Professor Ivor Browne talks to Mavis Arnold about the ethical responsibilities of the therapist to the client.
The Ethics of Responsibility in Therapy
All therapy has to be non-directive but, since Carl Rogers, this has often been used to abdicate responsibility on the part of therapists. Once a person comes into therapy they are not as responsible for themselves as they were before they started, therefore the therapist cannot opt out. The client may be living in a twisted, neurotic way but they are managing their own lives before they come into therapy. Once their personal boundaries are opened up, they are much less in control of their environment or of themselves. They may have difficulty in continuing to work, or in their relationships. This process is very necessary in therapy because, unless you open up and loosen the person’s boundaries, there is no possibility of change. There is a paradox here that has to be worked out.
The Therapeutic Relationship
When we set up a therapeutic relationship we create, in effect, a small group of two or more, and a boundary of confidentiality forms around that which enables us to interact in a freer way within it. Given that the therapist is aware of this and has invited the client in, he has to be responsible, not for that client but for what he is prepared to allow to happen within the context of therapy. There are certain ground rules which have to be made clear to the client before we accept them into relationship. If they are drinking to excess, for example, then we must explain that, for the duration of the therapy, this has to stop. It may be important for them to move out of home, for example, or to go on some training programme in order for them to achieve change and to hold their ego together. This course of action infers that we believe in the client’s ability to change their lives and in the successful outcome of the therapy. I do not believe that we have the right to tell people what they can, or cannot, do but we do have the responsibility to manage the context of the therapy and to say what we are prepared to do or not to do within the context of the therapeutic situation. I feel that some therapists have mis-used the non- directive approach.
Suicide
Suicide is an extreme example of who takes responsibility for what in therapy. I believe that if the question of suicide arises during the course of therapy then it is important to discuss it openly with my client, and to make it clear that I cannot continue with therapy with the threat of suicide hanging over me. Underlying this is always the belief in the possibility of change. I make it clear that I have no right to tell my client not to commit suicide, nor do I have the power to stop him. I am asking for this threat to be put to one side, in temporary abeyance if you like, while the therapy is in progress. If the client says he will agree to this, but may still, in the early hours of the morning, feel compelled to commit suicide, then I make a contract that he will contact me before he does and I give him telephone numbers where I can be reached I have found that this contract has worked very well since I introduced it ten or fifteen years ago. I believe it is the only honest way to proceed. People are basically honest. If you ask them to do something they will usually agree. It all hinges on the hope and conviction that people will change. [If, as happened to the present writer, a client on a suicide contract telephones to say she is breaking the contract and then makes a suicide attempt (fortunately unsuccessful), this, Ivor Browne says, is not the responsibility of the therapist.]
Legal Action
As a psychiatrist I could be sued by the family of someone who committed suicide because I failed to admit the person to hospital. I believe that to do that is a major intrusion into the person’s life and takes away their autonomy. Once you take away a person’s self-core and ability to manage self you remove the basis of his being alive. Whatever the courts might say, you cannot prevent someone taking his or her own life and being in hospital is no guarantee against this. There are more suicides in hospital than in the community outside. I believe legal action will become more frequent. The law always starts with the doctor’s responsibility. But it is the person’s curative powers which heal him. A doctor can only set up the context in which cure can take place. In the same way psychotherapists set up a therapeutic context within which their clients can heal themselves. It is important to face issues honestly and we must do this under ordinary therapeutic guidelines and look at what is necessary if the client is to make progress. We adopt the role of guide and what goes on in the relationship affects the client’s whole life, not just the therapeutic hour spent with the therapist
An Ethical Dilemma
Two years ago, Ivor Browne himself was faced with an extraordinarily difficult ethical dilemma. A patient of his, Phyllis Hamilton, made public her relationship with one of Ireland’s best-known priests, Father Michael Cleary, who had died the year before. She also revealed that she had two sons by him, one of whom had been adopted. The accusations that she was a liar and a blackmailer caused great distress to her and to the son who lived with her. Ivor Browne knew that she was telling the truth and she asked him to speak out in her defence. He knew that he had a duty to his patient but also a duty to Father Cleary, who had also confided in him. Which was more important: the well-being of his patient or the reputation of a dead man? ’If I had said I was not getting involved, that would not have been a neutral statement. I would have been joining those who walk by on the other side of the road, the people who wanted Phyllis Hamilton to disappear. Yet I had made a commitment to her and she was being directly damaged by the reaction to her revelations, but I also had a responsibility to Father Cleary who had spoken to me in confidence.’ In the Ethical Guidelines published by the Medical Council it states that confidence may be broken in the following cases: where information is required by a judge; to protect the interests of a patient; to protect the welfare of society; where it is necessary to safeguard the welfare of another individual. It seemed to Ivor Browne that, by failing to come out on behalf of Phyllis Hamilton, he would have been failing to protect his patient, he would have supported a lie and denied the truth.
After he had spoke out in the media in support of Phyllis Hamilton, he was summoned to appear before the Fitness to Practise Committee. The issue to be considered was whether or not it had been proven beyond reasonable doubt that he had failed to make an honest judgment in a complex situation. The committee rejected this charge but found that Browne was guilty of professional misconduct, not because he had breached confidentiality but because what he had said was “not the minimum possible disclosure in the circumstances.” It recommended to the Medical Council that he be censured and that he should engage in a one-to-one course on ethical issues relevant to psychiatric practice. This curious recommendation was later dropped, but Professor Browne was admonished for damaging the reputation of the medical profession. Now, a year later, he remains convinced that the reputation of a dead man is a less important factor than the reputation of a live person who is being wrongfully accused and damaged and that if a similar ethical dilemma recurred he would act in exactly the same way again.