Dr F. goes to collect his next patient from the waiting room, to find her sitting with two take-out coffees in hand. She follows him to the consultation room, and gives one of the coffees to him, explaining how she had bought herself and the therapist a coffee each, to take during the session. Dr F. proceeds to sip coffee with the patient for the rest of what would seem, in many other ways, like a typical session. The therapist explains to his supervisor afterwards that he has always hated coffee, and cannot stand even the smell. During the supervisory consultation, the therapist retains a degree of resentment towards the patient for offering the vile drink, and goes on to explain his decision to accept the offering by saying that he thought it would be therapeutic to take it, and, perhaps more to the point, that it would have been counter-therapeutic not to take it. He felt that he could not be honest about his own feelings towards coffee because it would have been at the expense of the patients feelings. It was either him or her, so he put himself second.
Dr F. might be said to have confused the ethical with the moral. If so, he would not be alone in this confusion. A personal impression is that the confusion of ethics and morality is not uncommon amongst psychotherapists and, as a teacher of psychology graduates, I find precious little in the local training programmes to remedy the conflation of the one with the other. The more common signs of this lack of clarity among psychology students include: the acceptance of behavioural definitions of ethical conduct (i.e., behaving in this or that way is universally ethical [or unethical]) which is to say that students are often taught the what of ethics before the why, thus transforming the complexities of ethical behaviour into the simplicity of moralistic rights and wrongs; and the idea that the patients needs are, ipso facto, more important that the psychologists, which can sometimes slip over into the idea that a therapist is acting ethically so long as she is frustrating at least some of her needs. Let us begin by arriving at a working definition of ethics and morality, which can be used to develop the argument of the paper.
I find a clear conceptual distinction between morals and ethics in the following quote from the psychoanalyst Arnold Goldberg (2000), where he discusses the work of Paul Ricoeur:
The moral is to be considered what is good and normal and so lays claim to a universal status. It typically leads to the positioning of rules of correct behaviour. The ethical has to do with the aim or goal being pursued and so directs us to the proper way to live. ... To transpose this distinction to psychological treatment we might say that we have a variety of moral standards or norms to observe in dealing with patients, all the while having a goal or aim in mind as to what we consider best for an individual patient. It may not be wrong in and of itself to tell our patients personal matters about ourselves or to have a cup of coffee with them, but it may not promote the treatment to do so.
Following this lead, let us define morals as a system of values that can produce a programme of behaviours to be considered good: When we do what we think is good, by whichever standards, we can be said to be acting morally. Let us define ethics as a system of values that can produce a programme of behaviours to be considered expedient of a specific purpose: When we do what we think will attain a pre-specified goal or purpose, we can be said to be acting ethically. So when the surgeon cuts you open, the violence of his action becomes ethical by virtue of the aim of improving your health. To return to our opening vignette, the behaviour of Dr F. accepting the patients offering of coffee would (much as Goldberg says) likely be seen by no-one as an immoral act, but it has a number of possible categorisations from an ethical point of view: the exhaustive list of hypothetical options is i) that it furthers the therapeutic purpose of their relationship, ii) that it works against the achievement of this purpose, or iii) that it is irrelevant to this purpose. Dr F. himself would likely say that the act was ethically sound, given that he already declared that drinking the coffee would be of therapeutic benefit to the patient. Other therapists might disagree about the therapeutic value of sharing coffee (or about the corresponding counter-therapeutic value of its refusal), and might, therefore, consider the therapist to have acted unethically. It is at the moment of questioning how the behaviour contributes to the treatment, that we move to prevent morals from obscuring ethics; in other words, being able to ask and then to explain why buying a patient flowers would be problematic in therapy, leads us to ethical considerations, and keeps us from reducing the complexity of therapeutic behaviours to a simple list of good and bad behaviours (i.e., morals) that have to be accepted as dicta. To teach a student that it is bad to buy patients flowers is to circumvent an ethical issue by superimposing a moral one.
