[In Gavin & Susan Fairbairn (eds). Ethical Issues in Caring. Aldershot: Avebury, 1988]

Psychotherapy: deliverance or disablement?
David Smail

The ethical questions which confront any individual working in the 'helping professions' presumably vary according to that individual's particular situation. For example doctors, nurses, social workers and psychologists find themselves working in contexts which are in several important respects different from each other: in terms, for instance, of the often implicit conceptual and ethical assumptions and preoccupations of their discipline, and also of the access they may have to the use of formal institutionalised power.

Let me start then, by trying to clarify as far as I can the ways in which my own situation may be helping to shape my view of the ethical issues and dilemmas in psychotherapy. My perspective is that of a non-medical psychotherapist working in the National Health Service, having specialised in psychotherapeutic work within the broader field of clinical psychology. As a psychological therapist in the NHS one has little formal power. Patients are referred by medical practitioners - usually psychiatrists or GPs - and are by and large unable to approach the psychologist directly for treatment. Similarly we have no power to admit patients to or discharge them from hospitals, prescribe drugs, write sick notes for them or otherwise exercise direct institutionalised influence over the material circumstances of their lives. It is not of course that we have no informal power; depending on the quality of relations and communications with medical and social work colleagues we may through advice or persuasion be able to bring influence to bear in all these spheres, but I think it is true that we would only seek to do so in a very small minority of cases. Working in the NHS we differ from non-medical psychotherapists in the private sector in that we make no direct charge to our patients for our services. While this may relieve us of temptations to doubtful ethical practices to which private therapists may be exposed, it may also mean that at times we, as well as our patients, are not as clear as we might be about the extent and nature of the contractual arrangement between us. For example, I have no doubt that large institutional organisations like the NHS and the Social Services at times breed in their employees a rather confused and blurred attitude towards the rights of the individual, which I am sure would be rapidly clarified and sharpened were we paid directly by the individual. I should add emphatically that I do not believe that this is an argument for the dismantling of the welfare state, but rather for those of us who work in such settings to stay alive to the issues involved and not allow the implicit and often unquestioned values of bureaucracy to determine our conduct. (I am thinking, as one example, of the extent to which the pursuit of 'cost-effectiveness' may replace a concern with what is best for the individual patient; or again how confidentiality may be sacrificed in the interests of social engineering in a situation where people have their 'best interests' decided for them by a kind of unseen committee of health and local authority workers.)

My own work, and that of colleagues like me, consists then in a series of face-to-face interviews or sessions with patients in which the focus of attention is how they see and feel about their emotional distress, their relations with others and their relation with the therapist. Though at times we may certainly give practical advice we will rarely attempt to influence patients' lives or circumstances through the use of power.

Now it seems to me self-evident that nobody would undertake this kind of work without having at least an implicit view of what, in some important sense, is good for people. For me this means that psychotherapy is centrally a moral undertaking dealing with fundamentally moral issues such as what constitutes psychological wellbeing, how people should conduct themselves in relation to each other, what stance we take towards emotional distress and psychological pain, where we locate responsibility for the tragic disorder in which so many people live their lives. And yet, with one or two notable exceptions (for example Thomas Szasz, 1978)l in their published literature psychotherapists have expended surprisingly little effort in addressing directly the ethical implications of their work, apart from giving some consideration to the desirability or otherwise of manipulating patients through the use of technical procedures ranging from psychoanalytic interpretation to methods of behaviour modification.

The reason for this kind of blindness to the broader moral issues lies, I believe, in the scientific/technological stance which most therapists have chosen to take towards their discipline. In the psychological and psychiatric worlds at least, this stance seems still to embrace mechanistic assumptions that science is value-free, and that the technological applications suggested by scientific observation, theory and experiment are somehow self-justifying unless unworkable for practical reasons (for example that they break the law). The justification which, at least since Freud, psychotherapists have most strenuously sought for their activities has been scientific, and the most damaging charge which can be made against psychotherapeutic theory and practice has been that they are 'unscientific'. As long as what we are doing can in some way be related to scientific credibility, few of us question whether it is right or good. Partly no doubt this is because, until relatively recently, our understanding of mental disorder has been shaped by an analogy with physical illness. The primary task of medicine in this century has been to support its moral position with acceptable scientific evidence that its procedures are effective. Its moral position has not been in question: few would doubt that in general it is right to save life and cure disease, and physicians and patients have been unlikely to find themselves at odds over this proposition, even if nowadays the very effectiveness of some medical procedures has begun to open up areas of moral doubt.

