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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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7. Moral dilemmas within psychotherapy

Jeremy Holmes Karnac Books ePub

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.

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8. Psychotherapists: servants of two masters?

Jeremy Holmes Karnac Books ePub

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.

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2. The case against psychotherapy

Jeremy Holmes Karnac Books ePub

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.

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6. The therapeutic relationship: ethical implications of transference

Jeremy Holmes Karnac Books ePub

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?

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