The Ethical Visions of Psychotherapy

Kevin Smith

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000095555
• Edition: 1
• Topic: Filosofia
• Subtopic: Mente e corpo in filosofia

The standard view of psychotherapy as a treatment for mental disorders can obscure how therapy functions as a social practice that promotes conceptions of human well-being. Building on the philosophy of Charles Taylor, Smith examines the link between therapy and ethics, and the roots of therapeutic aims in modern Western ideas about living well.

This is one of two complementary volumes (the other being Therapeutic Ethics in Context and in Dialogue ). This volume explores the links between therapeutic aims and conceptions of well-being. It examines several cognitive-behavioral and psychoanalytic therapies to illustrate how they can be distinguished by their divergent ethics. Smith argues that because research utilizing standard measures of efficacy shows little difference between the therapies, the assessment of their relative merits must include evaluation of their distinct ethical visions.

A key text for upper level undergraduates, postgraduate students, and professionals in the fields of psychotherapy, psychoanalysis, theoretical psychology, and philosophy of mind.

1  Introduction

The Means and Ends of Therapy

A central component of many of the psychotherapies is the exploration of aspects of psychological functioning that patients are initially unaware of or disavow. For example, psychoanalysis aims to bring to light wishes, motives, and aspects of the self that have been repressed or dissociated. Cognitive therapy aims to help patients see how, unbeknown to them, their thinking generates their depressed mood or anxiety.

A central aim of this book is to point to something therapists do that they don’t readily acknowledge, or are even motivated to avoid. Therapists think of themselves as offering treatments for psychiatric disorders, methods to change problematic behaviors and alleviate emotional distress, or ways to improve social and work functioning. This view of therapy as a means to bring about particular ends is not false, but it is incomplete. Therapy is also a social practice that enacts some perspective on what constitutes a good life, human well-being, or flourishing. To the extent that this latter characterization of therapy is true, psychotherapy is not simply a means to an end but proposes that some ends are more worth pursuing than others. In Robinson’s (1997) words, therapy “is and must be a theory about the good life; a theory about realistic and worthy pursuits; a theory about persons” (p. 676).

To think about therapy as proposing ideas about what constitutes a good life raises a number of important issues. Does such a picture of therapy apply to all therapies, even those that were expressly developed to be technical means to achieve specific ends? How can this view be reconciled with the position of many therapists who adamantly oppose telling patients how to live their lives? When a therapy seems to offer a notion of human flourishing, does this make it more than therapy, something like a philosophy of life? If ideas about what makes life worthwhile are at least implicitly present in the psychotherapies, is this a problem to be addressed, or an inevitable feature that needs to be acknowledged? And what do we do about clashes between competing pictures of human well-being that are present in different therapies? There are established methods for assessing differential therapeutic efficacy when therapy is understood as a means to a circumscribed end (as a treatment for depression or panic disorder, for example). How do we assess different ideas about human well-being?

To anticipate some of my conclusions, I will not be arguing that therapists need to develop a fully articulated theory of the good life. But I will be arguing that it is incumbent upon therapists to reflect on their implicit assumptions about what constitutes human flourishing. It is dishonest for therapists to claim that they have no ethical agendas. Therapists’ attachments to broad therapeutic orientations (psychodynamic, cognitive-behavioral, humanistic, mindfulness-based, etc.) are rooted in the sense that their preferred approach provides something worthwhile that goes beyond symptom reduction. The rational self-mastery of cognitive-behavioral therapy, the search for authenticity of humanistic therapy, and the honest acknowledgment and working through of previously repressed wishes and motives in psychodynamic therapy are all offered as key components of living well.

Unreflective commitment to the picture of flourishing in one’s preferred therapeutic orientation has its risks. Blind adherence can conceal the limitations of an orientation and the value of alternative approaches. But this danger is not resolved by claiming neutrality. To ignore broad ethical aims and focus only on narrowly framed questions of efficacy also has its cost, namely, that our understanding of therapy is distorted through the failure to take into account the visions of well-being implicit in therapeutic practices.