So long then as emotional distress could be seen as mental disease, it has seemed reasonable to leave ethical issues on one side and get on with the job of unravelling the complexities of the, so to speak, mental and behavioural apparatus, in order to find methods of adjusting it so as to reinstate its satisfactory functioning.

There are however a number of signs that our investment in the scientific/technological stance has been too one-sided, and our acceptance of the analogy with physical medicine mistaken.

For one thing the conceptual attack on the 'medical model' in psychiatry which gathered momentum in the 1960s led to the rejection of the view of mental disorder as mental disease by most professional groups working in the broad area of 'mental health' other than psychiatrists themselves. For another thing academic psychology seems in general to have failed to generate theories of human behaviour which could command the allegiance of any scientific community wider than the factions which invented them in the first place. Signs such as these suggest that our mechanistic notions may not be adequate to the task we have set ourselves.

For psychotherapists however, more important than calling into question their reliance on science for the justification of their practice is the actual experience of psychotherapy itself. Now I am sure that a lot of practitioners in this field manage to get by by assuming uncritically the values (buried often almost out of sight) of their professional world as well as of the broader culture in which they operate. It is easy, though I think incorrect, to believe that the psychological theories which inspire therapeutic practice (albeit loosely) are founded on secure scientific foundations, and it is equally easy, and I think almost equally questionable, to feel that one's therapeutic activity is in accord with the best ethical principles. Therapists may often disagree quite vehemently about the effectiveness of the means to an end but very rarely about whether the means are themselves justified by the ends. For example, I have found that to question colleagues in clinical psychology about the rightness of social engineering to alleviate anxiety is to be met with incredulity; almost anything, it is felt, is justified by the alleviation of 'symptoms' such as anxiety.

However the therapist who attends reflectively to his or her experience of therapy can scarcely fail to be struck by the primacy of moral issues and the inescapability of his or her moral view. It is of course true that, on the basis of their theoretical writings, it would be very difficult to arrive at conceptual generalisations about what psychotherapists do since there are so many different schools of psychotherapy claiming success for their methods on the grounds of widely conflicting theoretical principles. But several students of the psychological therapies agree that, whatever they say they do, experienced therapists tend to set about their work in very similar ways, no matter what dogmatic allegiance they profess.

As I tried to argue in Psychotherapy: a personal approach,2 it seems to me that an open-minded appraisal of what happens in most psychotherapeutic approaches reveals three main stages. The first consists in a, sometimes protracted, process of negotiation in which agreement is reached between therapist and patient about the nature of the latter's complaint. The initial complaint of the patient is not taken at its face value but, through the process of negotiation, is given a meaning for the patient in the context of his or her life and relationships which at first he or she did not perceive it to have. For instance many patients come to their therapists complaining of 'symptoms' which they find simply mystifying and unaccountable. Often such symptoms are suggestive to the therapist of anxiety - for example dizziness and nausea, difficulty in breathing, dryness of the mouth, choking sensations, palpitations and so on. The therapist's view then, is likely to be that on occasions the patient is anxious or afraid for what may in fact be very understandable reasons, while the patient's view might be that these symptoms are signs of an inexplicable illness. The analogy with medicine is so far not all that distant: the physically ill patient expects the doctor to offer an explanation (diagnosis) for his or her symptoms and will usually accept one unprotestingly as long as it carries a degree of plausibility. However the psychotherapist's suggestion that the patient's symptoms are not simply indications of illness but, say, indications of fear or anxiety, is as likely as not to be met on the patient's part with a kind of hostile disbelief that may take weeks or even months to overcome, so that any analogy with medical diagnosis ends about here. This of course is because many so-called neurotic symptoms constitute the means whereby patients may deceive themselves about the nature of their predicament, which in turn is so intimately related to the consequences of their own conduct that direct recognition of it would involve them in practical and moral self-questioning far more painful than the immediate somatic accompaniments of their anxiety and the bonus these offer for interpretation as illness. To tell people that their rash is due to measles is unlikely to be seen by them as an accusation of moral impropriety, whereas to tell someone that her fainting fits are related to a wish to murder her spouse is. It is of course unlikely to be part of the therapist's intention simply to make accusations of moral impropriety; much of the work of negotiating with patients an acceptable account of the meaning of their predicament consists in developing the view that, though it is necessary to become clear about who is doing what to whom in the patient's life, and hence to locate responsibility for all kinds of conduct, it is not part of the therapeutic aim to apportion blame or mete out punishment.

This kind of process of negotiation may go under all sorts of technical names, from 'interpreting the transference' to 'providing a behavioural analysis', but I argue that it is an essentially familiar activity to therapists of a wide variety of persuasions. Its end of course is the achievement of 'insight', but that is not the end of psychotherapy. For having achieved insight - having arrived, that is, at a degree of understanding concerning the reasons for what before seemed inexplicable distress - the patient is then confronted with the significance of being responsible.

