Conscience Group curriculum, I wanted two things more. First, I wanted some way to assess how well the residents grasped what had been taught, processed and learned. Second, I wanted additional ways in which the children and adolescents could creatively express what they had begun to bring inside them.
In recent years, I conceived of using versions of therapeutic narrative to expand the Conscience Group work. It seemed to me that story-telling and drawing would accomplish both of the things I wanted. I shared my vision with Dr. Galvin who was eager for me to put my ideas into practice. We talked about the mutual story telling technique as it had been described by Richard Gardner long ago. We talked about therapeutic metaphor. We talked about efforts that had been made in various elementary schools in which children would work with parent-volunteers to produce original children’s books. The ideas I was hatching would eventually result in extending our group time from six to nine months out of every year, but would still allow the three months of summer for turnover of most of the population in residence.
I began by using psycho-educational books for children (some of which had been authored or co-authored by Dr. Galvin; visit Open Library for a partial list). Soon, however, I moved out of the genre of psycho-educational books and selected from children’s books that had appealed to me over the years. I had a great time going to the library and finding old as well as new titles. I prepared my own question sets and drawing tasks for each story that I thought would elicit a conscience sensitive response. Each week, I asked one group member to read the story aloud to the group but to pause at appointed times to allow the other group members to draw responsively. How each child or adolescent completed the task was left up to their own moral imaginations. Group members became very engaged in the drawings that reflected some of their own conscience functioning, their individualized treatment issues and how the five conscience domains had been interwoven into their lives emotionally, cognitively and behaviorally. In due course, we began discussing aspects of creating children’s books. They were curious regarding everything about the process: ‘Can the author be the illustrator too?’ ‘How many pictures for how many words?’, ‘How should the cover look?’, ‘What is this copyright stuff about?’, ‘What is an acknowledgement?’ (which often led to skill building in moral emotional responsiveness by practicing yet another form of expressing gratitude), and ‘Tell us more about dedications.’
After that, they were ready for the next step: to write and illustrate their own children’s books complete with plot, characters, dialogue and, of course, a moral to their story. The only requirement I insisted on was that they utilize one or more of the conscience domains. This expansion of the Conscience Group was well received by the residents. They improved their grasp of the concepts of conscience. For some residents who incorporated their own therapeutic issues or personal conscience development into the creation of the books there followed tremendous self-disclosure and therapeutic work. Their creativity was exceptional. The residents embraced the creation of their books in choosing appealing titles, providing forewords and understanding authorial responsibilities. As a result, residents were very proud of their work. Many were eager to share their experience and the end product in family therapy sessions as a way to connect with their family and/or just share with younger siblings. Perhaps a testament to story-telling in combination with conscience work, most residents wanted the therapist to keep their books as examples for future residents who in their turn would participate in the weekly Conscience Group.
In summary, our work with residential youth in conscience sensitive individual, group and family therapy has positive impact. The addition of guiding them through the creation of healing stories makes residents even more aware of how they can engage their conscience not only throughout the therapeutic process but also in creative activity. They are stirred to see how moral imagination can be called upon in their everyday lives. It has become one of the highlights in my work as a therapist.
– Julia Bradshaw, MSW
Editor’s Note: Ms Julia Bradshaw holds a Masters degree in Social Work. She is a veteran psychotherapist who has conducted individual, family and group psychotherapies in the Rachel Glick Courage House Retreat residential program of Children’s Bureau Incorporated in Indianapolis, Indiana. She has been affiliated with the Conscience Project in refining conscience sensitive group psychotherapy for more than ten years. When not devoting herself to children and adolescents who have endured adverse life circumstances in Indianapolis, during her vacation time, Ms Bradshaw can often be found on missions to Haiti and Honduras.
Meeting Summary, July 2011
In our July meeting we prepared for the thirteenth annual meeting of the IAITMH was to be conducted at the Riley Outpatient Center on Friday, August 12th, 2011. The title was “Ethics in Early Childhood Fields: A Moral Psychological Approach.” Keynote speakers were to be Darcia Narvaez, PhD and Daniel Lapsley, PhD. Prior to the meeting, a training for facilitators was held on June 21, 2011. The meeting was also announced on websites and shared broadly by email.
In addition to preparing for the conference, we discussed: new research possibilities for the Conscience Project, ethics and neuroimaging, conscience and medical education, and an article planned for submission to MedEd Portal.
Afterwards, a member of the group shared his experience in presenting about issues of cultural diversity for mental health providers to consider when caring for Muslim patients. This member continues to read and share his knowledge of Muslim history and culture. Other members of the group are also reading on this subject.
The sharing then moved to an exchange on the subject of cheating in medical school. Being held accountable, and accepting responsibility for the harm done is a precondition for remediation. An ensuing discussion of techniques in the process of remediation followed.
Download a complete copy of the meeting minutes for July 2011.
Forthcoming meetings planned for: October 29, 2011 and January 21, 2012.
The 13th conference will be held in Indianapolis on August 12, 2011 in the Ruth Lilly Auditorium of the Riley Outpatient Center. The conference will focus on “Ethics in Early Childhood Fields: A Moral Psychological Approach.”
For more information, download a copy of the conference announcement.
Conscience Project Meeting 1-22-11
The meeting was conducted at Ethna’s home. Present were Ethna, John, Barb, Sister Mary, Jere, Deb H, Meg , Matt, Deb G, Beulah, Susan and Joe.
The minutes from the previous meeting 9-25-10 were reviewed and accepted.
Matt circulated A. Kaplan (2010): “Morality” professor responsible for research misconduct. Psychiatry Times XXVII (10): 1and 9.
Nota bene: On prior occasions we have discussed Harvard Professor Marc Hauser’s 2007 book Moral Minds: the Nature of Right and Wrong, Harper. The comment by a colleague in the field was reported: “I believe his work on morality is not tainted by this investigation but his work on animals has been, and of course, he is tainted himself by this.”
