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Art Therapy: Journal of the American Art Therapy Association

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Ethical Dilemmas of Providing Pro Bono Art Therapy

Bruce L. Moon
a a

Milwaukee, WI Version of record first published: 21 Dec 2011.

To cite this article: Bruce L. Moon (2011): Ethical Dilemmas of Providing Pro Bono Art Therapy, Art Therapy: Journal of the American Art Therapy Association, 28:4, 181-184 To link to this article: http://dx.doi.org/10.1080/07421656.2011.622696

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Art Therapy: Journal of the American Art Therapy Association, 28(4) pp. 181184

AATA, Inc. 2011

Ethical Dilemmas of Providing Pro Bono Art Therapy

Bruce L. Moon, Milwaukee, WI
Abstract
This viewpoint addresses ethical questions regarding the provision of art therapy as a pro bono service, a term from Latin roots that mean for the public good. Approaches to ethical reasoning are discussed using the case of pro bono art therapy in a residential treatment program for adolescents. The expression pro bono derives from Latin root words meaning for the public good (Merriam-Webster, 1996). Pro bono commonly describes professional work undertaken voluntarily as a public service and without payment. Unlike traditional volunteerism, in pro bono work professionals use their specialized skills to provide services to those who are unable to afford them. There is a long tradition of pro bono service in the legal and health care professions but literature on the ethics involved in such service is scarce. Ethical Principles for Art Therapists (American Art Therapy Association, 2011) does not address pro bono service; a review of the ethical codes of related professions finds sparse or nonexistent references on the matter. For example, the American Counseling Associations (2005) Code of Ethics states, Counselors are encouraged to contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return (pro bono publico) (p. 4). Although this is a fine aspiration it offers the clinician little guidance for ethical considerations that may arise in pro bono situations. For several years I have been providing art therapy pro bono on a weekly basis at a residential treatment program for adolescents. My arrangement with the facility is that I am referred those clients who are particularly resistive to engaging in therapy. Nearly all of the adolescents I interact with there have good reasons to be suspicious of adults and most of them actively avoid direct discussion. Consequently I use my art practice as an effective means for establishing relationships in both individual and group art therapy, in particular, helping clients form positive therapeutic alliances with an adult. It should be noted that at the time of this writing there is an art therapist on staff at the facility. However, there are more clients in need of art therapy services than either the employed art therapist or I can possibly treat. Recently I have grappled with a number of ethical questions regarding my participation in the program; this viewpoint is an effort to explore these questions further, to examine ways of thinkEditors Note: Bruce L. Moon, PhD, ATR-BC, LPC, HLM, is Professor and Chair of the Art Therapy Department at Mount Mary College, Milwaukee. WI. Correspondence concerning this viewpoint may be addressed to the author at moonb@mtmary.edu
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ing about them, and perhaps (but not necessarily) to resolve them.

Why Provide Pro Bono Art Therapy?

Why might an art therapist choose to provide pro bono services in the first place? One explanation is that it is an expression of altruism and social action through which society, or its individuals, derive benefit. Pro bono service is a way for professionals to give back to their communities, particularly in programs where these interventions may be financially out of reach for the individuals in question. Providing pro bono service also can be personally gratifying and life enhancing for the practitioner. The practice may offer novel professional opportunities that would be otherwise unavailable to art therapists in their places of employment, thereby broadening their clinical skill set. I am fortunate to be in a phase of my life where I am able to lend my expertise to others without needing to be reimbursed for my services. I am also fortunate to work in an academic institution that is deeply committed to social justice and service to the world. Pro bono service is regarded by my colleagues and my employers as a positive expression of the institutions mission to transform the world. Because service is one of the primary criteria used to evaluate faculty members, my pro bono activities also are seen as a logical extension of my responsibilities as a tenured professor. I love my work as an art therapist and because art therapy education is at present my primary occupation, I find that providing clinical services to the residential treatment facility keeps my skills current. Pro bono service also nurtures my work as an educator in that I can share with my students clinical vignettes that are fresh and based in a contemporary work setting rather than telling worn-out stories from 20 years ago. I have often told prospective students that I have been blessed by being an art therapist in that I would have probably done what I do for free had I not been fortunate enough to find employers that would pay me.

