The Values of Psychotherapy

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This first-class book provides an unrivalled basis for further discussion on to how to make psychotherapy more effective both, ethically and professionally.'By now, you may be wondering what sort of beast psychotherapy is. Well, this book gives a fine description. Above all, psychotherapy is a moral practice. However scientific its research, or however much scientific research is demanded of it, psychotherapy remains a practice born of moral dilemmas, of how we live together, each with the other...Above all, the book is a plea to accept psychotherapy as a profession.'- R.D. Hinshelwood, from the Foreword.

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1. Taking psychotherapy seriously

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THE ANXIOUS WIDOW

A farmer’s wife in her 30s consulted her doctor, complaining of feelings of panic and doom. She was referred to a psychiatrist. He, a humane and well-trained professional, asked her several questions about her state of mind, satisfied himself that she was not hearing voices or deluded, and sent her back to her doctor with a diagnosis of “anxiety and depression”. He offered some helpful ideas about which brand of anti-depressant and tranquillizer might be most appropriate in her case. She did not take the drugs, but some months later her depression spontaneously lifted and things returned to normal.

Four years later, she was referred again, this time to a psychotherapist. Her husband had died a few months earlier, at the age of 48, from heart failure. She had been left to run the farm on her own with her 17-year-old adopted son, who was more interested in his motorbike than in helping his mother. She said that she had “coped” very well at first after her husband’s death and had “buried herself in the work of getting in the harvest”. But when winter came, she felt his absence fully for the first time, and her feelings of panic reappeared.

 

2. The case against psychotherapy

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One of the most important claims of this book is that psychotherapy should become much more widely available; indeed that it should be regarded as no less essential than other forms of health care, or education. We argue this case in detail in chapters three and four. But, if this ambitious claim is to be worthy of serious consideration, it is necessary first to answer several criticisms of psychotherapy, the most serious of which are: that psychotherapy is unscientific; that it does not work, even on its own terms; and that even when it does work, it does not offer its beneficiaries anything worth the expense. We attempt to answer these criticisms in this and the next chapter. A final criticism concerns the social role of psychotherapy, and whether it is, or could be, a disguised tool of social control. This is considered further in chapter five.

We start with the questions of scientific status and efficacy because, unless psychotherapy can offer a reasonable answer to them, our moral argument for more resources to be put into psychotherapy would, at best, be of merely academic interest—for there could be no justification in seeking public support for a practice that is ill-founded and of little benefit.

 

3. Is psychotherapy a luxury?

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As we saw in the preceding chapter, one source of opposition to psychotherapy comes from those who hold it to be at best an unscientific form of treatment, and at worst simply an excuse for unscrupulous charlatans to exploit the misery or gullibility of their customers. We argued—against these and more measured criticisms—that psychotherapy is effective and, from the standpoint of scientific credibility, fares no worse than other kinds of psychological enquiry or psychiatric treatment.

We ended by looking briefly at whether psychotherapy is cost-effective. The studies we cited show that it can stand up well, even on its weakest ground—the areas of symptom alleviation and severe mental disorder. However, studies of cost-effectiveness require some assumptions of value—about the relative importance of potential goals. Once there is agreement about goals, the task is then to discover the most efficient method of achieving them. We believe that the strongest reason for seeking to expand psychotherapy is that it offers its beneficiaries something of vital importance which cannot be provided by other treatments or social interventions.

 

4. The unjust distribution of psychotherapy

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We argued in chapter three that psychotherapy addresses basic needs, and we suggested that its distribution should not be determined by the ability to pay for it. It is our belief that in this respect psychotherapy should be regarded, like basic health care and education, as something that should be equally available to people according to need. This follows from the Principle of Equal Respect.

This Principle is really about well-being or flourishing, and it states that people should not be disadvantaged on arbitrary grounds. Of course, natural differences, which from a moral point of view are arbitrary, mean that it is not possible for everyone to flourish equally. A person born with severe spina bifida may never be able to achieve a level of well-being that approaches that of the able-bodied. A child who dies of leukaemia will have less of a good life, no matter what we do to help, than someone who lives out a normal healthy life. The crucial point is that scarce essential services should not be distributed on an arbitrary basis. To distribute health care or education simply according to ability to pay is to do an injustice to those whose needs for the services are great, but whose financial resources are small.

