Ethics and Values in Psychotherapy

Alan Tjeltveit

• Publisher: Routledge
• Year: 2003
• ISBN:
  9781134730551
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Ethics and Values in Psychotherapy is an examination of the role of the therapist as ethicist and the ways in which the ethical convictions of both therapist and client contribute to the practical process of psychotherapy.
As Psychotherapy strives to establish itself as a 'Profession', practitioners are increasinly focusing on the issue of ethics as they attempt to agree on guidelines and standards for professional practice. Alan Tjeltveit argues that any discussion of professional and ethical practice in psychotherapy is inadequate if carried out in ignorance of or in isolation from traditional ethical theories. He applies this approach to issues such as:
* the role of therapy in society
* the goals and outcomes of psychotherapy
* techniques and practices
* the existence and operation of values
* the intellectual and social context in which therapy takes place.
In the second part of the book, he uses clinical examples and case studies to relate this theoretical discussion to clinical practice.
Ethics and Values in Psychotherapy will be welcomed by the growing number of experienced Psychotherapists and post-graduate students who are interested in the increasingly contentious issue of professional ethics.

Part I

Developing a Better Understanding of the Ethical Character of Psychotherapy

1

Introduction

Psychotherapy, once viewed as value-free, is now widely acknowledged to be value-laden. But what does it mean that psychotherapy is value-laden? In what ways is it laden? With which values? Can those values be eliminated from therapy? If not, with which values ought it be laden? Put another way, how can we best understand and address the ethical dimensions of psychotherapy?

When a client comes to a psychotherapist with complaints of sadness and meaninglessness and says “I feel absolutely horrible. What should I do?” the therapist’s response invariably represents some ethical position; it is value-laden. As Bergin put it, “Values are an inevitable and pervasive part of psychotherapy” (Bergin 1980b: 97).

Challenges immediately confront such assertions. But when we face them squarely and thoroughly, we can better understand the complexity of psychotherapy’s ethical dimensions and the field can move beyond its present impasse in understanding and addressing values in therapy.

Setting the Stage

The challenges to the claim that psychotherapy is invariably value-laden have much validity. Because they raise key questions, highlight some of the debate to come, begin to clarify the reasons for the current impasse, and help to clarify the central thrust of this book, six of those challenges warrant brief consideration at the outset.

Psychotherapy is Inconsequentially Value-Laden

Some psychotherapists deny that all therapy is value-laden. They hold that some or most therapy is not; therefore, therapists rarely function as ethicists. Although acknowledging that some therapist responses to the sad client’s entreaty would clearly be value-laden (e.g. “You should honor the sacred commitment you made on your wedding day, return to your spouse, and begin paying some attention to your obligations to your children”), they argue that other responses are ethically “neutral” (e.g.‘“Sounds like you’re really feeling sad. How long has this been going on?”). This challenge thus raises some key questions that need to be addressed to develop a full-fledged understanding of values in therapy: to what extent is therapy value-laden? doesn’t value-free therapy (or minimally value-laden therapy) remain an important ideal, albeit one not achieved by inexperienced or inexpert therapists? Another issue will also need to be considered: are there implicit values in therapy (even in “neutral” responses in therapy), values that are rarely examined, values perhaps subtly conveyed in the language, symbols, stories, and institutions of psychotherapy, values perhaps so widely or deeply held in a particular culture that they remain unnoticed?

Psychotherapy Involves Only Mental Health Values

Other psychotherapists acknowledge that therapy is value-laden but assert that it is (or ought to be) laden primarily with values that contribute to therapeutic goals, that is, with values that contribute to improved psychological functioning. Strupp, for instance, distinguishes between essential therapeutic values (e.g. “People have the right to personal freedom and independence”), which are essential to the therapeutic endeavor, and optional and idiosyncratic values, which are not (Strupp 1980:397–8). If psychotherapy is viewed in terms of essential therapeutic values and therapists practice in accord with them, he argues, “the issue of indoctrination or the alleged dangers of a laissez-faire stance are largely inconsequential” (Strupp 1980:400). Accepting Strupp’s distinction raises two questions: which values are “essential therapeutic values”? to what extent do therapists’ optional values (e.g. their deepest convictions about human flourishing) influence the outcome of therapy?

This challenge raises a vitally important, very complex issue: the relationship between values and the goals of therapy. To make my position clear (arguments will be developed later), I propose the following thesis: a central reason for the inevitability of therapy’s value-ladenness is that all therapy involves value-laden goals. As Bergin notes, “as an applied field, psychotherapy is directed toward practical goals that are selected in value terms” (Bergin 1980b: 97). So, for instance, if we want to understand “essential therapeutic values,” we need to examine therapeutic goals very closely.

This raises some key questions: what is the goal of psychotherapy? if it is “mental health,” or “improved” or “ideal” psychological functioning, what do those terms mean? to which values or ethical positions (if any) does endorsement of a therapeutic goal commit a therapist?