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Ethical Questions From the Pro Bono Clinical Context

In order to provide a context for the ethical questions raised in this viewpoint I will describe one of the clients with whom I work. Zeb (pseudonym) was a 17-year-old adolescent who had been sexually and emotionally abused by his biological parents. He was a large young man, overweight and with poor personal hygiene. It was difficult to assess his developmental level because he seldom spoke and could not

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write. When the referring therapist described him to me I thought she was exaggerating as she described his nonverbal nature. But in the first 8 hours of sessions with Zeb he said a total of 11 words, and most were monosyllabic. The following poem is my attempt to capture what it was like to work together:
There is darkness through the window Washed in sullen street light I paint . . . Zeb paints Secrets from a past he will not recall His fingers brush the mystery Of un-recounted history And I wonder at his life The shame and betrayal that brought him hereall the tainted scenes of home that haunt his memory the words he did not hear and the roles twisted and unclear cast in shadows and echoed reverberations making their way aching to be let go the rumbling and grumbling of an appetite never satisfied He paints with Colors oozing Sense of time confusing Is he recounting corruption, habitually says nothing at all sometimes he sighs, nhyuuuh I look at this man/boy and wonder Whyd they do what they did to you Whyd they do what they did to you Zeb looks at me Then turns the other way Streetlight through the window He turns his eyes away Inside my head the Who sing I cant reach you With arms outstretched I cant reach you I crane my neck I cant reach you Still, we paint, each Thursday From 3:30 to 4:30, week after week We paint One day I see an attendant walking across the parking lot. She waves, asks, what are you doing with Zeb I wonder why She says, hes always ready to go on Thursday afternoon Stands by the door waiting to be taken to you Usually we have to push himalmost drag him But not on Thursday afternoons Hmmm, whadya know He begins . . . he always begins by Staring at the canvas Just sitting, staring And then, at some secret inner signal paint begins to flow Blueblackredyellow

Are these feelings he keeps hidden shades that gush and splatter in a rushing river Of pain and passion My words cannot tell you Of the violence and loss and the unspoken cost Zeb, whyd they do what they did to you Whyd they do what they did to you He paints a forest and a river and a tent and a campfire . . . no people I am watching . . . I paint two people by the fire He looks at me, smiles I ask, what color should your shirt be, I ask Red, he tells me He paints a city at night and fishing pier I am watchingI paint a colorful fish And when the attendant comes to take Zeb Back to the unit, Zeb points to the pier Points to the fish Says to the attendant, Look. What this all means to him I can only guess His treatment team leader wants to know Zebs team leader wants my expert opinion my pathological interpretation of his paintings my calculation of his DSM number my prognostic assessment of a past Zeb will not tell and I am speechless

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Among the various ethical quandaries in this brief vignette are those related to the provision of a safe, predictable milieu, the interpretation of images, transference and countertransference, concern for whether or not to make art alongside clients, diagnosis and assessment, and communication with other professionals, to name a few. On the surface this situation seems to offer a positive outcome for all concerned: Zeb (and others like him) gets the benefit of my services and the facility benefits from receiving free clinical expertise with clients who are difficult to treat. I benefit from practicing my clinical skills and my employer benefits from my practice of living out the institutions mission. However, a number of ethical issues embedded in the case are worth examining. As the director of a graduate art therapy program I am aware of the adverse impact that the current economic situation in the United States has had on graduates seeking employment. Numerous treatment facilities have gone through downsizing and jobs for new and seasoned art therapists alike are hard to come by. Thus, one question that arises is: Does an art therapist who provides pro bono service shrink the opportunity pool for others who need jobs and is this ethical? Put more bluntly: Why would the residential treatment facility where I provide free services hire a new art therapist to whom they would have to pay asalary and provide benefits? I also know that art therapy is effective for many clients. The facility in question is struggling in the current financial climate and may have to cut services. Given these realities, would it be ethical of me to withhold my services in order to

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attempt to force the program to retain the current art therapist under their employ or to hire additional art therapists? But if I withdraw from providing services to the adolescents would I be doing them harm? What ethical decisions do I make in this matter? The study of ethical issues in art therapy is at base an exploration of our professional moral values. Whenever practitioners begin to grapple with morality, of course, they confront cultural norms, family mores, religious influences, political leanings, legal ramifications, and personal values. All of these intersecting elements create nuanced challenges that can be daunting, disconcerting, and difficult.