 

5. The social role of psychotherapy

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The previous chapter revealed some of the difficulties of trying to expand psychotherapy in such a way as to make it more accessible to working-class people. One of the major problems seems to be that while conventional psychoanalytic techniques are, for various reasons, unlikely to have widespread popular appeal, the newer therapies are unable, or at least are thought to be unable, to deliver the unique benefits of psychoanalysis. An important reason for this is that one of the central values of psychoanalysis is a commitment to the truth, whereas the newer therapies tend to place a greater emphasis on change. We shall discuss the central importance of truth in psychotherapy in subsequent chapters.

This conflict between what we called “high-culture” and popular psychotherapy raises a fundamental moral and political issue about the role that psychotherapy should play within a society, and this forms the focus of the present chapter.

We have been arguing as if it were obvious that more widely available psychotherapy would be desirable were it affordable and arrangeable. The argument is based simply on the claim that what psychotherapy offers its patients by way of emotional autonomy, selfesteem, and the capacity for improved personal relationships is so valuable that people in a relatively affluent society should not be denied its benefits. But this view is controversial even among those who appreciate the effectiveness of psychotherapy. The fear is that too much psychotherapy might, directly or indirectly, be an instrument of social conformity, threatening to suppress individuality and social dissent. It is worth noting that opposition to the expansion of psychotherapy comes not only from right-wing libertarian opponents of the welfare state, whom one would expect to be wary of any expansion of publicly supported welfare services, but also from left-wing social theorists. Rather cheekily, perhaps, we shall call these two groups “the libertarians” and “the Marxists”, even though their views are not espoused by all Marxists and libertarians, and are held by some who are neither libertarian nor Marxist.

 

6. The therapeutic relationship: ethical implications of transference

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Practitioners would, on the whole, rather think about technique than ethics. The embryologist studying the newly fertilized ovum is more concerned with working out how differentiation of the nervous system occurs than with the ethical issue of when an embryo acquires rights. Ethical issues lie at the boundaries of everyday practice, and clinicians, like football players, want to get on with the game rather than argue endlessly about rules and infringements. Passions may become momentarily inflamed, which is why referees are needed, but the less they have to intervene the better the game.

From this perspective, medical ethics—and, by extension, psychotherapeutic ethics—could be seen as concerned with questions to which no technical solution can be found within medicine or psychotherapy itself. Biochemistry alone will never indicate when to switch off a ventilator for a patient in a coma, or whether a managing director is more deserving of renal dialysis than a tramp.

Science and physical medicine have an advantage over psychotherapy in that at least in them the distinction between technique and ethics is usually fairly clear. In psychotherapy, the position is more complicated: the very subject-matter is a focus of moral dispute, and the moral choices faced by patients are the bread and butter of psychotherapy sessions. Should a therapist help an unhappy couple to stay together, or encourage an oppressed and intimidated wife to leave? How can therapists persuade suicidal patients that life is worth living? How far should therapists go in offering lonely patients friendship and support? Should a patient who is low in self-esteem be told that she is attractive and intelligent, or would this be seductive and perhaps lead to unproductive dependency on the therapist—and if she is not, would it not be dishonest to say she is? Is it justifiable to tell “white lies” to patients if it will help them to get better: should the therapist reassure patients that they will improve (as Freud is said to have done at times) in spite of being secretly doubtful about the outcome? Should the therapist reveal something of her own difficulties, in the hope that this will make the patient feel less isolated?

 

7. Moral dilemmas within psychotherapy

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Psychotherapy matters because autonomy matters. The crucial evaluative assumption on which the case for psychotherapy depends is that personal autonomy has intrinsic worth as a part of human well-being. As we argued in chapter three, this assumption cannot be proved, but it is, we maintain, central to the liberal democratic tradition and is widely accepted, even by many critics of psychotherapy. Closely connected with this belief in the great importance of autonomy are principles of respect for the individual, encapsulated in statements such as “Never treat a person simply as a means to an end”, “Every person is entitled to the maximum liberty compatible with a like liberty for all”, and “Treat other people as you would have them treat you”. The connection arises from the belief that it is people’s capacity for autonomy which gives them dignity, by virtue of which they should be treated with individual respect.

Principles of respect are inextricably linked to a recognition of the intrinsic value of individual autonomy. This means giving special consideration to what individuals autonomously want, and to the promotion of their autonomy through time. It does not mean that nothing else matters, but rather that, for example, where there is a conflict between what people autonomously want and what would spare them pain, including mental pain, one should be prepared sometimes to give greater weight to the autonomy than to the avoidance of pain.