Ethna provided further update on her efforts in promoting awareness and encouragement for uses of the Deb G’s illustrated version as well as the version of The Lyric of Lafracoth currently available on Conscience Works. Ethna had left an illustrated version with Professor V. Ethna reported very favorable comments regarding both text and illustrations from Professor V, who had given the work two readings and viewings: “The illustrations alone could sell it!” was Ethna’s direct quote from the professor. He encouraged further promotion with prospective publishers. He made the suggestion that the letter to prospective publishers contain a better summary with more material excerpted from the text to present the flavor of the work. He also indicated he could readily envision Lafracoth adapted for the stage. At our last meeting, Ethna had requested an additional hardcopy which she had intended to show Professor B. Matt and Deb G. had prepared the additional hardcopy in the interim and gave it to Ethna at this day’s meeting.
In her turn, Susan shared she had been intrigued by the possibility of rehabilitation of Michael Vick’s dog which had been subjected to the maltreatment entailed by vicious sport. She had learned dogs rescued after experiencing similar adverse life circumstances were divided into groups, adopted into families on the one hand or sent to refuge facilities on the other. Susan drew an analogy to people and inquired, “What prevents a person from being rehabilitated?” In response, Joe commented that pit bulls were biologically susceptible for selection according to their capacity for interspecies aggression. This exchange prompted discussion nature –nurture explanations which moved back and forth from animals traits to applications to human criminality: putative endo-phenotypes and gene-environment interactions. Beulah asked about the number of generations needed to realize changes in phenotypic traits. Joe supplied comments about how very quickly phenotypic changes could sometimes be discerned in breeding. He recalled a study of foxes bred for fur in the Soviet Union. In a single generation, both enlarged size and variations in color were evident from the breeding process. The notion of intended (and unintended) genetic breeding for aggression in species (including humans) was raised. In particular, emerging in discussion was the role of urban adversities and ‘structural’ poverty in establishing criminality.
Matt related how once a year, around the time of the winter holidays in the Conscience Group at Children’s Bureau Retreat, the film version of Lionel Bart’s musical adaptation of Charles Dicken’s Oliver Twist. Oliver! is shown to the youth in residence. Each youth is assigned a character in the film to whom s/he is expected to pay particular attention. Subsequently s/he engages in the task of conducting a conscience sensitive analysis of that character, using the domains of conscience to organize his or her thoughts. S/he then presents his or her theory of that character’s conscience to the entire group for further discussion. Matt indicated that a perennial topic for discussion pertains to the different developmental trajectories of the characters Oliver Twist and Bill Sykes, both of whom are obliged to form their early childhood conscience in adverse circumstances. Apropos Susan’s topic, Matt inquired: what might have differed between the two characters in terms of the modulation of genetic expression by environmental adversity or protective factors that could account for their different outcomes? Matt made passing reference to the work of Caspi et al’s 2002 study on genetic alleles (available in PDF on Google Scholar) seeming to make a difference in whether conduct disorder follows from maltreatment. He also mentioned relevant articles he had recently encountered in the Journal of the Academy Child and Adolescent Psychiatry (JAACAP), given here with full citations:
Caspi A, McClay J, Moffitt T, Mill J, Martin J, Craig I, Taylor A, Poulton R (2002): Maltreated children role of genotype in the cycle of violence. Science 297, 851-853.
Nota bene from the Abstract: “A functional polymorphism in the gene encoding the neurotransmitter-metabolizing enzyme monoamine oxidase A (MAOA) was found to moderate the effect of maltreatment. Maltreated children with a genotype conferring high levels of MAOA expression were less likely to develop antisocial problems….”
Jonson-Reid M, Presnall N, Drake B, Fox L, Bierut L, Reich W, Kane P, Todd R, Constantino J (2010):The effects of child maltreatment and inherited liability on antisocial development: an official records study. JAACAP 49 (4): 321-332.
Nota bene: Use of a twin registry and court records.
Bagota R, Meaney M (2010): Epigenetics and the biological basis of gene x environment interactions. JAACAP 49 (8): 752-771.
Nota bene: recent review article.
In the context of the capacity for rehabilitation after in some sense ‘being bred’ for aggression or criminality (cf: the conscience domain moral emotional responsiveness, reparation and healing), Meg was reminded of a book: McCall N (1994): Makes Me Wanna Holler, Random House. This is an autobiographical account of how the author’s conscience, shaped by the survivalist values of street and neighborhood as well as his strong sense of foreshortened future, was reformed by the author’s self examination and exercise in moral imagination. In the context of differences in developmental trajectories that seem inadequately accounted for by environment or genes or epigenetic considerations, an anecdote related somewhere in Rabbi Kushner’s writings was recalled: this involved twins who by and large shared environment, one of whom became a generous philanthropist and the other who became a convicted murderer on death row. Both were posed the same question, something like: ‘How do you account for who you have become?’ Both replied, something like: ‘Given that with which I began my life and all that has happened to me since, how could I have turned out otherwise?’
In her turn, Deb G. reflected upon an interview on the news with a spokesperson for ATF whose attribution of motive to—or explanation for the behavior of—the shooter in Tucson AZ, distilled to ‘He was mentally defective.’ Deb G. wondered why this remark so stigmatizing to those struggling with mental illness went unchallenged by the interviewer (cf. conscience domains: moral de-valuation and absent or suppressed moral emotional responsiveness). Matt promised to distribute an article on the subject of stigma of childhood mental illness at the next meeting:
Mukolo A, Heflinger, Wallston K (2010): The stigma of childhood mental disorders: a conceptual framework. JAACAP 49(2): 92-103.
