11 Slices
Medium 9781855751514

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.

See All Chapters
Medium 9781855751514

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?

See All Chapters
Medium 9781855751514

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.

See All Chapters
Medium 9781855751514

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.

See All Chapters
Medium 9781855751514

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.

See All Chapters

See All Slices