What follows is an effort to spell out the idea that the therapies include at least implicit proposals regarding what constitutes living well (an “ethic”), and that part of what is at stake between different therapies are the differences between these proposals. In Chapter 2 I articulate the link between therapeutic aims and conceptions of well-being, clarify terminology (“flourishing,” “well-being,” and “ethics”), and offer a preliminary justification for examining therapy in these terms. Chapters 3 and 4 provide illustrations of the link between therapy and ethics. Chapter 3 starts by exploring the idea that therapeutic efforts to improve well-being are simply attempts to restore psychological health, and as such have little to do with what we ordinarily think of as ethics. In response I examine how psychological problems implicate ideas about living well that go beyond ordinary conceptions of health. I illustrate this by examining how even therapies that were designed to target circumscribed mental disorders include broad ethical aims. In Chapter 4 I look at three different versions of psychoanalysis to show how closely related forms of therapy can be distinguished by their different ethics. Chapter 5 takes up a “So what?” question about the link between therapy and ethics: Why bother with the competing pictures of well-being in the therapies if we can simply research which therapies work better? I argue that psychotherapy research highlights the significance of the ethical disputes between the therapies, for they are generally equivalent in efficacy. I conclude with some reflections on the need to supplement the standard assessment of therapeutic efficacy with consideration of the contrasting ethical aims of different therapies. Deeper engagement in the latter task requires a better grasp of the cultural roots of therapeutic ethics and the development of a discourse of ethical evaluation and dialogue that is often missing in the field. These topics are taken up in more detail in the companion volume, Therapeutic Ethics in Context and in Dialogue.

Explorations of the intersection of ethics and psychotherapy do not figure centrally in dominant conceptions of therapy. To work on these topics is to labor in a peripheral corner of the field in this era of practice guidelines and evidence-based treatment. I owe a large debt to many who have already written on these topics: Atwood and Stolorow (1993), Cushman (1995, 2019), Fancher (1995), Fowers et al. (2017), Lear (2003, 2017), London (1986), Martin (2006), Miller (2004), Orange (2011), Richardson et al. (1999), Richardson and Zeddies (2004), Robinson, D. N. (1997), Stern (2012), Tjeltveit (1999), and Woolfolk (1998, 2015). They have shaped my own thinking and have provided ample evidence in their work that psychotherapy has a great deal to do with ethics.

However, my approach does not consist of a close engagement with these writers, examining points of agreement and disagreement among them, or considering how their thinking aligns with or diverges from my own views. Instead, the central thread that runs through this book is the philosophy of Charles Taylor. A key aim of his work has been to show how the evaluative and interpretive nature of human existence limits the prospects for an objectivist science of people. I rely heavily upon several themes from Taylor’s work that elaborate on this central idea: the concept of strong evaluation and the inevitability of ethics; the obscuring of ethics by modern objectivist and scientistic thinking; the constitutive role of language in giving shape to our ethical views; and the holistic nature of the meanings by which we live—which is related to the holistic nature of the language through which they take form. In Therapeutic Ethics in Context and in Dialogue I also borrow heavily from Taylor’s work on the culture of modernity in order to provide a context for therapeutic ethics and apply his ideas about practical reasoning to the prospects for dialogue between conflicting therapeutic views of flourishing. Taylor’s ideas provide the anchor points and structure for the claims I want to make about therapy. Taylor does not write in detail about psychotherapy. Rather than build upon his few comments on the subject, I make use of fundamental concepts from Taylor’s philosophy to develop better ways to frame some basic questions about the nature of therapy. When I enlist a major theme of his work I will give an overview of it and illustrate how it applies to the specific issue I am exploring. A background in his philosophy is not necessary to follow my argument. Those who are unfamiliar with Taylor’s work and would like a summary will find a brief introduction in the appendix to Therapeutic Ethics in Context and in Dialogue.