Nota bene: Basically the nature of stigma can be conceptualized at three levels: self, public and institution. Self stigmatization and the stigma that attaches to caregivers and caring professionals are addressed.
As a corollary, Deb H. shared her impression that parents of afflicted children have a tendency to deny the affliction because there is an implication something must also be wrong with them.
There followed a spirited discussion on gun control. Barb remembered how the attempted assassination of Ronald Reagan (1981) added impetus to the fledgling formation of the National Alliance on Mental Illness (NAMI, inception: 1979) as well as to passage The Brady Handgun Violence Prevention Act (signed into law in 1993). She observed, however, that subsequent assassinations and mayhem had not seemed to provide sufficient impetus to build upon these foundations. Joe recalled that Don (of Don’s Guns) had recently remarked he could not keep some form of ordnance in stock, demand being so great following the shootings in Tucson.
‘Defective’ human beings came up again along with the question ‘Who’s entitled to deem the imperfections as making persons more or less worthy?’ As Deb H subsequently put it, “Who decides who can be rehabilitated?” Listening to all the conversations represented in the above account, Sister Mary inquired, “Where does love fit into this- these genetic issues, these ‘imperfect’ [persons] what do we do with ‘them’?” One further question Sister Mary seemed to imply, might be put: ‘Should we be asking what is ‘their’ purpose (Meg’s notes of the meeting reflect a reference was made in the context of “purpose” to C. Gates) or what is ‘ours’?’ (cf. conscience domains: moral emotional responsiveness, moral valuation and moral autonomy).
Matt commented how it seemed to him we were all ‘dross-laden souls’, operating from mixed motives. Even among our worthiest deeds, how many and how much of any can ever be attributed to altruism? In this context we revisited the status of altruism in any given person’s motivational hierarchical arrangement, according to relative goodness and then again according to relative strength (cf. Meg’s application of the British admonition: ‘Mind the Gap’). Barb introduced the phrase ‘strategic altruism’ which takes into account personal financial advantages, such as tax breaks for charitable donations.
The imperfectability of human nature aside, opportunities to purposely nurture giving and giving back do occur. This was evident in Susan’s remarks about plans for students to make a school sponsored trip to the Dominican Republic. Among recommendations for reading that came up in this discussion was Richard Gunderman’s book on the nature of philanthropy: Gunderman R (2008): We Make a Life by What We Give, Indiana University Press, Bloomington, In.
In his turn, John shared reflections on his therapeutic work with veterans, conveying his impression that trauma pushed certain fundamental questions such as ‘purpose’ into the forefront. He subsequently provided the simile: “The trauma is like an earthquake, the flashbacks like aftershocks.” John was reminded of an encounter with a returning warrior who, bewildered by his lack of success in making suicide attempts, began to consider after all if there was some purpose in his life that he had been trying to thwart. John referred to Chaplain Clyde Angel’s group work at VA conducted along themes such as “Search for Meaning” and “Wounding of the Soul.” For background John referred to an article:
Litz B, Stein N, DelaneyE, Lebowitz L, Nash P, Silva C, Maguen S. (2009):Moral injury and moral repair in war veterans. Clinical Psychology Review 29(8): 695-706.
Nota bene, from the front matter: “Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as moral injury).
Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury.”
John referred to 12 Step programs as well, noting the spirituality inherent in them, their promotion of the project of the examined life, and their emphasis upon the role of suffering for growth.
So much attention to purpose might be what prompted Barb to remark on her priorities and activities now that she is 75. She wants to do things completely enjoyable: some memoir writing, completing her term of office as president of her neighborhood association, volunteering at Spring Mill School, biking, walking ballroom dancing and going off to camp in Vermont in August. Her grandson Glen comes by every Thursday. We appreciated that Barb could acknowledge that one among the enjoyable things, so long as no conflict emerged with other more enjoyable things, was attending Conscience Project meetings.
Matt provided copies of an article in which Jerry Fletcher, Barb and he collaborated last year.
Galvin M, Stilwell B, Fletcher J (2010): Conscience sensitive psychiatry clinical applications: retrieval and incorporation of life affirming values in a personalized suicidality management plan. Annals of the American Psychotherapy Association, 13(3): 14-23.
Matt promised not to bother Barb (too much) with any more conscience projects.
Barb provided an anecdote about Glen’s changes in sharing attitudes with respect to chocolate pudding which nicely and humorously illustrated both progressions and vicissitudes.
In July, Ethna, too, turns 75. Joe will soon retire: “Now what will my purpose be?”
No one could say for sure, but Matt indicated there might be purposes at hand for some of the Conscience Project participants. Matt is on the Board of The Indiana Infant and Toddler Mental Health Association (IAITMH) a division of the Indiana Mental Health Association (MHA) IAITMH is developing a means by which early childhood mental health professionals in Indiana could engage in documented study and supervised experiences to receive endorsement. This is already done in Michigan and other states. The endorsement does not substitute for professional training, it is not licensure nor does it provide ‘institutional credentialing or privileging’ of any sort. Part of the process will entail exposure to ethics pertinent to the early childhood fields. In keeping with the mission of IAITMH to promote social emotional and social cognitive development, Matt proposed to the IAITMH Board that a moral psychological approach be made to ethics. He advocated that the approach be interactive as well, beginning with personal conscience before moving onto the professional conscience. Should this proposal be agreeable to IAITMH, the possibility would arise that interested participants in the Conscience Project (CP) might pair with Child Development (CD) Specialists (somewhat akin to the model Meg has promoted in Introduction to Clinical Medicine pairing primary care physicians with psychiatrists and psychologists prepared to lead discussion about development across the life span). The CP and CD specialists would co-facilitate educational groups for learners. The course format would resemble what Meg and Matt did over six sessions in November 2009 at Trinity Episcopal Church for moral educators of various sorts. The CP specialist would need to learn to conduct the educational groups organized around conscience sensitive tasks (see the following paragraph) that reveals the ‘signatures’ of the domains of conscience: conceptualization, attachment, moral emotional responsiveness, moral valuation and moral volition. The CD specialists would make essential teaching points about cognitive, emotional development, attachment, temperament and so forth. Already in process are plans for the 13th annual conference of IAITMH. The conference lasts a day. One or two experts in moral psychology, both at Notre Dame, will be invited to make presentations providing an overview of the field. They are Professors Darcia Narváez and Daniel Lapsley. Meg has agreed to present on ethics and the professional conscience. It is hoped we can inaugurate the collaboration of the first among CP and CD specialists in time for the conference, which will then serve as a model for future courses perhaps held in 1-2 hour sessions and conducted over several weeks.