Discussion of therapy goals is often difficult, for several reasons: the terms therapists use to express therapy goals (e.g. “mental health,” “behavior change,” and “self-actualization”) vary widely. Therapists use the same terms in significantly different ways. And many therapists individualize the goals they set for clients—so goals in a particular therapeutic relationship depend on the nature of the problem, the client’s stated goals, client characteristics (including client personality and personal and social strengths), financial considerations (character reconstruction is rarely a goal for a managed care client of modest means), the stage of therapy, and so forth. As an example of the second difficulty, two significantly different meanings of mental health (and related terms) need to be distinguished: freedom from serious psychological dysfunction, and positive mental health. In general, greater consensus has developed regarding values tied to the former than to the latter. For instance, in working with a severely depressed client a therapist may establish the therapeutic goal of decreased depression. That goal involves a value (“It is good to be free from severe depression”) about which there is wide agreement in society. However, mental health professionals disagree, at times sharply, about the meaning of mental health understood as ideal human functioning. In 1958, Jahoda sought—without success—to find agreement among therapists about the meaning of “positive mental health.” And it is likely that there is even less agreement now.

Introducing different perspectives on mental health (including those of non-therapists) makes even more complex the tasks of defining concepts of mental health¹ and clarifying the values (if any) tied to such definitions. Stiles, Shapiro, and Barkham suggest that, “stakeholders—individuals or groups, therapists, clients, families, or others in society—may have different perspectives, interests, and values regarding psychotherapeutic outcomes” (Stiles, Shapiro, and Barkham 1993:116).²

Adopting cross-cultural perspectives makes clarifying, evaluating, and justifying the values tied to therapeutic goals (and thus to therapy itself) even more daunting, because some argue that traditional therapy goals reflect Western cultural values. And so, those goals may or may not be transportable to other cultural settings. Any claims that they represent the essence of psychotherapy and ideal human functioning may thus need rethinking. To give one example, consider autonomy, a value Strupp (1980) considers an essential therapeutic value and which 96 percent of the US therapists surveyed by Jensen and Bergin endorsed as “important for a positive, mentally healthy life-style” (Jensen and Bergin 1988:293). Varma noted that in India “there is a greater degree of mutual interdependence” than in the West. Thus, he argues:

it is questionable how far Western psychotherapy with its high emphasis on autonomy and individual responsibility can be prescribed for members of such a society; and accordingly what modifications are required in the rules and practice of conventional psychotherapy.

(Varma 1988:145)

Western feminists (e.g. Adleman 1990; Ballou 1990; Feminist Therapy Institute 1990; Lerman and Porter 1990) have also criticized dominant values in therapy, challenging the sexist values implicit in traditional therapies and codes of ethics.

These considerations raise several questions: with which values are therapy goals laden? to what extent is it possible for therapists to free clients from their presenting problems without also changing them in directions valued by the therapist? how do various concepts of mental health represent answers to classic ethical questions concerning what is good, what is virtuous, and what is right? which therapy goals are best? and why?

To sharpen the terms of the debate, let me state an assertion, a qualified version of which I will defend in this book: any therapeutic goal held by therapists, clients, or third parties (e.g. insurance companies or government funding sources) represents a commitment (implicit or explicit, limited or extensive) to some value(s) and some working ethical theory.

Some psychotherapists suggest that the problems of values in psychotherapy goals can be solved by adopting, to the widest extent possible, the consensus among therapists regarding essential therapeutic values (while of course continuing to allow ample room for individual differences among therapists regarding regarding nonessential therapeutic values). This seems plausible. And I will argue that it is essential, as a matter of public policy, that a society should develop some measure of basic agreement about the goals of therapy (in part to justify why insurance companies, managed care entities, governments, and other third-party payers should continue to pay increasing amounts for “mental health” coverage). But I will also argue that the articulation and development of a consensus needs to occur much more explicitly, and involve all stakeholders in therapy, not just third-party payers.

At a deeper level, however, those psychotherapists who rely solely on consensus to define the goals of therapy may adopt a decidedly conservative (“when it comes to therapy goals and values, therapists should believe what our elders passed on to us”) and profoundly problematic position. One of the marks of the scientist, indeed of any well-educated person, is the ability to question received tradition and to use reason and evidence to formulate an argument, either supporting or rejecting a particular intellectual claim. The goals of therapy in particular, and the whole set of questions having to do with ethics and values in therapy in general, require this kind of rigorous intellectual scrutiny. The fact that therapists do endorse certain values does not establish that those values are best, are correct, or should be endorsed. That is, we cannot move directly from a fact about an existing consensus to the claim that those values should be adopted; we cannot move in any straightforward way from assertions about what is to assertions about what ought to be.

