Heinz Dilemma story as presented in this practice:
Once upon a time, a long time ago, there was an old couple, a man and a woman who had been married for many, many years and lived in a small town in Europe – (to the younger kids “you know where that is, right?). One morning they got up and the woman was feeling sick, which was unusual because she was always a pretty healthy lady. So, she and her husband went to see the town doctor. The doctor took her back into his office for a long time, examined her and ran a lot of tests.
Some time later, he came out to talk with the husband. He said “I’m very sorry, but your wife has a rare form of cancer”. The old man was shocked, and he said “Well, is there anything we can do?”
The doctor said, “Well, there’s only one cure for the cancer, and that’s a drug that’s been developed by the pharmacist in the town next door, so I’d suggest you go there and get the drug from him.” The old man said “OK, I’ll do that as soon as I can.”
The next morning he got in his horse-and-buggy and took the long drive down the mountainside to the next town. When he got there, he located the pharmacy and went in, introduced himself to the pharmacist, and explained to him that his wife had just been diagnosed with this rare form of cancer and the doctor told him that the pharmacist had a drug that could cure her and was that true?
The pharmacist said “Yes, that’s true. I do.”
And the old man said, “Well then, I’d like to buy it from you.”
And the pharmacist said “Alright. I sell it for $2000 dollars.”
The old man was surprised and he said “Gee, that’s a lot of money.”
The pharmacist said, “Well, I know it is, but the drug was expensive to develop, and I’m entitled to get some kind of profit out of it, so I only sell it for $2000.”
So, the old man said “Well, I don’t have anywhere near that much money. Can I pay you as much as I can now and pay the rest as I can?”
The pharmacist said “No, I’m sorry, I only sell it for the $2000.”
The old man said “Well, I guess there’s nothing I can do.”
And the pharmacist said “Well, I’m really very sorry.”
And with that, the old man walked out, got in his horse and buggy and took the long drive back up the mountainside to his home, thinking all the way about what to do. That night, he drove back down to the town, and he broke into the pharmacy and stole the drug.
Now, the question is, should he or should he not have stolen the drug, and why?
Boy, 13 – “No, he could have done it another way” Stage 4
Boy, 12 – “Yes, it was wrong, so he should have stolen the drug because his wife might die” Stage 2/3
Boy 10 – “He should have because I wouldn’t let her die”. Stage 2/3
Girl, 9 – “No, the police would be arresting him and then he would go to jail and his wife would be alone.” Stage 3
Boy, 12 – “Yes, he really cares for his wife and wanted to save her and didn’t care what was right or wrong.” Stage 4
Girl, 15 – “No, he shouldn’t because he’ll get arrested and he’s not going to win in the end” – Stage 2
Boy, 14 – “Yes, it was OK to take the medicine because he cared more for what would happen to his wife than what would happen to him.” Stage 4
Girl, 16 – “He probably shouldn’t steal it because if he gets caught it won’t do his wife any good and then she wouldn’t have him around, but if it’s the only way to get the drug, then it was OK”. Stage 4
And the winner is: Boy, 11 – “He should have stolen the drug because his wife had cancer and he wants to show that he really loves her and cares for her and that it was OK to steal even though others may have the cancer. He thought he had to because he doesn’t want his wife to die and he loved her. He may have a high price to pay for the theft because he may have to go to jail, but jail is only temporary.” Scoring is 3 + 4 = 5++
Assigning a level value to Heinz Dilemma responses was often less than straight forward. With the child and young adolescent population, distinguishing between level 2 and 3 could be difficult, introducing a degree of subjectivity if the rater was required to score a specific number. Older adolescents were less problematic. As far as adults and higher functioning adolescents are concerned, one common type of answer is that ‘stealing the drug was appropriate because life is more valuable than property (or profit), a response that could fit either stage 4 or 6, but not really 5. That is something of a trifle when compared to the benefits of the exercise.
Kohlberg’s system paired the six stages into three broader groups, the first two stages being Pre-Conventional, the second two Conventional, and the last two Post-Conventional. My own interpretation coming from a developmental framework for the three groups is that: stages 1 and 2 focus on the needs of the individual, the first being a very concrete choice of good or bad, and the second exclusively focusing on the individual’s own needs; the Conventional third and fourth stages focus on self-and-other relationships, or how to act in ways that at least considers the needs and rights others, and the importance of obeying the rules that lead toward social order; and the last two stages of the Post-Conventional refer to moral decision making that was based on broader principals that stressed the importance of societal needs and conventions, and universal principles of justice.