Meg provided an update on the conscience sensitive course work already established at the medical center: the small group Meg and Matt conduct in the year long ICM I, which on 11/9/10 was graciously hosted at Key School by Susan, the upcoming senior elective in which she engages learners in conscience sensitive tasks such as conscience drawings, moralized genograms, value matrices and harm prevention planning, and the course on conscience and ethics for psychiatry residents, four consecutive sessions which had been moved from August to begin this academic year February 23rd.
Based on the cheating, plagiarism and other violations of age appropriate norms and rules Susan had had occasion to observe in k-12, she advised the educators at the medical center that a train wreck was headed their way. In response to Susan’s dire prediction, surreptitious looks of envy might (or might not) have been cast in Joe’s, Ethna’s and Barb’s directions. An announcement was made about an upcoming Petticrew Faith in Action Program entitled “Leadership, Business Ethics and Faith” featuring Dr. John Lechleiter, Eli Lilly and Co, and Fr. John C. Haughey, SJ Woodstock Theological Center, Washington DC May 3, 2011 9AM-130PM (830 registration, Indpls downtown Marriott, 350 W. Maryland St. co-sponsored by Brebeuf . Deadline for registration: April 26, 2011. No phone number given ( I would go to www.cts.edu/events or contact Brebeuf). $20 for the AM seminar, $40 for AM, lunch and PM, 4320 for a table of 8.
In his turn, Jere produced a rough draft of a bibliography on conscience based on his search of recent literature informed by what he knew were topics of interest to us. His search yielded titles of recent books and articles published between August and December 2010. Subjects included medical ethics, psychology, social issues and philosophy. Jere was thanked and encouraged to put his results on Conscience Chronicles and to continue making this invaluable contribution. There followed discussion about the eventual possibility of a periodic (quarterly?) annotated bibliography organized according to the domains of conscience. Matt said he would send Jere the beginnings of such an annotated bibliography based on something of the kind he had put together for a course.
Lastly, the sad news of the death of Dr. Linda Sue Harrington Stephan was shared by Barb. A one-time participant and ever the friend of the Conscience Project who liked to receive her copy of our meeting summaries and who recommended our work to colleagues and learners, Linda passed away October 22, 2010. She was a loving, kind, brave and memorable soul. Her obituary can be viewed at: http://www2.indystar.com/cgi-bin/obituaries/index.php?action=show&id=121734
Both of our websites have changed URL’s:
Find Conscience Chronicles at: http://iuconsciencenews.org/
Find Conscience Works at: http://shaw.medlib.iupui.edu/
The next meeting of the IU Conscience Project will be hosted by Ethna at her home, on Saturday
4/30/2011at 10:00 AM to noon.
Respectfully submitted,
3-23-11
Edited for Conscience Chronicles 5/31/11
Matthew R. Galvin
Conscience Project Meeting Minutes: 9-25-10
The meeting was conducted at Ethna’s home. Present were Ethna, John and Matt.
The minutes from the previous meeting 6-19-10 were reviewed and accepted.
Although Jere could not attend our meeting, he had prepared a submission entitled “Medical Schools, Students and the Conscience Policy” for Conscience Chronicles. In his submission Jere reviewed and applied ideas put forth in Wicclair MR. Conscience-based exemptions for medical students. Camb Q Healthc Ethics, 2010 Winter; 19(1):38-50. PubMed PMID: 20025801. Matt and Meg agreed Jere’s submission should appear on Conscience Chronicles as soon as he could make some minor typographical corrections Meg had detected. Copies of Jere’s article were distributed to those present.
An update was provided on our efforts in promoting awareness and encouragement for uses either of Lafracoth with Deb’s illustrations or the current version available on Conscience Works. For this purpose, one hardcopy with Deb’s illustrations had been made with two additional copies made from the that. Although Meg also could not attend our meeting (she was at an Indiana State Medical Association meeting), she conveyed the following. In August Meg had taken a hardcopy to show to members of the book club she attends and to ask for ideas. Meg also took the copy with her to the Poynter Center and left it with Professor M. Professor M. had agreed to look it over while considering who among colleagues at IU might harbor some interest. Ethna requested additional hardcopies of the illustrated version be made which she intended to show to Professor V. at Vincennes and Professor ND. at Notre Dame. Professor V. is already known to us by some of his work. Matt said he would be glad to prepare two additional hardcopies of Lafracoth with cover letters to prospective editors for Ethna. On behalf of himself and Deb, Matt expressed his gratitude to members of the Conscience Project, especially Meg and Ethna, for their ideas and efforts in promotion.
