by Mary Stefanazzi
This article is the full text of a paper delivered at the Irish Council for Psychotherapy Conference in Dublin Castle on 26th January, 2012.
This paper will consider Ethics and the contemporary practice of psychotherapy. The consideration will begin by addressing some of the myths and fantasies about ethics and proceed with a proposed working definition of ethics. This definition will propose a specific context for professional codes of ethics so the two distinct topics of ‘ethics’ and ‘codes of ethics’ are less likely to be confused. The role and relevance of ethics to psychotherapy today will be considered against some established ethical principles, together with due consideration of what some scholars have to say relevant to the theme of this enquiry. Consideration will also be given to some possible ethical challenges facing the profession at large, together with the need for some supportive structure which can facilitate discourse on emerging and on-going challenges so that they can be embraced in a meaningful and productive way.
In conclusion, the paper will consider the question ‘what role, if any, does ethics currently play in contemporary psychotherapy’, before arguing in favour of the need for a sound ethical foundation for contemporary psychotherapy which can ensure the creative horizons of the profession, and the community it serves, flourish.
The very mention of the word ‘ethics’ in psychotherapy circles can sometimes evoke fantasies of excessive regulation, legal complications and a dread that embracing ethics will mean losing the essence of what psychotherapy is about. Ethics is of itself a fascinating and valuable topic of relevance to every walk of life, including psychotherapy. But first, I want to begin by defining ethics and will do so by addressing what it is not. We most frequently come into contact with the word ethics in the context of our ‘codes of ethics’. I would invite you to consider these codes, in whatever context you come across them, as ‘guidelines for good practice,’ so we can dedicate our use of the word ‘ethics’ to the particular discipline of Ethics which I will attempt to define and summarise. I choose to reference Aristotle because his ethical focus is on character, virtue and community which link well with the structures we are familiar with in psychotherapy.
Aristotle (384-322BC) was the first to classify areas of human knowledge into various disciplines, one of which was ethics. The word is derived from the Greek ethikos, ethos, meaning ‘character’, other words such as moral, good, right and excellent are used to mean the same thing. Ethics is concerned with action. Therefore, the study of ethics involves more than simply knowing and studying the truth. Aristotle acknowledges that intellect and knowledge are important, but he stresses, repeatedly, that they are not ends in themselves – but the means to an end. In order to act morally, investigation and deliberation are required, followed by decision and the corresponding right action. So ethics is not about following codes or rules, it is, in the main, about character. Aristotle’s work on Ethics is called Nicomachean Ethics after his son, Nicomachus, who is believed to have edited the work and gave it its final form some years after his father’s death. This work belongs to the category of ‘practical philosophy’ which deals with action.
Aristotle’s aim in writing the Ethics was to provide an account of how the good person should live, and how society should be structured in order to make such lives possible. Aristotle stressed that the good life is a life lived in the community and that the individual is seen as a part thereof. Moral education implies more than giving people a good understanding of what is good and morally worthwhile. Aristotle makes some general observations on the reasons we might give for our actions. His observations are deliberately general, in order to get to the basic assumptions involved in ethics. We often try to think out problems such as, ‘How can I pay these bills?’ but rarely, if ever, do we ask the deeper questions, ‘What should I be doing with my life?’ or ‘What is the best way to live?’
These deeper ethical questions are like sand to the oyster. We need to let them irritate us for some time before their pearls of wisdom can be understood. Such irritation can sometimes be the impetus for a person to seek psychotherapy. For some, it can seem like something is terribly wrong, for others they may consider themselves depressed. There are many other constructs which can equally apply. The initial assessment is therefore our opportunity to determine a person’s reasons for seeking the professional assistance of a psychotherapist.
In this simple example of a person questioning themselves, we have opened the much larger philosophical question of the complexity of the human condition (MacNamara, 2010:49). This is likely to arise when working in any role that bears witness to the struggle of another human person. Before even thinking about what the right response might be, I would suggest that we need first of all to have a construct of the human condition that can provide a sound foundation to how we work – irrespective of the discipline we have been trained in. Again, I shall draw on Aristotle’s wisdom – which emphasises that we need to reflect and deliberate before we can know what the right thing to do is. The aim of ethics is to do the right thing for its own sake. Acting rightly is the practical expression of ethics, which Aristotle considered to be the most important of the sciences, to such an extent that he does not consider the alternative to be a viable proposition – “to entrust to chance what is greatest and most noble would be a very defective arrangement”, (Aristotle, 1984:1738, 1,9, 1099b 23-24).
One Aristotelian scholar argues that you can get the good things you are searching for only through a lifelong commitment to the pursuit of argument: “Other figures in the culture soothsayers, magicians, astrologers, politicians – all claim to provide what people want, without asking them to think critically and argue….” (Nussbaum, 2009:xi). So what might all this have to do with psychotherapy? To answer this in context, we will next look to some established ethical principles with reference to the UNESCO Universal Declaration on Bioethics and Human Rights (Have, 2009) and then relate these back to the contemporary practice of psychotherapy. Where sections of the Declaration are referred to throughout this paper, reference will be given by citing the relevant Article number.