As with Erikson, Piaget, Hy, et.al., and other developmental theorists, Kohlberg’s view is that an individual’s moral development goes through an identifiable and sequential series of steps or stages that do not reverse, except as a result of cognitive diseases or disorders. The pertinent question here is whether effective mental health treatment, particularly of the young, can foster the growth of moral developmental.
The stages of psychosocial and cognitive growth as per Erikson and Piaget, resp., seem more biologically than experientially rooted, metaphorically being rivers that ‘can’t be pushed’. The effect of therapy is more one of enhancing one’s thoughts and behavior to make the experience of the particular stage in which the client is living more robust and satisfying to self and others. On the other hand, in doing post-testing on a small few long-term clients – three to six years in treatment – I did see concrete evidence of accelerated stage movement in Hy’s ego development, certainly in Piers, Harris’s self-esteem and self-concept, and at least a couple of memorable cases where re-test answers to the Heinz Dilemma had jumped two/three stages. These developmental areas can be impacted, not as a primary goal of treatment, which would have to be behaviorally and relationally rooted, but as a side benefit.
Using this overall Conventional construct, teaching and inculcating “useful principles of right conduct… and the distinction between right and wrong” (the definition of moral development via dictionary.com), can be seen in basic developmental terms. The individual first begins to develop increasingly sophisticated personal governors of conduct taught and shaped by parents, other family, teachers, and other caretakers. Then comes learning to recognize the needs of others and the ability to both accommodate and assimilate to solve differences, first through family and then out into the community, e.g neighbors, schools, social activities, teams, jobs, skill building, etc. Via education, experience, and general observance, the person comes to appreciate broader community needs and standards of conduct, and eventually develop a sense of universal principles of personal liberty, fairness, and standards of justice. At least in the abstract…as said earlier, some adults do not fully emerge from the pre-conventional state. A tarheted, programmatic intervention to improve or accelerate moral development, per se, is probably not necessary to achieve desired changes.
Family therapy has a certain place insofar as ego, self-concept, self-esteem, and moral development processes are concerned, being the setting of first impact and the primary recourse, along with marriage or adult life partnership, for most people through life when in doubt about being or handling other’s moralities. The therapist becomes a guide of sorts just by doing the work well.
At the least, a family therapy would likely facilitate discussions about client issues bearing on ego development, including self-concept and self-esteem, and moral development, as defined above, personal self-care, responsibility, initiative, effort, honesty, trust, and other aspects of being. Getting along with others, recognizing another’s perspective and needs, learning to give-and-take, respect boundaries, being a classmate or a member, etc., can and usually will appear as sub-themes in therapies for children and young adolescents. As a young client’s social world develops, discussions involving their own thinking about how they are being perceived by someone else, and then by a group of others, and then a community of others occur with some frequency. These are also fertile grounds for therapies of many kinds. Post-conventional Stage concerns such as the social contract and the greatest good for most people and the universal principles involving justice and the ethics of obeying were generally not a source of discussion in a child and family therapy, but every once in a while….
The most direct impact of the moral development construct and the Heinz Dilemma task was the reinforcement value that was bring offered. That appeared in three basic ways.
If the child is operating at a level that is two or more stages higher than their age would predict, that offered a great opportunity for me to praise and reinforce. Again, think of Johari’s Window. The parents get informed about the accomplishment in the next session, and they almost inevitably experience some kind or level of reinforcement themselves as parents. Presumably, the parents convey those feeling once again to the child when they get home. To be sure, this did not occur often, but could be powerful when evident.
If the child is operating at two stages below, that situation also gets reviewed with the parents in the following session. More likely than not, that information at least reinforces their perceptions of their child’s strengths and weaknesses, and lends credence to their decision to seek help. Shoring up that area of cognition can be incorporated into the treatment plan as developed during that session.
Possibly the best reinforcement to come out of the exercise is the parents’ awareness that their child took the Heinz Dilemma seriously. As parents, they are in the best position to read their child’s involvement just from the circumstance and quality of answer, and usually indicated so in one way or another. And they appreciated this entirely unanticipated display on their child’s part.