The assumption of responsibility I see as the second stage of therapy, bridging and shading into each of the other two. Assuming responsibility for one's own conduct (not, let it be noted, for the evils of the world or the inequities of society, which have their own major roles to play in the generation of psychological misery) is the necessary result of seeing how one has come to occupy one's predicament, and the necessary precondition for doing something about it - which latter is the third stage of therapy.

The aim of negotiation is to demonstrate that our past experience and present circumstances give us reasons for being the way we are, but do not inexorably determine the way we are. It leads thus to the notion of people as agents, originators of their own conduct in some important respects and whether they know it or not. Having acknowledged this degree of responsibility they are then faced with having to do something to alter the actual circumstances of their lives. It is certainly very much easier to see what is wrong - for example that one has helped construct a desperately unhappy and destructive marriage - than to do something about it.

For me the most important concept to invoke at this point is again a fairly clearly ethical one, and that is - courage. Actively to throw oneself into situations which have for years been laden with threat and contemplated with dread takes more than just the application of a few mechanical techniques and a touch of insight: to face those elements in their lives which they have been so assiduously avoiding through the strategies of, say, neurotic anxiety, demands of patients' degrees of courage which they may only be able to muster with the active help and support - in a word, the encouragement - of the therapist, who in turn may well find that this is no time to remain seated on a professionally constructed ethical fence. In doing something about his or her predicament the patient takes a leap in the dark, often on the assurance of the therapist that it is safe to do so, that nothing unspeakably awful will happen as the result. What is actually therapeutic of course is the patient's discovery that this is indeed the case, and the consequent learning of new solutions to old problems. Therapists do not operate technically on passive patients in the manner of the surgeon, no matter how tempted they may be to characterise their work in this way, but more like a music teacher and pupil, for example, help patients to place themselves in the best position for finding out for themselves.

In helping patients to understand the reasons for their predicament, to accept responsibility for those aspects of it which originate in their own conduct and to strive actively to do something about it, I do not believe it possible for therapists simply to follow some kind of scientifically established technical manual. Much of the time it is the therapist's personal qualities - personal experience and personal judgement, and indeed personally constructed ethical stance - which determines his or her view both of the patient's situation and of what course he or she feels the patient should take in dealing with it. In this sense the therapist is in much the same situation as anyone else who tries to offer support, advice or encouragement to those in distress: there are no objective solutions to the emotional confusions and ethical dilemmas in which so many patients find themselves. The mechanistic bias of psychotherapeutic theory does, it is true, seek to convey a sense precisely of such objectivity in the language used to describe so-called therapeutic techniques. For example, this is particularly obvious in the area of 'behavioural methods' of treatment, in which the jargon of stimulus and response, behavioural 'shaping', 'cognitive restructuring', 'social skills training' and so on, seems to present a picture of a psychological world in which obvious mechanical fault suggests established procedures for the reinstatement of satisfactory functioning. As far as this suggests the possibility of objective value-free therapeutic technique, it is in my view spurious and serves only to further professional mystique and protection from ethical doubt. Human beings evolve a moral world through their own conduct, they do not simply occupy more or less efficiently a world in which standards of behaviour and relationship are objectively established in a way which permits automatic assessment of who is conforming satisfactorily and who is not. Patients and therapists moreover are not insulated from the moral uncertainties of the human situation, but are frequently engaged at their very centre. Often then, there can be no established guidance about what to do in this or that situation: therapists have to make judgements based on their own personal experience and values, and they have to face unflinchingly the fact that they are indeed engaged in the enterprise of influencing patients, which they may do for better or for worse. This means, I think, that the justification for therapists' status as professionals is not to be found in criteria of technical training or competence or in the scientific adequacy of the theories to which they subscribe. What presumably makes the difference between a helpful layman and a competent psychotherapist consists essentially in little more than the latter's greater experience of people in distress. Of course whether or not good is made of that experience is another question, and not one, I think, which has yet been dealt with very convincingly by the psychotherapeutic profession. The criteria we offer the public by which to judge the adequacy of our credentials and our right to practise involve for the most part claims concerning scientific respectability, technical efficiency, academic degrees and approved courses of training. As I have said, I do not believe that these explicit criteria take proper account of the essentially moral nature of psychotherapy as an undertaking, although they probably do conceal implicit criteria of who is and who is not a competent therapist, which we operate informally and not entirely unsuccessfully.