Examining Questions With Modes of Ethical Reasoning

Historically ethicists, theologians, and philosophers have identified three primary modes of ethical thinking (Fletcher, 1966). They are (a) deontologicallegalistic, (b) antinomian, and (c) teleologicalutilitarian/situational. The ethical doctrine of deontology holds that the worth of an action is determined by its conformity to some binding rule rather than by its consequences (Moon, 2006). As I have written previously (Moon, 2006), art therapists who consider ethical dilemmas from this perspective enter into problem situations with a set of preestablished rules and regulations in the form of a code of ethics (p. 5). Solutions to particular ethical dilemmas are preset and the primary thinking one must do is to determine which rule applies to a given circumstance. The antinomian mode of reasoning, by contrast, is the opposite of legalism and views each situation as unique; antinomianism argues that people must rely upon the moment itself to provide its own ethical resolution (p. 7). In contrast to deontologists, who are guided by the written rules for behavior, antinomians are anchored in the belief that there is no underlying order to consider. They are so averse to rules that their ethical decisions may appear to be entirely unpredictable. Finally, teleological reasoning evaluates conduct in relation to the end or ends that it serves. When art therapists reason from the teleological perspective they make decisions regarding ethical problems with an eye toward bringing about the greatest good for the greatest number (Moon, 2006). The ethical dilemmas presented in the case vignette can be reexamined from these three modes ethical reasoning. Does an art therapist who provides pro bono services shrink the opportunity pool for art therapists who need jobs and is this ethical? From a deontological perspective, one can consult the document Ethical Principles For Art Therapists (AATA, 2011). Because there is no direct reference to pro bono service in that document, one must look for guidance indirectly. The question seems to relate to the viability of the art therapy profession, which is discussed in Section 9, Responsibility to the Profession: Art therapists respect the rights and responsibilities of professional colleagues and participate in activities that advance the goals of art therapy (subsection 9.0, p. 7) and Art therapists value participation
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in activities that contribute to a better community and society (subsection 9.5, p. 7). Using deontological reasoning, if the rule is that I must respect the rights and responsibilities of professional colleagues and participate in activities that advance the goals of art therapy, then subsection 9.0 implies that I should not provide pro bono services. It could be construed that my provision of free service may intrude on another art therapists potential hire. On the other hand, subsection 9.5 suggests that I should participate in activities that contribute to a better society. Thus, there is a deontological conflict built into this point. Superficially, deontological legalism frees art therapists from the uncertainties of having to take personal responsibility for their behavior. However, as evidenced in this discussion, selecting the appropriate rule and deciding on the proper interpretation of the rule is seldom a simple task. The rules can, and often do, simultaneously point in two different directions. Approaching the question from a teleological perspective, I have to consider the various pros and cons of providing pro bono service with a mind toward determining how to ensure the greatest good for the greatest number. In essence I must ask whose needs are more pressing, the adolescent clients who would benefit from my services or the art therapist seeking employment at the institution. However, there are no clear guidelines for resolution other than that I carefully weigh the benefits and the consequences of my actions. Thus, I might reason that I have a responsibility to provide pro bono art therapy services because I know it benefits the adolescent clients and the institution. Because the facility is facing potential cuts in services, I could argue that withholding my services might encourage hiring additional art therapists. On the other hand, providing these services carries out my responsibility to my profession by helping to spread the word about art therapy. Perhaps the institution will be in a better financial situation over time to hire additional art therapists. In any event, it is clear that I would have to assess the relative merits of pro bono service, taking into account the welfare of clients and what is best for the professional community. I would need to think about the consequences of my actions in the context of many relationships. This discussion leads to yet other questions. If I withdraw from providing art therapy to the adolescent residents would I be doing them harm? Given that I am able to provide pro bono service, do I have an ethical responsibility to do so in order to improve the quality of therapy that clients may receive? From a deontological perspective, I do not have to look very far to find an applicable section of Ethical Principles for Art Therapists (AATA, 2011). Section 1.0, Responsibility to Clients, states that art therapists endeavor to advance the welfare of clients, respect the rights of those persons seeking their assistance, and make reasonable efforts to ensure that their services are used properly (p. 2). If this principle is approached as a rule then I am compelled to provide art therapy because this would advance the welfare of the clients. From a teleological perspective, however, I would have to determine what course of action provides the greatest good for the greatest number. I would ask myself to whom am I most responsible,

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and I would carefully consider the consequences of my decisions.

Conclusion
It is impossible for any ethics document to address every dilemma that an art therapist might face. The development of a vigorous set of ethical principles for art therapists work, according to the American Art Therapy Association (2011), requires a personal commitment and constant effort to act ethically; to encourage ethical behavior by students, supervisees, employees, and colleagues; and to consult with others concerning ethical problems (p. 1). It could be argued that the lack of specificity regarding pro bono service is a shortcoming of that document. However, I assert that the document is aspirational by design: It is intended to lay out principles of ethical behavior that practitioners aspire to rather than to provide a set of commandments. As such art therapists are encouraged to think deeply about the circumstances of their professional lives and to strive to act ethically. This, I believe, demands a higher level of commitment, and certainly more conscious effort, than simply adhering to a set of legalistic rules. In this viewpoint I have not resolved the questions I raised regarding pro bono art therapy. Nor have I done so

in real life. I continue to struggle with the ethical questions that emerge as a result of my voluntary practice. It would be much easier if there could be a book of rules that would simply tell any art therapist what to dowhether to continue or desist. We must instead use our abilities to reason, to wrestle, and to search for answers to the ethical dilemmas of practice.

References
American Art Therapy Association. (2011). Ethical principles for art therapists. Retrieved from http://www.americanartther apyassociation.org/upload/ethicalprinciples.pdf American Counseling Association. (2005). Code of ethics and standards of practice. Alexandria, VA: Author. Fletcher, J. (1966). Situation ethics: The new morality. Philadelphia, PA: Westminster Press. Merriam-Webster. (1996). Merriam-Websters dictionary of law. Springfield, MA: Author. Moon, B. L. (2006). Ethical issues in art therapy (2nd ed.). Springfield, IL: Charles C Thomas.

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