Matt announced that Charlie Shelton’s latest book had recently been published. The book is: C Shelton (2010): The Gratitude Factor, enhancing your life through grateful living, Hidden Spring (Paulist Press); New Jersey. Charles Shelton SJ PhD has been friend and advisor to the Conscience Project since its inception. Matt said he hoped to provide a summary of Charlie’s book for Conscience Chronicles. Matt also called attention to a volume edited by Daniel K Lapsley and Darcia Narváez (2004): Moral Development, Self and Identity, Lawrence Ehlbaum Associates, New Jersey. Contributions to the volume are in the form of a festschrift honoring Augusto Blasi. Matt had encountered passages in the contribution by Lapsley and Narváez entitled “A Social Cognitive Approach to the Moral Personality” expressing ideas (pp189-212) which seemed to Matt very congruent with those Joe had articulated at our last meeting. Joe had been discussing “filtering”. The authors under consideration address research using The Spontaneous Trait Inference (STI) paradigm which assumes “the meaning of social events is constructed routinely, habitually, and unintentionally.” The authors go on to characterize “moral chronicity [as] an individual differences dimension that influences social information processing.” Matt also read excerpts from the concluding contribution to the volume (pp 335-347) by Blasi himself entitled “Moral Functioning: Moral Understanding and Personality,” in which Matt discerned congruence with ideas represented in our recent discussion of value matrices, best reasons and basic motives.
Relevant to some of the excerpts read out and discussion of cross-cultural studies on moral development , Ethna remarked upon a recent convocation at a private high school with the theme “Our God is God of All” in which youth read prayers from diverse faith traditions including Hindu, Muslim, Buddhist, Christian Protestant and Catholic. She also associated discussion of a moral dilemma presented in a review of the research to an experience at another school on Grandparents’ Day in which a shy newcomer asked to join their party.
John’s remarks involved using conscience as a guide.
There followed discussion of addictions (eg substances, sexuality, gambling and the Internet) and addictive personalities, and more generally, of personal predispositions to harm. There ensued a description of templates for personalized harm prevention plans, such as those with clinical utility in conscience sensitive group therapy and those with moral educational utility in conscience sensitive medical education (e.g. Introduction to Clinical Medicine) and appearing in the Conscience Guide as well as some of our articles:
Roadblocks to making the turn-a-rounds depicted in green above (that is, making efforts to right one’s course by using autonomous coping skills and to retrieve affirmative values or goals) were envisioned. Among the roadblocks, Depression was seen as paradigmatic in torpedoing self –esteem. In this context, John reported on a program with the Chief of Chaplaincy at the VA Hospital entitled “Search for Meaning.” He described how persons engaged in this program listed things they saw themselves doing, and goals they saw themselves accomplishing but could not secondary to the Depression. Hence a useful distinction between Depression and demoralization secondary to Depression could be made. In her turn, Ethna looked at the other side of the coin: Depression as a result of meaninglessness, or a failure to seek meaning. Ethna also remarked on other conditions besides Depression including mood dysregulatory disorders across the lifespan.
In passing, John remarked upon the keen interest sometimes taken by patients in whether, after a clinic visit, there would be any record made of positive change in their Global Assessment of Functioning (GAF) score because it might be used against them to reduce benefits.
There followed inquiries by Ethna directed to John about genuine help from/for spouses and support from/for families to improve the adaptation of returning warriors. The threat of redeployment to recovery and restored functionality was readily recognized. There was discussion of “seamless transition programs” aimed at reintegration (in this connection John mentioned the work of L Harrison Reede MSW, LCSW). John also shared impressions of a conference sponsored by the North American Association of Christian Social Workers (NACSW) he had attended the day before (9/24/10): Serving Military Personnel and Their Families: What Every Christian Social Worker Needs to Know. John conveyed that– irrespective of the title– there was much valuable in the conference for any counselor. This conference included a panel discussion on “Battlefield Minds: Caring for the Spiritual Being of Returning Military Personnel and Their Families.” Major Jim Staggers Indiana National Guard was among the presenters. John recalled a particular remark made at the conference to the effect: if a person had experienced combat trauma and yet professed not to be changed as a person, in itself there would be sufficient cause for worry.
Find Conscience Chronicles at: http://iuconsciencenews.org
Find Conscience Works at: http://shaw.medlib.iupui.edu/conscience
The next meeting of the IU Conscience Project will be hosted by Ethna at her home on Saturday 1/22/2011 at 10:00 AM to noon.
Respectfully submitted,
1-7-11
Edited for Conscience Chronicles 3/19/11
Matthew R. Galvin
Conscience Project Meeting, Minutes 6-19-10
The meeting was conducted at Ethna’s home. Present were Ethna, John, Sister Mary, Deb H, Matt, Deb G, Beulah, Meg, Susan and Joe.
The minutes from the previous meeting 3-20-10 were reviewed and accepted.
Deb H. introduced herself. A psychotherapist currently practicing privately, Deb indicated her special interests and areas of expertise included bipolar spectrum disorders, borderline and narcissistic personality disorders, and adult attention deficit disorders. Before arriving in Indianapolis, she had practiced six years in Alaska and was involved in infant mental health. While preferring not to work with couples she said that she did conduct family therapy. Deb was welcomed to the Conscience Project.
Ethna said that Bernard Verkamp had sent an article she would like to forward to us. She is hopeful that he will be able to join us at some future point. Matt indicated he had finished Professor Verkamp’s book Moral Treatment of Returning Warriors and joined with John in recommending it.