Accordingly, whether or not there is a consensus (and the evidence is mixed; see Consoli 1996; Haugen, Tyler, and Clark 1991; Jensen and Bergin 1988; E.W.Kelly 1995a), we must still ask why therapy should be devoted to a particular goal or goals, and not to other goals, and what ethical justification (if any) can be provided for such goals.

From Strupp’s perspective, psychotherapists addressing such questions face a dilemma: “We don’t know how to research the problem” of values in therapy (Strupp 1980:397). While we should not underestimate the difficulties of arriving at ethical knowledge, if someone interpreted Strupp to mean we are unable to make any ethical assertions, I would think that person unduly pessimistic. Psychotherapists have, in fact, always answered ethical questions—by drawing upon consensus, training, experts, experience, intuition, rational arguments, science, and so forth. Furthermore, pessimism that paralyzes efforts to reflect deeply about therapy’s valueladenness has contributed substantially to the present impasse in the field of values and therapy. While definitive solutions will likely remain elusive, I think progress can occur in the ethical arena. The challenge is to determine the best, or the best possible combination, of those approaches to address a particular ethical question. Accordingly, in Chapters 4, 5, and elsewhere, I will defend the thesis that it can be fruitful for therapists to think about ethical convictions and ethical theory (e.g. to think about the reasons for holding certain ethical convictions as opposed to others). From this thesis (which stands in stark contrast to the philosophical stance adopted—at times after careful reflection—by many in psychology) follows a second: since ethics and values inevitably play a role in psychotherapy, therapists need to think well about the ethical theory and values with which therapy is laden. In accord with those theses, this book addresses how to think well (“how to research”) the problems of ethics and values in therapy.

Clients Alone Should Choose Therapy Values

Other critics of the idea that therapy is value-laden raise a (related) challenge: therapists do not, and ought not to, determine goals or values in therapy but, rather, simply serve the goals and values clients themselves choose. This position could, of course, lead to the conclusion that there are as many legitimate therapeutic goals (or notions of mental health) and values as there are clients. While this position has considerable intuitive appeal, and substantial merit, it faces several intellectual challenges.

This position is not, finally, a claim that therapy is value-free, but an argument that therapy involves, or should involve, a particular value or set of values (e.g. the value that all client goals are good or acceptable, that it is best or most good for clients to choose their own values, or that it is wrong for therapists to impose their values on clients). It is thus not a claim that therapy is value-free, but that therapy should be delimited to a narrow range of values—those chosen by clients and those supporting client choice of therapy goals. The argument is defensible, but it raises its own set of questions: why should we adopt this position? how can its “essential therapeutic values” be justified?

A practical issue must also be faced. When third parties (government agencies or corporations, acting directly or through insurance companies or managed care entities) pay for therapy, they increasingly want a say in determining therapy goals. Taxpayers and retirees may well wish to pay only for therapy to reduce serious psychopathology. Government funding (provided by taxpayers) and insurance companies (who serve corporations, whose stock is often owned by pension funds, upon which the elderly rely for their income) may thus limit their support for psychotherapy. Accordingly, only the wealthy may be able to afford therapy intended to reach any goal clients choose.

In addition, those arguing that clients alone appropriately choose therapy goals must wrestle with the possibility that some clients might choose therapy goals many would consider undesirable or unacceptable. A client goal may conflict, for instance, with the “essential” therapeutic value of client autonomy. Suppose a new client states, “I came to therapy because I want to feel better. Now, I don’t want to change how I lead my life, but I want you to make me feel better.” Or, “My goal for therapy is for you to tell me what to do.” Few therapists would accept those client goals, because they conflict with therapist values about proper therapy goals, with values therapists believe necessary for the development of ideal psychological functioning, or both.

The issue of how to handle other types of questionable client goals was raised in connection with a case discussed by R.J.Kohlenberg (1974). In accord with a male client’s wishes, Kohlenberg successfully decreased the client’s behaviors associated with child molesting and increased his sexual arousal to adult males. In a commentary on the case, Strupp (1974) raised the question of whether, had the client sought treatment for his ineffective prowling behavior (which meant little sexual contact with young boys), Kohlenberg would have used assertiveness training to increase the efficacy of the client’s prowling behavior, and thus increased his sexual success with young boys. Strupp suggested that Kohlenberg’s likely unwillingness to do so would have stemmed from Kohlenberg’s and society’s values, which, in that instance, would have (appropriately) superseded the client’s goal. Similarly, Garfield (1974) posed the question of how Kohlenberg would have responded if the client’s goal had been the elimination of the discomfort and stress he felt about being se...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Preface
• Part I: Developing a better understanding of the ethical character of psychotherapy
• Part II: Intellectual tools for examining values and ethical theory in therapy: assumptions and criteria for analysis and decision-making
• Part III: Ethical dimensions of the contexts of psychotherapy
• Part IV: Change in psychotherapy: ethical facets
• Part V: Implications
• Notes
• References
• Index