This definition of ethics implies that in order to defend ones actions (as ethical), the theoretical rationale for treatment must justify a therapeutic intention. The variety of theoretical perspectives on psychotherapy would offer a corresponding variety of codes of ethical conduct: I submit that many therapists would feel that holding hands with a patient and gazing into her eyes would not constitute therapeutically helpful (i.e., ethical) behaviour, while others insist that it is, and supply a theoretical rationale to boot (Lichtenberg, Lachmann, and Fosshage, 2002, p177). The question of creating a code of ethics clearly requires a degree of consensus within the community of scholars and practitioners, as any number of boundary violations (as defined by the community consensus) are routinely justified theoretically by the therapists in question (Gabbard, 1996; 2003).
But what of the fact that Dr F. committed an act that was reasonably uncomfortable for him? Irrespective of whether or not one agrees with the very idea that a patient might gain therapeutic benefit from seeing her therapist drink her gift of coffee, the question of the significance for Dr F. of this agreement to drink deserves our attention. Psychotherapists routinely do things that they feel will help their patients, i.e., they act ethically as a matter of course, but these ethical interventions typically come from a repertoire of techniques that the therapist trained in and studied, and which he or she intended to perform from the outset. Thus therapists usually do what they signed-up for in taking the job as a psychotherapist. What makes Dr F.s action so singular, is that he never agreed that his job should involve drinking a beverage he dislikes, yet he agreed to it on that occasion. A number of possible countertransference motives could be assigned (e.g., the therapy or the therapist would not be enough in themselves to heal the patient; something more was needed, etc.). Aside from the preceding issue of questioning whether coffee-sharing is of therapeutic value, we must address this separate factor of the therapist choosing to do something he does not want to do. Here we must consider the question of masochism.
Suffice it for the purposes of this paper to define as masochistic, that psychic configuration that leads one to perform behaviours that are contrary to ones own interests and wellbeing, when the option not to do so (however dimly recognised or ignored) remains. A number of characteristics of this configuration are worth identifying before proceeding, including i) permitting or inviting a violation of ones boundaries, ii) a diminishment of self-expression, typically the expression of anger, and iii) a diminishment of the sense of ones freedom, typically as a consequence of conflating the needs of others with ones own needs.
Dr F.s action qualifies as masochistic under this definition, insofar as he acted against to his own (true) wishes regarding coffee. His subsequent resentment of the patients request is a function (dynamically, and therefore in corresponding degree) of his failure to retain his free will in the face of the request; had he felt comfortable enough to refuse the invitation, he would not have had reason to resent the patient for asking. Dr F. had already set-up the patients comfort and happiness as competing with that of the person of the therapist. That is to say, he conceived of the situation as one from which only one person could have emerged satisfied, and he agreed to surrender his comfort in favour of his patient. Had he been a coffee drinker, his response would have taken-on an entirely different meaning; given that he dislikes it so much, his supervision session began with resentment, gradually evoked a sense of curiosity, and finally led to a clarifying of some of his assumptions about therapeutic change. He spoke for some time about theoretical concepts of giving the patient what she never got, and about the therapeutic importance of the real relationship, all the while ignoring the fact that his action precluded a genuine interpersonal exchange with the patient: Instead, it was a phoney one; it was one person lying in order to affect anothers feelings. If taken to its logical extreme, Dr F.s not-uncommon emphasis on the personal interactive aspect of treatment as therapeutic implies that a therapist and patient should begin the prospect of psychotherapy with a kind of compatibility check, much like a dating agency would prescribe. If the therapist cannot take for granted at the outset that a standard treatment is likely to be effective, then treatment becomes more a matter of whether the therapist can expect to meet the expectations of treatment peculiar to each patienta kind of customer knows best approach to psychotherapy: You tell me what you need and Ill just do it. To think of psychotherapy in this manner makes some therapists happier than others.