Susan provided an update on the high school seniors who shoplifted while on school sponsored outings. All graduated. There was perhaps some reflection among participants but not much verbal commentary on this outcome. There followed a discussion about the maltreatment experiences of the basketball team member, recently in the news. Criminal charges had been dropped in favor of charges of misdemeanors. Questions and speculations came up regarding both the perpetrators and the victim. In the case of the perpetrators, the concern was to identify possible becauses for the serious harms they had inflicted upon their victim –was sadistic pleasure and domination the chief motive behind the vicious humiliation of another person? Then the question was raised, how did the perpetrators (and/or their defenders) rationalize what had been done sufficiently to reduce a charge of extreme violating behavior, indistinguishable from a brutal rape, to a charge of misdemeanor? In this regard, the cultures of hazing and abusive initiations coupled with a sense of entitlement or exemption were nominated as contributing to societal as well as individual minimization. In the case of the victim, there was concern to understand possible becauses for not disclosing the serious harms that had been endured. At several turns, the conversation we were having seemed to lend itself to applications of the Value Matrix (as had been utilized in group therapeutic and educational settings) in which participants might be engaged in identifying becauses, on the one hand, for abiding by and, on the other hand, for repudiating a particular mandate (which might be paradoxically stated as do engage in some form of vicious behavior) and then sorting through the becauses twice, first in terms of their relative goodness and second in terms of their relative strength.
Value Matrix (an example in the context of therapy)
Figure: Foursquare Organizational Schema.
The foursquare organizational schema (see Figure) is the graphic outcome of a dynamic process in which the therapist facilitates the patient’s self- examination of the valuational contents embedded in her conscience. Operationally defined, for any x, the inquiry takes the form:
If you (a person) went along with x, it would be because —- (fill in the blank).
The form in which x is put is a matter for the therapist’s discernment. The therapist may discern that the patient continues to harbor suicidality and so x may be given forms like ‘do make myself die’ or ‘do allow myself to die.’ Either form is treated as an urgent demand to which the patient is asked to make attributions: becauses both pro- (to abide the urge) and con- (to resist the urge). Alternatively, the therapist may discern that the patient is denying suicidality without a genuine repudiation of it (as in a ‘flight into health’) or is having heightened experiences of remorse which nonetheless threaten to deteriorate into self loathing or a self defeating attitude.
The therapist notes the patient’s initial because as a starting point for the dialogue but then stretches the patient’s moral imagination by hypothetically blocking the motivational power of whatever was put in the blank in order to elicit another because. The role of the therapist is to allow other becauses both pro- and con- to emerge. This may turn out to be an iterative process.
Meg highlighted how this process allowed for an appreciation of the incongruity (“minding the gap” as she put it in a recent presentation on conscience sensitive medical education) between goodness and strength often characteristic of our becauses. Both Susan and Ethna observed that values (as well as emotions, urges, impulses, and dispositions to do harm) are, however, still sources of motivation.
Beulah returned us to the topic which had emerged tangentially in trying to understand more egregious violations of persons, that is, the more or less accepted cultures of hazing and potentially abusive initiations in various institutions. Beulah acquainted us with initiation sequences with which she had become familiar in the US Navy and also provided background on ceremonies connected with ‘crossing the line’ (ie crossing the equator). She observed that historically there had been often only a thin veneer of civility in the conduct of these ceremonies, and sometimes even that thin veneer could no longer be discerned. Without safety monitors, harm could and would have occurred. Her impression was that that particular rite of passage had become much more humane and truly ceremonial.
Matt wondered how the activities of initiations into hierarchically organized institutions contribute to overall programs that expand the individual’s capacity to engage in egregious behaviors during war (or war like circumstances), which in other contexts would be contrary to the individual’s conscience. In this regard, there was reference made to Verkamp’s treatment of ‘concupiscence’ which, in spite of such indoctrination, might even afflict the warrior who engaged solely in sanctioned war behaviors (albeit with some level of awareness of satisfaction in being so engaged, an inability to sanction that satisfaction and accordingly experiencing a corresponding dis-ease). Some titles emerged that were deemed relevant to this part of the conversation: Koonz, C (2003): The Nazi Conscience, Belnap Press of Harvard University Press, Cambridge, MA; and two novels: Hegi, U(1994): Stones from the River, Scribner, New York, and Penman, S (1988): Falls the Shadow, Ballantine Books, New York.
There followed discussions of duties within institutions (eg in nursing and medicine) and the notion of separate applications of duties for separate selves in separate situations. The separate situations under consideration were professional and/or institutional vs personal. This discussion was highlighted by the query: “Is this [separate application of duties for separate selves] [a]good [notion]?” A subsequent query was: “Without necessarily invoking a separation of selves, what are our duties to institution, self and others and how are they to be reconciled (cf: the intrinsic value operating in the conscience domain moral valuation and the Valuational Triangle)?” Another subsequent query was: “Is it the role of the institution to support or to go against (personal/professional) conscience? [cf: MacIntyre A (1984) After Virtue, University of Notre Dame Press, Notre Dame].”
There was then a connection made to the value of equanimity (cf: the intrinsic value operating in the conscience domain moral emotional responsiveness), permitting segue as Sister Mary recalled that John, in reference to his work with returning warriors, had said “The key to change is acceptance.”
Matt recommended a book he was reading: Radden J and Sadler J (2010): The Virtuous Psychiatrist, Character Ethics in Psychiatric Practice Oxford Press. The authors are a Professor of Philosophy at U of Mass/Consultant in Medical Ethics at McLean Hospital and Professor of Medical Ethics and Psychiatry at UT Southwestern, respectively. While the authors sometimes become preoccupied with claims (appearing somewhat tenuous to Matt) to ethical concerns emerging sui generis in psychiatry as opposed to health care professions in general, their book is definitely an important resource for most mental health professionals and also health professional educators involved in teaching ethics and professionalism. Their inclusion of the inner states available to the consciousness of the virtuous psychiatrist in their case illustrations is noteworthy and likely to be much appreciated. The discussion of the awkward progression of the learner from mimetic compassionate behaviors to genuine empathy is given considerate attention—putting one in mind of how painfully problematic for integrity the admonition ‘If you would like to be good then find someone who is good and begin by acting as he or she does’ can be in the learner’s life. While he wished to make more of a study of it, Matt pointed out some apparent differences between the authors’ virtue based approach to psychiatric ethics and the conscience sensitive approach taken in our annual course for PGYIII residents in Conscience Centered Psychiatric Ethics. Aspects of the conscience sensitive approach that seem to differ from the virtue based approach include, in the former, the deliberate progression from an understanding of developmental moral psychology (specifically that of conscience formation and functioning) to ethical concerns that honor the intrinsic values operating in each conscience domain as well as traditional bioethical principlism. In the conscience sensitive approach there is a recognition that persons ‘coming to know together’ in order to resolve whether or not –and then how– to take moral action, already arrive with consciences likely to be contoured differently from one another as well as being possessed of varying dispositions towards deontologic, consequentialist, virtue based and intuitionistic resolutions to moral dilemmas and issues. In the conscience sensitive approach there is also emphasis upon the potential contributions that might be made by psychiatrists, psychologists, other mental health professionals, and educators who are grounded in this particular developmental moral psychology. These contributions might be made not merely in psychiatry but in any field of ethical inquiry.