 

8. Psychotherapists: servants of two masters?

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In the previous two chapters, we focused on the responsibility that therapists assume for their patients. Part of this seems to require therapists, in a sense, to be the champions and advocates of their patients. Many of the moral dilemmas faced by therapists arise out of the ambiguities entailed in trying to respect patients’ autonomy. In this chapter, we discuss another range of problems, related to the fact that therapists, like everyone else, remain citizens of a society—and, however much they might wish otherwise, that society cannot be ignored. There may be circumstances where the broader society’s interests may conflict with the interests of a patient. There are also occasions where the patient’s interests may conflict with another individual, a “third party”. How should these conflicts be resolved?

The main libertarian worry about the state’s involvement in the care and treatment of the mentally distressed or disturbed is, we argued in chapter five, the fear that large-scale state-organized mental health services will inevitably be used as an oppressive tool of social control, undermining the fundamental liberty of social dissenters to enact their dissent. Nowhere is this thought to be more a cause for concern than in the compulsory detention and treatment of the mentally ill. We argued in chapter five that such a worry, if directed against psychotherapy, is misplaced. Unlike drug treatments, most psychotherapy cannot be “administered” against the will of its patients, and the nature of psychotherapeutic explorations makes them especially likely to be autonomy-enhancing.

 

9. Ethical codes and codes of practice in psychotherapy

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If, as we argued in the previous chapter, both simple appeal to therapists’ consciences and attempted direct control by legislation are unsatisfactory vehicles for minimizing incompetent or unconscionable conduct among therapists, the most obvious alternative is for some regulation from within the body of psychotherapists itself. The medical profession has attempted to regulate its own professional standards at least since the fourth century BC when the Hippocratic Oath was formulated. Since the Second World War, several codes of medical ethics have been published, most notably the 1947 International Code of Medical Ethics following the Geneva Declaration of the World Medical Association, amended by the 22nd World Medical Assembly held in Sydney, Australia, in 1968.

As psychotherapy has expanded, so ethical problems arising out of therapy have become one of the central issues for the nascent profession. Our discussions in the previous three chapters have shown how the therapist has special moral responsibilities, and inevitably faces tough moral dilemmas. There is therefore a need for considerable moral integrity among therapists.

 

10. Psychotherapy: the makings of a profession

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Despite a long history (Ellenberger, 1970) and considerable cultural significance, the status of psychotherapy remains ambiguous. Many who practise psychotherapy are members of established professions—psychiatrists, psychologists, social workers. Psychoanalysis claims to be a profession but was described by Freud, in a moment of ambivalence, as an “impossible” one— “because one can be sure beforehand of reaching unsatisfying results” (Freud, 1937c). But psychotherapy ranges from its conventional and established centre to obscure and quasi-religious fringes. Despite aspirations to acceptance and respectability, psychotherapy as a whole does not yet present the public with the unity and ideological coherence that are the hallmarks of a profession.

It should also be noted that within psychotherapy there are those for whom the very notion of respectability is contradictory. They see the subversiveness and ramshackle aspect of psychotherapy as a necessary consequence of the radical nature of its subject-matter. If psychotherapy is to confront (and be trusted by) that which is repressed, how can it ally itself with the very forces of convention and normality which are responsible for that repression? “Psychoanalysis is like a nomadic tribe, never settling in any one place” (Kohon, 1984). We have, to some extent, discussed this issue in chapter five and will not pursue it further here, except to note that the ambivalence that it represents has probably played no small part in the slow progress that psychotherapy has made towards achieving professional status.

 

11. Epilogue: the future of psychotherapy

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Throughout this book we have returned repeatedly to the idea of autonomy. Autonomy, as we have characterized it, implies personal independence, emotional freedom, and the capacity to form satisfying relationships. Understood in this way, autonomy is one of the most valuable goals that psychotherapy can help its beneficiaries to achieve.

By focusing as we have on autonomy, we could perhaps be accused of neglecting other goals that embody the values of many psychotherapists. We have said little about the relation between psychotherapy’s emphasis on childhood experience and the Christian tradition of reverence for innocence and simplicity. We have touched only lightly on the role of imagination and play in psychotherapy, nor have we related these to the heritage of Romanticism. We have only glancingly referred to the Kleinian emphasis on renunciation, suffering, and deferment of pleasures, nor have we related these to the tradition of radical dissent within Lutheran and puritan Christianity. We have barely mentioned concepts such as non-attachment (Holmes, 1996) and enlightenment, or their secular equivalents which include irony and humour, where the influence of Eastern philosophy and religion has made its impact on psychotherapy. We have said nothing of the connections between Judaism and psychoanalysis.

 

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