2 The Ethics of Therapeutic Aims

Prologue: A Tale of Two Therapies

Jane¹ has been having panic attacks. At least she thinks they are panic attacks. That’s what the doctor told her at the emergency room last week. Despite the doctor’s reassurances, she’s not entirely sure. She still wonders if the chest pressure, racing heart, and shortness of breath might be an indication that there is something medically wrong, and if the next time this happens she will have a heart attack, not a panic attack. The emergency room staff suggested she try therapy and gave her the names of a couple of psychotherapists.

Depending on which therapist she sees, Jane may have very different experiences. Suppose she sees Dr. Adams. Dr. Adams begins with a careful assessment, asking about the nature, intensity, and timing of Jane’s symptoms; the history of their onset; the impact of these symptoms on Jane’s functioning; and some general questions about Jane’s life apart from this presenting problem. Seeing no other obvious difficulties that would complicate the clinical picture, Dr. Adams begins in the first few sessions to outline a formulation of the problem and to sketch a course of treatment. A summary of what she tells Jane goes something like this:

I’m glad that the hospital ruled out any cardiac involvement, but I realize that that hasn’t entirely reassured you. It can be difficult to believe that a panic attack isn’t something medically serious. Part of what makes panic attacks so frightening is the belief that they are something serious. If I thought I was having a heart attack, I’d be scared too. During a panic attack the fight-or-flight response, your body’s alarm system, has been triggered even though there is no real danger. It is physically intense, your heart races, you get short of breath, but it isn’t dangerous. What makes it really terrible is that you think it might be something truly catastrophic. What we need to do is help you to get greater confidence that these symptoms aren’t dangerous. But you’ll need more than information, more than me simply telling you they aren’t dangerous. I want to work with you on ways you can be more convinced of this, through some education about panic, but more importantly, by teaching you some ways to test out your fears in order to see for yourself that you aren’t in danger. This will involve learning a method to carefully think through your fears and some practical exercises that will help you train yourself not to react automatically with fear to these bodily sensations.

If Jane goes to see Dr. Bonn things may start in a similar fashion. Dr. Bonn will ask about what Jane is looking for help with and listen carefully to Jane’s descriptions of her symptoms, sometimes asking for further details about the context in which the panic attacks arise and what Jane fears about them. Dr. Bonn, however, is more interested than Dr. Adams in the details of Jane’s life circumstances apart from her panic attacks. He is not just interested in ruling out co-morbid diagnoses, but wants to know the broader concerns of Jane’s life, her relationships, her work and family life, etc. A fair amount of the preliminary sessions are spent on exploring Jane’s personal history, including other times in her life that have been difficult for her, what she is currently happy about and frustrated with in her life, and at least some inquiry into her childhood. Dr. Bonn will be listening not just to what Jane says, but also to how she says it. Is her self-description impressionistic, angry, or filled with extraneous details? And how does Jane seem to be positioning herself toward Dr. Bonn? As an unworthy and helpless supplicant? As a stoic sufferer who doesn’t really need help? Over the course of these early sessions Dr. Bonn begins to formulate a picture of what may be amiss for Jane beyond her panic attacks. In contrast with Dr. Adams, Dr. Bonn places less emphasis on the therapeutic role of providing Jane with information about her symptoms. He is likely to offer early reflections in a less definitive way, and the following message may be given piecemeal in short comments across several meetings, rather than as an overall summary.

I can hear how frightening these panic attacks are for you and that you’re eager for them to stop. I also hear there are a number of other problems that have been overwhelming, and that you feel helpless to change. You spoke of feeling trapped in your job and angry with your husband for his lack of effort in helping you with the kids and the household chores. But you also say that you’re afraid to confront him, afraid that he’ll leave you, which might only make everything even more impossible to manage. You said that feeling trapped like this also reminds you of your mother’s situation when you were growing up. You were determined not to repeat her mistakes and now you sound despondent, even embarrassed, that you may be in a similar position. Your panic attacks have something to do with feeling backed into a corner in your life. I think that addressing your panic will require doing something about these binds that keep you from living the kind of life you would like to live.