With reference to attitudes and behaviors of consumers of fossil fuel at the local pump (for example) on the one hand and the BP Gulf Oil Spill (for example) on the other, Beulah observed how, in modern times, consequences have become very far removed from our actions. This led to much affectively laden discussion about remarks, already infamous, made by the BP CEO to the effect he longed for his life back and what seemed to many a condescension acknowledging the suffering of ‘the little people’. While animated, our discussion remained respectful of one another’s sentiments, and perhaps in consequence flowed along separate currents away from the topic of oil. None present seemed disposed to forgive corporate greed, failure of stewardship or lack of accountability, but some remarked upon the CEO’s unfortunately limited facility in the language he was obliged to speak. Others expressed commiseration /gratitude that they were not in the position of the CEO. Sister Mary wondered about the phenomenon of people evincing grudging respect for the scofflaw so long as the scofflaw cleverly evades detection (“You gotta like them!”) giving way under public scrutiny to people’s disposition to crucify those who have been exposed or upon whom blame is laid.
One current flowed away from the topic of oil to the topic of vitriol with attention being paid to how sometimes (maybe more and more of the time) there is obligatory polarization on issues. With separation into two camps nothing resembling civilized discourse endures. Rather we are offered a spectacle of opposing pundits judging and crucifying one another. Joe opined that once a person possesses a polarized opinion, all new incoming data is filtered according to whether it can be used to sustain or confirm the opinion. Moreover, under polarized conditions, there is lack of compassion in the social judgments made by and upon the persons at antipodes. At this point it was observed that we might well have been discussing how modern political arguments and ethical discourses can be distinguished. In political argument opponents engage on the diagonal of any given value matrix, solely representing their own best reasons while only allowing their opponents’ base motives. In ethical discourse, the ethicists desire to engage each other on the level of best reasons while making explicit (and attending to) their own base motives (eg conflicts of interest).
Valuation Matrix cont.
Political Discourse
The Valuation Matrix in Political Argument
Ethical Discourse
The Valuation Matrix in Ethical Discourse
Only imagine valuational matrices in 3-D with all moral stakeholders brought into connection and organized in an array in which sapiential and practical authority are distributed, authoritarian hierarchy minimized and accountability shared.
There is a resemblance to an adaptation of the square of oppositions that can be used to depict therapeutic progress in the context of psychotherapy.
The Square of Common Cause
THE SQUARE OF COMMON CAUSE (adapted from the square of opposition in syllogistic logic) and the representation of maintenance of the therapeutic frame is depicted above. The square maintains integrity only if the strength of the concordance at the top (represented by the bi-directional vector) plus the work done effectively to prevent excesses on either side (represented by unidirectional vectors) together exceed the disintegrating forces generated at the base by the contrarieties at antipodes, plus those distortions of perception diagonally directed from corner to corner. However, many will have concluded through their own work that D is unpredictable, a wild-card, that can sometimes be positive and transformative.
Returning us to persons who violate or cause harm, Sister Mary and Susan joined in an inquiry how blame and responsibility ought be assigned depending upon the disposition to cause harm arising from a person’s reduction to survival mode, versus a person being prone to “just going along” versus a person given to deliberate viciousness. Ethna followed on the heels of this inquiry with another about genetic predispositions not only to survive but to save, protect and act on behalf of others (eg altruistic versus egoistic motivations). John observed that looking back in judgment on one’s action may truly be a luxury. A fireman, he said, although trained to fight the fire in a house and make judgments accordingly is not prepared for the floor of the house to cave in. The situation will determine the reflexive action.
Deb brought her illuminated copy of The Lyric of Lafracoth to show and was complimented on her work. Susan said the illustrations put her in mind of embroidery. Matt asked everyone to keep the work in mind should they encounter persons who might consider it for adaptation for theatre (college, amateur, or even professional) as well as persons in a position to consider the work for publication. Ethna said that she hoped to be in touch with a philosopher /medieval historian and an Irish scholar involved in theatre both of whom might have some ideas.
Illus. from The Lyric of Lafracoth
Meg gave an account of the reflective group experience she and Matt conducted last November as guests of Reverend B at a local church. The class was entitled “Understanding Conscience in Ethics and Faith Experience.” There were six sessions modeled after the conscience work done in Introduction to Clinical Medicine I, Conscience Centered Psychiatric Ethics and the Senior Elective in Ethics. A Guide to Conscience prepared in 2007 by Conscience Works editorial staff with special assistance from Sister Mary and Tamara H was our workbook. Reverend B was joined by the Very Reverend G to carry the conversation forward into the context of the faith experience in that community.
Upon conclusion of the class, Reverend B sent word that:
[T]he feedback was stellar. Participants enjoyed the opportunity to explore the topics of conscience and morality in depth … a safe and holy space for conversation [was created] and the discussions around the table were fascinating and allowed us to know ourselves and know one another more deeply. This format for short-term courses on Sunday mornings was an experiment for us, and I could not have hoped for a better outcome.”
