The ethics of psychotherapeutic intervention in practice
The Psychotherapist magazine - Feature Articles
Issue 42 Summer 2009
The ethics of psychotherapeutic intervention in practice
Paul McDermott explores ethical and moral behaviour
in the context ofWestern philosophy
There is an imperative which commands a certain conduct immediately, without having as its condition any other purpose to be attained by it. This imperative is Categorical ... This imperative may be called that of Morality.'
- Immanuel Kant ( 1955)
Bob loves his cat. Bob and Alice argue, and Bob locks himself in the bathroom. Alice threatens to kill the cat if Bob doesn't come out. Bob doesn't come out. Alice kills the cat. Who is responsible for the death of the cat?
I began lectures to psychotherapists on ethics with this conundrum. Responses came quickly and strongly, differences of viewpoint appeared, debates ensued, as people grappled with the depth of the issues involved.
Ethics and morals
Ethics is 'the science of morals ... the rules of conduct recognised within a certain limited department of human life' (Shorter Oxford English Dictionary, ( 1944)). Ethics come from institutions or societies, and are physical and constitutional.
Morality is 'the power of apprehending the difference between right and wrong, especially when viewed as an innate faculty of the human mind'. Morality comes from within the individual, and is psychological.
To behave ethically is not always the same as behaving morally - one can consent to the ethics of a group without any moral faculty whatsoever, simply by obeying the rules as, for example, the eight thousand "staff`' at Auschwitz. Nietzsche agued that instead of developing their own moral faculty, people follow the prescribed rules by way of a 'herd instinct'.
In Britain it is unethical to attack someone who insults your family, in another country it may be unethical not to. But is it moral? In terms of psychotherapeutic interventions: What is 'good'? Is 'helpful' 'good'? And for whom, and when, and under what circumstances?
Greek sophists argued that ethics are only conventions, with no relation to nature or divine absolutes. If hot and cold are subjective, so are standards of right and wrong. To be ethical is merely to be conventional. Is psychotherapy an effort towards the conventional well-adjusted citizen? Or is this opposed to, or irrelevant to, psychotherapy's purpose? What is the difference between adjustment and maladjustment? What is treatment actually for? What constitutes improvement? Deterioration? Is an increase in pathology good or bad, or neither?
Jacob, a manic-depressive drug addict who had recently made his third suicide attempt by taking an overdose and slashing both wrists, said to me five minutes before I was about to leave on holiday: 'If you go away I will kill myself.' We are back to the dilemma with the cat. What are the ethics? Where is the morality?
What is good?
Socrates sought to undermine convention, arguing that when someone does wrong, they have not understood the right - unethical behaviour comes from ignorance. Genuine knowledge and morality must be earned through experience - 'The unexamined life is not worth living' (Plato). If you know what is good, you will do it because you will benefit; you won't do evil if you know it is evil because it will harm you. But, we still haven't answered our question: What is good?
Plato said the aim of philosophy was to free the soul from delusion. Psychotherapists may resonate with this and recollect the transcendent ideas which form the basis of ethical behaviour - divine ideas of goodness, truth, etc. So now at last we can know what is good.
But then Aristotle renounced Plato's ideas - there is no idea of good relevant to all situations, but only good persons doing good actions in varying contexts. Ethics are necessarily contingent, having a probable value within the complexities of human experience. The aim is not absolute knowledge, but to be virtuous. The ethical task is complex and ambiguous, evading final definition, requiring singular responses, in practice, in individual cases, relative to their specific conditions.
Truth and ethics
Christianity rejected Aristotle's contingent individual responsibility. The Church's ethics were established, disseminated and sustained by an authoritative Church, which was the court, the prosecuting arm and the punitive arm of moral law. Christian truth and ethics then became a matter of power politics, legislative battles and military enforcement. Although an injunction to love and serve all humanity, which many psychotherapists may aspire to, the Church's ethics-in-action were sometimes in stark contrast to this: forcible conversion of other peoples, ruthless suppression of other perspectives, persecution and oppression of non-believers (Tarnas, 1996).
Aristotle's proposition that the earth moved became the centre of the scientific and moral challenge to the authority of the Church. This theory, argued by Copernicus, undermined a basic principle of Christianity: if the earth moved then it could not be the centre of God's creation or of His plan for salvation. Science and the Church were at odds; ethics were up for review once again.
Faith moved in one direction with the Reformation, while reason moved in another with empirical science, and the Enlightenment. Kantian ethics were based on the human situation itself. Inner personal experience became the new ground of religious and moral meaning. This point is of particular relevance to psychotherapists. Why? Because it raises this question: can the psychotherapist ever know the true meaning of an individual life?
What is it to be moral?
If not, or if this knowledge is partial at best, can it be moral to make an intervention in the patient's inner or outer life? Is it possible to discern what, in the end, will be a good intervention? As TS Eliot put it: 'the last temptation is the greatest treason: to do the right deed for the wrong reason' (Eliot, 1976). We can be ethical by following rules, but because our motives can so often be unconscious, what is it to be moral?
One evening a patient telephoned and told me she had a bottle of bleach in her hand. She said: 'Tell me, what's the fastest way out of this, suicide or therapy?' We are back with the cat again. Should I tell her the truth - drinking a bottle of bleach is faster - or intervene? Is any response, or nonresponse, in fact an intervention?
Modern Western liberalism replaced the Church as the cultural and therefore the ethical norm. When Nietzsche said there are no facts, only interpretations - that an unconscious part of the psyche influences our perception, cognition and behaviour - he was pointing towards the task of twentieth century depth psychology (Tarnas, 1996 ). If Nietzsche was right, then we can be ethical in our work, but only attempt to be moral.
Freud responded to Nietzsche and represented, in his terms, the third wounding blow to man's self-love and pride (Tarnas, 1996): the first being Copernicus's heliocentric theory, the second Darwin's theory of evolution, the third psychoanalysis. That is: the Earth is not the centre of the universe (Copernicus); man is not the centre of creation (Darwin); and man is not even master of his own house (Freud).
True ethical behavior?
Perhaps then, regardless of ethics, the psychotherapist's primary moral responsibility is to become conscious. If so, how conscious? How do you measure that? Aristotle argues that true ethical behaviour comes from the moral faculty - earned from experience, not given by laws.
The Emperor of Japan loves his people. President Truman tells him if he doesn't surrender, America will drop another atomic bomb. The Emperor doesn't budge. America drops another bomb. Who is responsible for the death of the cat?
References
Aristotle, The Complete Works of Aristotle: The Revised Oxford Translation, U Barnes (ed.) Princeton University Press, Princeton, 1984)
TS Eliot Murder in the Cathedral (Faber & Faber, London, 1976)
I Kant, Principles of the Metaphysics of Ethics (Longmans Green and Co., London, 1955).
F Nietzsche, The Gay Science (Cambridge University Press, Cambridge, 200 I)
Plato, The Last Days of Socrates - The Apology (Penguin Classics, London, 1993)
Plato, The Republic (Penguin Classics, Second edition, London, 1974)
Shorter Oxford English Dictionary (Third edition, London, 1944)
R Tarnas, The Passion of the Western Mind (Pimlico, London, 1996)