The therapists happiness
At a recent meeting, I posed the following question to a large assembly of analysts:
A young male patient comes for treatment, is not actively suicidal but has suicidal thoughts now and then. He comes for two sessions, pays at the first, then asks at the second whether he can pay next time. What do you do? Almost everyone was happy to forego the payment until the second session. I continued:
He doesnt attend next time; he doesnt pay. He doesnt respond to follow-up phone calls; he doesnt respond to posted invoices. What do you do? Almost everyone was happy to give-up the hope of payment, writing it off as a risk of running any business. I continued:
Three months later you get a phone message from him, in a distressed voice, saying, please phone me urgently. What do you do? Almost everyone was intent that they would phone the patient as soon as possible, most of whom cited suicide risknever mentioned by meas their justification. Only one felt that the man no longer qualified as a patient, and was therefore beyond the responsibility and the ethical boundary of the therapists professional responses. The disagreement between this one therapist and the rest lay in the definition of ethical: The majority felt that it was the therapists duty to return the phone call, while the one felt not merely that it was not the therapists duty, but further, that it was his duty not to call, that not calling was the appropriate action and not simply the absence of a duty-driven act.
I then laid another scenario before the same group, asking how therapists would feel under the following three circumstances: A new patient calls wanting to see you as soon as possible when you were just about to go home for the day.
Circumstance One: The patient says that he is happy to return the next day instead if that would be more convenient.
Circumstance Two: The patient is distressed and wants to see someone as soon as possible. You agree to stay back and see the patient, who is some 15 minutes away.
Circumstance Three: The patient is distressed and wants to see someone soon. You tell your secretary that you are going home for the evening, to have a beer and watch television, telling the secretary to get the patient to contact his GP.
Clearly, these silly scenarios were designed by me to be controversial and to elicit emotional reactions. Expectably, therapists responded by insisting that they would take the highest moral ground wherever possible, and described their position as ethical. What interested me most was the debate sparked by the third circumstance, after no-one could feel comfortable going home to watch television and have a beer while a patient was waiting to be seen. This debate resulted in a reasonable consensus about the list of activities that would allow the therapist to feel OK about going home in preference to seeing the patient: Most therapists could tell the secretary they were going home so long as the activity they went home for furthered the best interests of anyone other than the therapist: For example, going home because the therapist wanted to relax was not acceptable, but going home to take care of three young children was.
Working in a helping profession clearly demands some degree of preference for the wishes of the patient over those of the therapistwe do not interrupt a session to eat when we are hungry, to go to the bathroom, to run an errand we remember we had neglected. However, these vignettes might suggest that psychotherapists cling to an extreme position on the matter, and such lack of flexibility or uncertainty can often serve as a safe haven for those who are unsure of the issues at stake. In avoiding the extreme positions, the question remains: How can we include the therapists rights, wishes, and comfort into a framework for ethical treatment?
It is typically in the response to a question or an invitation from the patient that the therapist is faced with an ethical dilemma: Do we answer the personal question truthfully? Do we agree to a course of action with which we feel uncomfortable? Let us consider a vignette from the self-psychological analyst Heinz Kohut, in which he considers a response to a prospective patients question.
The surface and the unconscious
Kohut recounted a vignette where a patient and he decided to begin an analysis after some initial consultation. The patient said he could begin only if Kohut would agree to take the first three months payment at the beginning of the fourth monthto have his payment delayed for three months. Kohut describes how he wondered immediately what the unconscious significance of this request might be, and what the corresponding transference significance of his reply might be. However, he assigned no therapeutic value to his eventual agreement to the patients request. Instead, he based his decision to agree upon how he actually felt, and whether he genuinely wanted to agree, all the while flagging (with the patient) the as-yet-unknown extra meaning of the request. Thus, in short, unlike Dr F., Kohut based his actual response on his actual feelings, and responded to the patients having made a request (with all its transference significance) with analysis, that is to say, with words instead of actions. In other words, he did not agree in the hope that the patient would experience the agreement as therapeutic (although the patient may or may not have), but he reserved his expectations of therapeutic impact for the interpretation of patient-unknown reasons for why the patient asked (which interpretations he posited as the essence of the curative mechanism; Kohut, 1984). What is significant for our discussion of countertransference and masochism is that the expectation of therapeutic change was assigned to nothing beyond the expected repertoire of treatment, which is defined before the patient is first met. The intersubjective dimension is not relied upon for therapeutic effect; neither is the chance compatibility of wishes (such as an appreciation of coffee) assigned the status of a prognostic factor. Hence, the invitation to masochism is never made.
