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11. Epilogue: the future of psychotherapy

Jeremy Holmes Karnac Books ePub

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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10. Psychotherapy: the makings of a profession

Jeremy Holmes Karnac Books ePub

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.

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9. Ethical codes and codes of practice in psychotherapy

Jeremy Holmes Karnac Books ePub

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.

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4. The unjust distribution of psychotherapy

Jeremy Holmes Karnac Books ePub

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.

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5. The social role of psychotherapy

Jeremy Holmes Karnac Books ePub

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.

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