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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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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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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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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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