Dr F. might have explained his dislike of coffee to his patient, refused the invitation, and proceeded to analyse the patients experience of this sequence of events. However, such a course of action would have made Dr F.s subsequent explanations for how therapy cures, a much-more complicated affair. Essentially, Dr F. would either have had to regard his refusal of coffee as an unethical act (according to our definitions); or he would have had to conceive differently of the therapeutic course of psychotherapy, perhaps as a pathway of two (or more) prongs: If the therapist cannot meet the wishes of the patient, the analysis of the wishes remains as an alternative (of equal or lesser value). Either of these possibilities leaves the treatment situation as an invitation to a masochistic position on the part of the therapist, because the patients wishes and the therapists wishes remain in competition for the delegated goal of satisfaction. The question I believe we must be alert to, is which theories of therapeutic change permit a cognisance of therapist masochism, and, in the decision against masochism, still provide a technique that affords the theorised mechanisms of change?
If the therapeutic action of the treatment is positioned theoretically to be the unpredictable thing that the patient wants/needs of us, in the form of a specific action or interaction that is peculiar to a given case (cf. Bacal, 2006), then the danger of masochism lurks at every moment in treatment. One colleague responded to Dr F.s story by saying that he would have told the patient truthfully of his dislike of coffee because that would have made for the real interaction that Dr F. had espoused, namely one of honesty. Another colleague said that he would have refused the drink on the grounds that only a frustration of this wish for shared boundary crossing could ever lead to a healing for the patient. Add these to Dr F.s position and we have three alternative that might seem variedtwo of them antitheticalyet they all share the belief that the interaction rather than the analysis will help the patientone of accepting an invitation, one of refusing it, and one of uncompromising honesty in the face of it.
If the therapeutic action of the treatment is positioned theoretically to be a function of specific therapist interventions (e.g., interpreting the unconscious) then the training therapist has the option to decide in advance whether she can (and whether she wants to) work as a psychotherapist for a living. For those of a theoretical bent that endorses some version of personal responsiveness as the therapeutic essence of treatment, the entire endeavour becomes a kind of lottery of match-making: If, as a patient, you want hand-holding, then you must hope or search for a therapist who likes to hold hands.
The set of behaviours and responses that the patient wishes of the therapist, and the set of behaviours and responses that the therapist can give freely, could never be identical for any therapists entire practice. So it seems foolish to build a model of treatment upon an utter impossibility. I submit that the place where these sets overlap defines the possibilities for psychotherapeutic interactions, and only a subset of this overlapping area could be the prescription for any treatment founded on any given theory of change. However, the therapist who transgresses beyond the bounds of what he can give freely flirts with masochism, and must, to some degree, adopt a countertransference posture that assumes his patient cannot get better on the strength of the overlapping sets, or in other words, that his patient cannot get better in psychotherapy.
As usual, there may be something to learn from the analogy of a far simpler situation. As Menninger outlined in great detail, psychotherapy involves a contract between the parties: an agreement that defines the ethics of the treatment (1958). If we consider the marketplace vendor of apples, the matter becomes a simple one. The ethics of the market place is clear: The vendor has apples, asks a price for them, and the customer is free to agree or not to agree to take an apple for that price. He does not respond to orders for berries by leaving his stall, to go off into the woods in search of berries.