This first venture into a faith community was experimental for the Conscience Project as well and Meg and Matt were likewise encouraged by the experience. The format employed for the reflective group experience seemed to work well.
Birthdays in July were acknowledged among Conscience Project participants. Susan reported that 16 of her school’s seniors achieved first place nationally in recognition for service for Earth Day through “the League,” for the second year in a row. According to its website, the LEAGUE combines service, learning, and friendly “co-opetition” with live, interactive events (www. theleague.org).
Joe concluded the meeting with an update on academic cheating.
All depictions and illustrations used in this Summary are under copyright © 2010 IU Conscience Project.
Used by permission.
Find Conscience Chronicles at: http://iuconscienceproject.org/
Find Conscience Works at: http://shaw.medlib.iupui.edu/conscience/
The next meeting of the IU Conscience Project will be hosted by Ethna at her home on Saturday 9/25/10 at 10:00 AM to noon.
Respectfully submitted,
9-9-10
Edited for Conscience Chronicles
9/28/10
Matthew R. Galvin
Medical Schools, Students, and the Conscience Policy
Most medical students enter their professional educations with a “moral integrity” or “conscience”, but can they keep it and their careers?
Not long ago, March 2009, a counseling student was dismissed from her graduate studies when she refused to see a patient regarding his same-sex relationship. Julea Ward insisted that advising the client would conflict with her religious convictions. Insisting that her refusal to treat the patient violated her obligations as a counselor, Eastern Michigan University asked Ward to leave the program. Claiming that her constitutional rights of freedom of religion and speech had been violated, Ward sued the school. (The case was dismissed earlier this year. For more about Ward v. Eastern Michigan University, visit: ACA/Julea Ward case: Eastern Michigan University.)
Not every conflict between personal conscience and professional ethics leads to a lawsuit, but Ward v. Eastern Michigan University is a reminder of what is at stake for students and educators in an increasingly pluralistic culture. Although Ward was not enrolled in a medical school, it also prompts some interesting questions for medical educators and students, including: What should medical students do when they object on moral or religious grounds to an aspect of their professional education? How should medical schools respond to these conscience-based objections? And why should any of us care about the divergent scruples of a medical-student-ethics-outlier here and there?
To address questions like these, Mark R. Wicclair, in “Conscience-based exemptions for medical students”, reviews the most current professional standards for respecting and responding to the conscientious objections of medical students. Wicclair reminds us of the recent history of policy development regarding conscience-based exemptions (CBE); addresses the reasons for and against granting medical students CBEs; and stresses the importance of clear institutional policies on the subject.
According to Wicclair, good reasons for permitting CBEs for medical students, include:
1. Allowing objections on “conscience” preserves student’s professional sensitivity to ethical issues. (Wicclair notes that 62% of medical students feel that their education has led to an erosion of their ethical principles.)
2. Granting CBEs will sometimes lead to a more ethical medical school and profession. (Wicclair provides, as an example, the student-driven opposition to the use of animal laboratories for student training. Today, only a few medical schools still use animals in this way.)
3. Denying CBEs discourages building and keeping a diverse student body.
4. Outright denials of all CBEs undermines students’ moral integrity. (Given the importance of the conscience to self-perception and identity, such undermining could be considered a harm and a violation of the principle of respect for persons.)
After building the case for CBEs in medical education, Wicclair turns to the challenges of validating and addressing objections without compromising a rigorous professional curriculum. Schools have grounds for denying CBEs when these objections:
1. Conflict with core educational requirements. (Both the LCME and the AAMC provide curricular standards and guidelines which can serve as a basis for denying conscience-based exemptions.)
2. Conflict with local core requirements. (Some medical schools serve unique populations or have missions which necessitate local curricular requirements. These too could serve as a basis for denying CBEs.)
3. When the objection is not “conscience-based”, but, rather, is based on “invidious discrimination”. (To refuse a patient in disdain of their personal characteristics, is not an act based on conscience.)
4. When granting the CBE would unavoidably harm a patient or colleague.
Even with Wicclair’s criteria in mind, deciding when to grant and when to deny a conscience-based exemption for a medical student is a tricky task. To anticipate these decisions and to support the moral integrity of current and future students, Wicclair advises the implementation of clear, readily accessible policies on how a medical school will address conscience-based objections. In addition to complying with AMA guidelines (see: AMA Policy H-295.896), maintaining an operational policy on CBEs gives prospective students an opportunity to make good choices about the school to attend. A policy on conscience-based objections shows that universities are sensitive to the developing professional consciences of its students. Perhaps a proactive CBE policy would have averted the impasse between Julea Ward and the Eastern Michigan University. At the very least, a conscience sensitive medical education builds a stronger profession–one that values the moral integrity of the provider while protecting patients; one that benefits everyone.
Reference:
Wicclair MR. Conscience-based exemptions for medical students. Camb Q Healthc Ethics. 2010 Winter;19(1):38-50. PubMed PMID: 20025801.
Related:
AMA Policy H-295.896: Conscience Clause: Final Report
Gaffney M, Galvin M, Stilwell B. Conscience sensitive medical education. The Conscience Project, Indiana University School of Medicine. 2002. [PDF - 837 KB]
Meg Gaffney and Eric Meslin. Sound Ethics: Medical Conscience. Sound Medicine. April 5, 2009.
Guttmacher Institute. Refusing to Provide Health Services. State Policies in Brief. September 1, 2010. [PDF - 241 KB]
Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI. Understanding the clinical dilemmas that shape medical students’ ethical development: questionnaire survey and focus group study. BMJ. 2001 Mar 24;322(7288):709-10. PubMed Central PMCID: PMC30097.