In hindsight, the Kohlberg’s Moral Development construct could have been used more frequently. Taking the specific elements of each stage as outlined in the paragraph above (beginning with “…using this overall Conventional….”), they could have been used as a template for a more detailed and comprehensive list covering the first five stages that could help focus discussion profitably and provide basis for suggestions and recommendations. An instrument like that may not have been used very often, but for a client that did seem to be struggling with socio-moral issues in age-appropriate manners, that could well have been a key for a few select cases that otherwise did not do as well as hoped.
The girl whose Heinz reply was “no, he shouldn’t steal the drug because he’ll get arrested, and he’s not going to win in the end”, was a 15 year-old going on 30 going on 3, driven by id and impulse, seen for a couple of session stretches in between which she managed to close down a mid-major airport for an hour after racing away from security guards. She was living with a sincere father beside himself, minimal contact with mother who by description sounded like an immature Axis II-type. But the girl would talk, as much a release as anything else, likable to me, could make sense, and could demonstrate some insights in the right circumstance. Seeing me, at least for the time being, was sort of one of those circumstances. And then she’d be gone.
What could have been done, and wasn’t, would be to take that Heinz answer, have her identify with the old man, share an equivalent experience of disappointment, or two, or three, that she had had, help her take the ‘assimilate and accommodate’ tack playing the old man toward the pharmacist, work with that until she arrives at a reasonable place, and then have her apply the same approach to the one, two, or three circumstances she had found similar. That would be an example of using a developmental skill that is useful for stage 3 answers, and maybe help her stage 3 growth just a bit.
Instead, I just took the information and relayed it to the father in the next session. Too bad about being in hindsight. I did see the father three or four times over the next few years as she struggled, but seemed to have tenacity at the right times.
The 11 year-old “winner” was entirely different. When relayed verbatim to the parents during the summary session, his ‘answer’ became pivotal in understanding the family and the particular impacts on the client. He was the youngest of four boys, the other three being 14 -18 years old. His retired father had day-to-day household responsibility as the mother was a high level corporate exec. She did attend the intake and the summary, as well as two regular sessions. The parents were somewhat floored by the their son’s elaborate response to the Dilemma, he being usually quiet at home. His presenting problems at school of poor focus and concentration, disruptiveness, and a couple of tic-like mannerisms brought him into the office, but what became apparent during the debriefing in this summary session was that the client was getting lost in the midst of this toxic triangle formed by his three brothers. Those three were at each other with a certain constancy just below the line of unbearable.The father was a serious consumer of erudite writers from Dostoyevski to William F. Buckley, from whom he could recite passages, so the turmoil could grow from three to four fairly quickly, leaving the client to his basement bedroom. At least the “problem” was identified. Discussing the format options and in his innately conservative nature, the father insisted that the treatment be brief.
I said “10 sessions, then stop”, which may sound like hubris, but during my MSW practicum I learned how to do a time-limited brief therapy technique developed by Otto Rank (an ex-valet of Freud’s) in the 30’s, and used the approach in some 30 cases while working at the NPO counseling clinic in Everett. The method was of uncanny effectiveness. Still, though, this limit was a reach.
The cathartic event in this time-limited process is a reenactment of the presenting problem after the sixth session – most commonly before the seventh session – by the client. Such occurred here, as per the norm. My role was commenting to the client that the end of the ten weeks is coming and how did they feel about that. The boy was going to miss it and felt kind of bad, and was then asked if anything else that’s making him feel the same way. I’d like to say he wanted more attention from his father but that would be a maudlin script. He did talk in essence of concerns about the mother’s stress and welfare, and the father enthusiastically involved himself in a serious discussion about all three of them, father, mother, and son, what each of them needed, wanted, etc. reassuring his son but also making a couple of suggestions. And the client, who had been improving, continued to do so until termination. I’d like to say they lived happily ever, but follow-ups are verboten in Rank’s view, and my practice was not to do so anyway without some specific purpose to concern. The Heinz dilemma did become the catapult, though. And the father was happy.
Again, the personal concentration and thought the young clients almost universally gave to the Heinz task was impressive in and of itself regardless of the answer’s particular quality or stage.