Since the recent eligibility of psychologist services for Medicare benefits in Australia, general practitioners have started referring, (to psychologists) patients primed to ask for and to expect strategies for dealing with their mental health problems. Some of my colleagues (who do not regard their work as the dispensation of strategies) tell me how they feel stuck in that referral situation, forced to decide whether to give the patient the asked-for strategies, or to refuse the treatment. Contrast this with the vendor who is clear about the apples he has chosen a priori to sell, and leaves in the hands of the customer, the decision to purchase or not to purchase.
If taken too far, the analogy of the marketplace will oversimplify the complexities of the ethics of psychotherapy and psychoanalysis. Nevertheless, as mentioned above, it does provide clarity on certain central or perhaps bounding issues, which can serve to create a kind of framework for considering the subtler aspects of ethical psychotherapies. If we take the example of psychoanalysis, the marketplace apple on offer is the goal of therapeutic change for the patient via the specific pathway of understanding the patient in depth (e.g., Kohut, 1984). The analysand and analyst come together for this purpose. This remark, particularly the identification of the means to the therapeutic end, serves both to define the treatment, and to sketch the broad outlines for the ethical conduct of that treatment. If these outlines are clear from the start then every event in the treatment can (and must) be understood from this point of view. So if an analysand asks for more personal interactions with the analyst, or requests some other non-analytic behaviourbehaviour which lies outside of this ethical boundarythen ethical conduct stipulates that these requests should be analysed, because their analysis is the ethically-defined means of achieving the ethically-defined aim. Thus the definition of the treatment serves to establish the ethics of its conduct, and thereby defines as unethical such alternatives as i) the enactment of these requests, or ii) the mere refusal of such requests; alternatives such as these are often employed from a position of insinuated morals, as an unfortunate distortion of proscriptive ethics (Goldberg, 2007). However, the aforementioned ethical framework provides more than just the template for a programme of action on the part of the analyst. As implied above, it participates in an epistemological role; it permits such requests to be seen as an opportunity for understanding, rather than to be seen as requests that have some other claim to legitimacy.
This in turn offers a solution to the problem of having to decide whether the patient’s motives for requests are right (read good or bad), or whether the analysts theory-based interpretations of the motives are right. In an ethical framework, the question of Whose reality is real or right? becomes subservient to the ethically-defined task. We are not left to flounder on the intersubjective seas of relativism, because the ethics of the treatment together with its theoretical framework serve to define the phenomenon as datum, and demand a certain response of the analyst for the treatment to be considered ethical. Again we see this clearly in the extreme cases, such as the cases of sexual boundary violations that occur when the analyst is persuaded by the patients pleas for sexual acting-out, such as the case described by Gabbard (2003) where the patient virtually begs to sleep with the analyst on pain of suicide, and asks him, so what’s more important, my life or your ethics? The masochism is palpable.
Other common forms of therapist masochism include the belief that the therapist is responsible for therapeutic change, rather than responsible for administering the treatment. And the belief that the patients reactions to the treatment are the responsibility of the therapist. Clearly these examples speak to complex issues with no simple answer, but I submit that losing a clear sense of a boundary to ones responsibility is more common among psychotherapists than other professionals. If a surgeon lances a boil, she would never feel responsible for the puss (Rolfes, 2009). Psychotherapists seem driven to accept a more-encompassing responsibility, whereby the masochistic tendency can be easily rationalised as a tendency towards charity or altruism. Yet as we would surely tell any of our patients, self-sacrifice is not always true charity, especially if it is not given freely, or if one has felt required to give. Charity and altruism are not possible in masochism.
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Gabbard, G.O. (1996). The Analysts Contribution to the Erotic Transference, Contemporary Psychoanalysis, 32, 249-273.
Gabbard, G.O. (2003). Miscarriages of psychoanalytic treatment with suicidal patients, International Journal of Psycho-Analysis, 84, 249-261.
Goldberg, A.I. (2000). Being of Two Minds, the Vertical Split in Psychoanalysis and Psychotherapy, NJ, Hillsdale: The Analytic Press.
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Menninger K. (1958). The Theory of Psychoanalytic Technique, NY: Basic Books.
Rolfes, A.E., (2009). Personal communication.