Both Dr. Adams and Dr. Bonn conclude their initial assessment sessions and feedback with an inquiry as to whether their respective preliminary understandings and suggestions about how to proceed make sense to Jane. In both cases the therapists are inviting Jane to make an initial endorsement of a particular take on human psychology and of how to understand problems like hers in light of their approach. Dr. Adams paints a picture of persons as psychological systems shaped by biology, conditioning, and cognition, systems which can be re-worked to ameliorate symptoms like her recurring panic attacks. Dr. Bonn focuses on the patient’s frustrations with her job and marriage, what makes her feel helpless to change things, as well as her concern that she has failed to be the kind of person she has aspired to be. Each of these therapists is proposing a different way of relating to oneself and of addressing difficulties in living. Each is emphasizing different ideas about the most important elements of being human. One might object that these ideas about how to understand people are brought to bear upon the specific problem of panic disorder. They are not offered as a general psychology or as an approach for handling all aspects of life. But this way of putting the matter is not innocent. For to suggest that the heart of the matter is treatment of panic disorder as a free-standing problem is already to lean toward one way of understanding human difficulties. It is to begin to side with Dr. Adams over Dr. Bonn.

Different therapies are rooted in different takes on what it is to be human, how problems in living arise, what makes something a problem, and how to go about making things better. In short, different therapies rely on different philosophical anthropologies, although they are rarely discussed in such terms by therapists and researchers. Instead, the arguments are often framed in terms of questions about whether one therapy is more effective than another at treating the symptoms of a disorder, or whether one delves more deeply into the psychological roots of various problems. One consequence of avoiding the more fundamental questions of philosophical anthropology is that the opposing sides in these arguments often talk past each other. I want to offer some suggestions about how to deepen these debates by offering a different way to think about what is at stake.

Therapy Wars

Current views of psychotherapy often seem to issue from camps that battle one another blindly. The camps are sometimes divided based on therapeutic orientation. Cognitive-behaviorists, humanists, and psychodynamic therapists tout the merits of their respective therapies and focus on flaws of the other therapies, flaws that seem obvious when viewed through the lens of their own approach. Warring camps are also formed around different ways to study therapy. Clinical experience is pitted against research and both are critiqued by those who examine therapy with the tools of social, cultural, or political analysis. The arguments are unresolved and partisans retreat to conferences, institutes, and journals where they find like-minded people.

When I say that there is a fair amount of “blind battling” in disputes about therapy, I am suggesting two things. One is that various therapies and methods for studying therapy often operate from a narrow or distorted picture of alternative views. The other is that I think there is potential value in a more robust dialogue among the contrasting positions. That dialogue can be deepened by examining an aspect of psychotherapy that I want to highlight. The one-sided nature of the positions often held in therapy debates is rooted in attachment to something more than a scientific conception of psychological disorder and what may alleviate it. The interlocutors in these debates are also often devoted to a personally and intellectually compelling conception of human well-being. Dedication to the improvement of the human condition (whether this is couched in psychological, political, or other terms) often comes in the form of passionate investments that can make competing views appear to be not just incorrect but also dangerous and harmful. For example, proponents of longer term, exploratory or psychodynamic psychotherapies indict short-term treatments that focus on symptom reduction as quick fixes for the superficial manifestations of more complex problems. The psychodynamic and humanistic therapies are critiqued in turn as exercises in endless, expensive self-exploration ...

Table of contents

• Cover
• Endorsements
• Half-Title
• Series
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• Series Foreword
• 1 Introduction: The Means and Ends of Therapy
• 2 The Ethics of Therapeutic Aims
• 3 Therapeutic Ethics in “Technical” Therapies
• 4 Different Therapies, Different Ethics: The Example of Psychoanalysis
• 5 Psychotherapy Research: From Effective Techniques to Ethical Aspirations
• 6 Conclusion: What Works? What Matters?
• References
• Index