There was perhaps a time, not all that long ago, when the lay stereotype of the psychotherapist was of a somewhat mysterious figure possessed of an esoteric wisdom and an arcane knowledge of the human psyche. This image, in its day not altogether disavowed by psychotherapists themselves, is now fast disappearing, to be replaced by that of the therapist as competent professional technician. possessor of a repertoire of 'clinical skills' from which judicious selection may be made to suit the needs of the individual case; it is an image which is enthusiastically fostered by many psychotherapists. A recent working party of the British Psychological Society, for example. quoted with approval in its report on psychotherapy a definition of the latter as an:

informed and planful application of techniques derived from established psychological principles by persons qualified through training and experience to understand these principles and to apply these techniques with the intention of assisting individuals to modify those personal characteristics as feelings, values, attitudes and behaviours ... as are judged to be maladaptive or maladjusted.

In my view (which I have elaborated in Smail, 1983)3 this is far from accurate as a definition of what actually happens in psychotherapy, but serves its purpose in suggesting a view of therapy which many therapists would like to be the case and are only too happy for the population at large to believe. In other words it serves the aim of achieving professional credibility as well as going some way towards satisfying a widespread desire in our culture for people to see themselves, when emotionally distressed, as 'dysfunctional' machines.

In adopting the role of the expert technician the therapist, as I have already suggested, apparently steps out of the moral arena and offers his or her services on the basis of a kind of ethically neutral technological efficacy, in principle no different from that which might be claimed by motor mechanics, brain surgeons or indeed psychiatric dispensers of tranquillising drugs or electric shocks. For psychotherapists this stance can, I believe, be maintained only in bad faith or through lack of reflection, but is reinforced through the opportunities it gives for the social legitimation of an ever-increasing, and increasingly prosperous, profession of psychotherapy.

Even though in their activity with individual patients therapists may in fact be working against the expectations set up by this kind of professional pose, its wider effects on the community at large may be positively harmful. As long as people see, and are encouraged to see, their psychological malaise and emotional pain as arising from mechanical fault within them, as essentially unrelated to their place in and contact with the world, as nothing to do with their conduct towards others and others' conduct towards them, or as far as such conduct is viewed simply as the interplay of socially manipulative 'skills', then I believe their ability to evolve any kind of better world is stifled. As professional experts, that is, we encourage a view of the world as basically all right or at least as basically unalterable, a world to which people have to adapt if they are to get by in it, a world which is so solidly, finitely, objectively real that it can be understood, after an appropriate course of study, by experts who can then use their technical knowledge to interpret it to the less expert and modify them to fit more comfortably into it. Being the achievement of an increasingly closed professional group it comes to be accepted that people cannot do this kind of thing for themselves; they become progressively more passive and more unable to understand and criticise their own conduct, the conduct of others and the significance of their own experience.

For example, I have a patient who lives in a terrace council house with four children and a gregarious and periodically alcoholic husband, and neighbours on either side whose noisy adolescent children maintain a kind of constant disruptive feud with her which amounts at times almost to a reign of terror. My patient works every hour God sends, fetching her children to and from school, washing (two of her children are bed-wetters), shopping (her husband is often out of work and she is responsible for budgeting), cooking meals for her own and her husband's family, the numerous members of which may appear, singly or in groups, at any hour of the night up to 3 a.m. expecting a meal. Her children are loving and loved but noisy and demanding. Her husband may come home sober, chatty and concerned or drunk, savagely ironic, brutally demanding food or sex. Until recently (and only because of my encouragement that she should do so) my patient has never, as far as I am aware, complained about any of this. What she has done every so often is collapse with exhaustion and anxiety. Taking these 'symptoms' to her doctor at one time she was psychiatrically diagnosed as an 'inadequate personality' and tranquillised so heavily that, by her own account, she scarcely knew what she was doing and as a consequence scalded her hand - now badly scarred - with a saucepan of boiling water. The circumstances of her life, her housing, her neighbours, the demands of her children and of her husband and his family, she has never seen as anything but justifiable, unalterable, simply real and there; her experience, as far as I can see, has never suggested to her the possibility of an alternative world. Like her psychiatrist she thinks she is inadequate. As far as I can see, as well as being a sensitive and intelligent person she is the most adequate woman I have ever met - anyone else I know would in the face of this strain have died, committed suicide or run away. Before she came to psychotherapy I do not think she had met anyone, professional or otherwise, who had suggested to her anything other than that her occasional failure to operate successfully as a wife and mother in this context was due to some kind of mechanical failure in her ability to cope: she, and not the world, needed changing.

