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

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.

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

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
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

See All Slices