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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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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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3. Is psychotherapy a luxury?

Jeremy Holmes Karnac Books ePub

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.

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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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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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