Now I suppose it would be possible to characterise this lady's difficulties as a deficiency in her 'skills' - for example in organising her daily routine, standing up to her husband and his relatives, achieving a measure of discipline with her children; it is certainly true that I have spent a lot of time examining these issues with her. To use this kind of language however would be to obscure the moral issues which confront her: would in fact be tacitly to assume one particular moral position while hiding it behind an apparently objective technical analysis. In fact she has a number of options open to her: to keep going as she is, propped up by pills and the occasional enforced rest; to drive herself to be an even more selfless slave to her family; to agitate for better living conditions both with her family and with the housing authorities and so on; to commit suicide, and so on. When she went to see a locum GP to complain about the painful sequelae of a recent operation he readily offered another obvious solution to her difficulties. He had never seen her before but after waving her to a chair riffled through her notes in silence for a few seconds, and then delivered himself of the sentence: 'I see you've had a lot of problems; when are you going to leave him?' It is of course perfectly possible that after due deliberation and negotiation it may seem to a therapist that to encourage a patient to leave a bad marriage would not be inappropriate. More usually, perhaps, one would want to limit one's activity to helping the patient to become aware of the range of choices before her. In this particular case my judgement is that the woman in question has a fundamentally affectionate and warm relationship with her husband, may be partly responsible for occasioning his drinking bouts and would probably not be better off without him. But whether or not this is true, my point is that these are moral questions, that they arise out of circumstances not untypical of those one meets frequently in psychotherapy, and that in practice there is no way in which a therapist can honestly avoid taking up some kind of stance towards them.

As long as therapists make this clear to their patients as well as to themselves, I think they stand a chance of being, at least some of the time, a valuable source of support and encouragement to people in misery and despair who, as things are, have no one else to turn to. It is no doubt sadly ironic that such comfort comes to be dispensed mainly by paid professionals with degrees, qualifications and years of specialised training behind them. However, in so far as we seek to obscure the essentially unpretentious, if morally risky, nature of our calling behind professional mystique, technical mumbo-jumbo and scientific self-righteousness, I think we are likely indirectly to weaken the already failing ability of the wider community to shape its own destiny. This is not to belittle psychotherapy or to suggest that the insights it affords into the reasons for psychological distress and the ways people come to cope with it are inconsiderable. There is no doubt that by acquainting oneself intimately with a particular area of human experience one comes to acquire, if one is able to keep a fairly open mind, a knowledge of some of the principles which operate within it which is unlikely to be developed by just anybody. To pretend that knowledge of such principles should somehow be patented as our own professional property, when in fact it could be laid open for critical public scrutiny and made available for general use, does not seem to me justifiable or in the interests of the moral evolution of our social life.

Presumably therapists are shy of discussing their moral position because of the uncertainties which attach to it. Any moral position is debatable, and a therapist's practice, no matter how extensive his or her understanding of human nature or scientific knowledge, must at every moment be open to question and challenge by anybody prepared to reflect upon whether what he or she is attempting to achieve is right. For the sake of a quiet life it is much easier to point to the technical rather than the moral justifications available for therapeutic practice, and much easier to mystify the layman thereby. Many people in our present-day world moreover seem to become paralysed in the face of moral debate: we seem to have an unremitting yearning to change 'oughts' into 'ises', to distance ourselves from the painful necessity of moral reflection and argument - we should on the whole like the world to be mechanically ordered and our 'behaviour' determined by processes outside our responsibility. To raise moral questions and issues is often, it seems, to commit a kind of indecency (as it is in some circles to discuss politics or religion), and is frequently responded to with embarrassment or contempt. If only we could leave everything from parenthood to psychotherapy to the computer: what we need are programs and packages, and training in skills.

In the face of this, no wonder therapists are reticent about what many of them sense is the moral nature of their undertaking. But not all of them are. Those that are not certainly face us with a difficult critical task but, I believe, one we cannot afford to shirk. While we may be put off by the simplistic fervour of some devotees of the 'encounter' movement, or the cloying sentimentality of some, for example American therapeutic gurus, we might be wise to examine carefully the measured arguments of some therapists (as, for example, Peter Lomas in The Case for a PersonalPsychotherapy4) who suggest that, among other things, honesty and love, and even wisdom, have more to do with psychotherapy than professional authority and technique. Things like honesty and love are however extremely difficult to talk about.

Notes

1 Szasz, T. (1978), The Myth of Psychotherapy. Oxford University Press.

2 Smail, D. J. (1978), Psychotherapy: a personal approach. London, Dent.

3 Smail, D. J. (1983), 'Psychotherapy and psychology' in D.Pilgrim, ed., Psychology and Psychotherapy: current trends. London, Routledge & Kegan Paul.

4 Lomas, P. (1981), The Case for a Personal Psychotherapy.  Oxford University Press.

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