Moral Crises in Clinical and Forensic Assessment
By Amir Ramezani, Ph.D.
Center for Cognition and Compassion
When faced with a moral crisis, remember that the choices we make not only define who we are but also shape the world we wish to live in.
- by Unknown Author
As I sat across from the recent mental health graduate, I couldn't shake the feeling of existential doubt that had been gnawing at me for some time. The sterile room felt colder than usual, its fluorescent lights casting an unforgiving glare on the situation at hand. "What am I doing?" I silently questioned myself, the doubt lingering like a persistent shadow.
The young woman before me had come seeking an assessment for a potential disability claim, alleging a head injury and PTSD. She looked at me with a mix of anticipation and trepidation, as if she knew the script we were about to follow all too well. Her voice trembled slightly as she probed, "Are you going to ask me about my memory and my nightmares?"
I obliged, though deep down, I wondered what difference it would make. She responded with rehearsed precision, offering textbook descriptions that mirrored those from the Diagnostic and Statistical Manual of Mental Disorders. She detailed memory lapses and moments of lost consciousness, textbook symptoms that could lead to a diagnosis of mild neurocognitive impairment. Records said otherwise. She then shared her experiences of nightmares, flashbacks, hypervigilance, and avoidance, the classic criteria for diagnosing PTSD. She had gone through a great extent to tell multiple professionals similar phrases, though no formal diagnosis had been given. She was having financial challenges and needed this claim to go through, and the pressure was palpable in the room.
As I diligently transcribed her words onto paper, a wave of self-disgust washed over me. Why was I here, reduced to the role of a mere conduit for her disability claim?
I felt like an automaton, a typewriter that merely transformed her narrative into a bureaucratic document.
I was aiding her goal for financial support, but at what cost to my own sense of purpose.
Yes, I could administer validity and malingering measures to ascertain the legitimacy of her claims, but would that truly answer the deeper question nagging at me – why was I doing this kind of work? The answer was painfully clear: it was the money. I needed to make ends meet, and this work provided a reliable income. My own economic and financial hardship as a person of color (POC) in a fast, high-cost region had led me to the same point she was in. Both of us here, in the room, with a similar path point, though with different journeys. Both of us POCs and facing the fact that most POC don’t come from generational wealth or financial literacy.
But in the midst of this moral crisis, I couldn't help but reflect on what truly mattered. That is, what about my intention in my profession to help people and communities and what about my purpose? Was it all reduced to a paycheck? I couldn't deny that my financial security was tethered to this unfulfilling endeavor. The prospect of quitting seemed tempting, yet equally daunting. What would I do if I stepped away from this role? As these thoughts swirled in my mind, I realized that it wasn't the work itself that had lost its meaning, but rather the way I had allowed it to be reduced to a mere transaction. There was a purpose, a deeper calling buried within the seemingly mundane tasks I performed. What is that purpose?
I was experiencing a moral crisis. The moral crisis I faced while assessing individuals who may be exaggerating or outright lying about their conditions added a complex layer to my already introspective journey. As a professional in the field of disability assessment, it was my duty to uphold the integrity of the process while also preserving my own sense of ethics and compassion. The struggle often began when a claimant exhibited inconsistencies or signs that raised suspicions about the legitimacy of their claims. These situations were more common than I had anticipated, and they stirred within me a profound sense of unease.
There was a constant battle between the obligation to ensure fairness and the temptation to cast doubt on those who might be attempting to manipulate the system for their own financial gain.
Each time I encountered a potentially dishonest claimant, it was as if I were presented with a moral crossroads and a painful sensation in my gut saying “what is going on here!” On one path, there was the possibility of dismissing their claims outright, preventing potential misuse of the system, and protecting limited resources for those who genuinely needed them. This would protect and allocate resources to appropriate individuals in the community. On the other path, there was the risk of dismissing someone who might be struggling silently, facing hidden demons, and desperately seeking assistance. It was during these moments that I questioned the purpose of my work more profoundly.
I grappled with the ethical dilemma of whether I should become a gatekeeper, rigidly applying my judgment to discern truth from deception, or whether I should become an advocate, striving to understand the deeper complexities of each individual's situation.
The realization dawned that my role should not be defined by a rigid binary of right and wrong, truth and deception. Instead,
I needed to navigate the wild sea of the mind and gray zones with empathy and fierce compassion. My moral crisis prompted me to approach each case with a compassionate skepticism, allowing room for doubt while remaining committed to seeking the totality of the truth.
Yet this story is not about me alone. It is about any clinician who face similar moral dilemmas in their clinical and forensic work.
What would you do if faced with this situation? What if a client is seeking you out for therapy to document their impairments. What will you do when a client is requesting you to form a diagnostic and functional opinion about their trauma because they have been involved in a personal injury claim without your knowledge. How would this impact your counter transference? Can you see the client in the same empathic and compassionate way if they are deceptive and disadvantaged?
While I don't possess a definitive solution, I can offer some constructive strategies to navigate moral dilemmas effectively. Seeking supervision or consulting with a trusted colleague can illuminate your practice's true objectives and help uncover the underlying motives driving your responses and reactions. It's essential to explore potential courses of action that align with your individual morals and professional ethics. Explore the cultural and societal financial limitations. By delving into the roots of internal and external conflicts, both within your own culture and with others’ cultural system who are involved, you can cultivate self-awareness and gain valuable insights. Additionally, examining the sociocultural constraints and environmental pressures that may lead individuals to deviate from socially accepted norms can foster understanding, compassion, and rational decision-making. A comprehensive assessment of consequences, spanning individual, family, societal, financial, professional, and moral dimensions, can further enhance your grasp of the moral dilemma at hand. Maintaining a delicate equilibrium between personal and professional boundaries is crucial, preventing emotionally driven decisions and preserving your comfort zone. Finally, prioritizing self-care can offer new perspectives and directions in both your personal and professional life.
About Amir
Dr. Amir Ramezani is a psychologist, professor, expert witness, and a creative at heart.
For questions and comments about this essay, contact Amir at ramezani.amir@gmail.com.