Identifying Ethical Dilemmas
The aim of the UNESCO Universal Declaration on Bioethics and Human Rights is to address ethical issues as applied to human beings. The declaration is notable because member states committed themselves, for the first time in the history of bioethics, to respect and apply the fundamental ethical principles. It was adopted in 2005 and sets out 15 ethical principles in Articles 3 through to 17. My reason for referencing this document is that it is the first international document in bioethics adopted by all governments. It is significant that all UNESCO Member States were able to agree upon the relevant bioethical principles.
Article 5 talks about the need to consider the narrative of the patient in considering what would be a desirable outcome. The principle of autonomy is based on human dignity and informs the principle of consent in Articles 6 and 7. To illustrate this further and give you a flavor of these principles in practice, within the limited time we have together, I will focus more particularly on one area, the area of informed consent.
Article 6: Consent
The historical context to the principle of consent is interesting and still relevant in some instances. In ancient Greece healing was considered a religious practice performed by initiated persons. It was essential to follow the commands of the healer without question for treatment to be successful. The concept of the patient being asked for consent is linked to the secular concept of medicine, which only developed around the fifth or sixth century in ancient Greece into what has become known as the ‘Hippocratic Oath’, where physicians were obliged to act for the benefit of their patients and to avoid harm. However the core mentality did not change and in western countries the doctor-patient relationship continued to be a paternalistic one which prevailed until the latter part of the twentieth century. Today it is established that the patient is the one who finally authorizes any medical procedure (Have, 2009:123-138). I would argue that as the contemporary practice of psychotherapy stands, a person is considerably restricted from exercising their autonomy with regard to their mental health.
To illustrate this dilemma, consider the case of a person choosing to exercise their autonomy by wanting depth psychotherapy as their preferred treatment option for depression, in contrast to the medical model of treating the same depression with medication. Presume that this person has currently taken time off work and has sufficient private insurance cover to provide them with an income during their absence from work, and that they have met with a psychotherapist and have mutually worked out a viable therapeutic contract.
The first obstacle this person will likely face is when making a claim for payment from their insurance company. The company will seek medical or psychiatric references and will not, in my experience to date, accept working with an accredited psychotherapist as a viable treatment option. The outcome is that this person cannot practically follow through with their preferred treatment choice and their autonomy is restricted as a result notwithstanding the fact that they were willing to pay the full cost of their psychotherapy treatment out of their own pocket. Were they to have chosen the medical model, most of the cost would likely have been borne by their insurance or by the State.
There are a number of ethical principles important in this scenario: Autonomy and individual Responsibility (Article 5), Consent (Article 6), Human dignity and Human Rights (Article 3), Respect for Human Vulnerability and Personal Integrity (Article 8), Equality, Justice and Equity (Article 10) and Non-Discrimination and Non-Stigmatization (Article 11). The next stage is to balance these principles with view to arriving at an ethical assessment of the situation.
The extraneous fact to the above example is that psychotherapy is not yet subject to statutory regulation in Ireland. This fact will support insurance companies, social welfare, employers, and any other stakeholder in disregarding psychotherapy from their acceptable treatment options. This fact displaces some of the ethical considerations already mentioned since it could equally be argued against including an unregulated profession on ethical grounds, namely, Benefit and Harm (Article 4). The articles, Autonomy and individual Responsibility (Article 5) and Consent (Article 6), are really worth considering, from the perspective of the profession of psychotherapy, at this juncture in our history.
The debate about statutory regulation has been on-going for many years now and I presume it will happen at some unknown date in the future. In the meantime, I would argue that there is plenty of preparatory work to be done on ethical grounds in relation to these principles of autonomy and consent. In general, making a choice in favour of psychotherapy can be instead of the medical model or in conjunction with it. However, medical personnel and psychotherapists do not currently have a forum to discuss what they each can offer a client seeking help at the level of primary care in spite of the aspirations of A Vision for Change which recommends that services should be:
“Person-centred and adapted to each individual’s needs and potential; services should be delivered by skilled professionals working together in community-based multi-disciplinary teams, where the contribution of each member is valued and where skills and expertise are combined to design and deliver integrated care plans; the range of interventions offered should be comprehensive and should reflect best practice for addressing any given mental health problem.”
Vision for Change (2006)
This aspiration could be interpreted as a challenge to the mental health profession at large to provide some forum where psychotherapists, doctors, psychiatrists and other primary care personnel can begin a dialogue towards the development of a comprehensive multi-disciplinary approach to mental health where the health care professionals and potential clients are all afforded equal respect. This leads us to consider further the role of psychotherapy in the community.
Psychotherapy and the Community
It seems to me that we need a sound ethical foundation for contemporary psychotherapy that can be clear to all citizens. This prospect raises the question of ‘where does psychotherapy fit in our society?’ Before this can be answered we need to consider the main focus of psychotherapy as a profession to establish where psychotherapy fits with regard to other areas of society such as mental health, religion and spirituality, law, education, research, public health policy, media, voluntary sector, finance, and health insurance (Tjeltveit, 1999). Determining these issues ought to answer whether psychotherapy is made available to all members of our community or not, and whether long-term therapy is supported when required.
Public policy on psychotherapy affects us all – for better or worse. I am at a loss to see how the profession can flourish without these challenging issues being addressed. One of the most challenging ethical issues for public policy makers will likely be whether, or under what circumstances, psychotherapy benefits society. Particularly when there is extensive literature arguing that the ethical influence of many therapists on clients is individualistic – that therapists are more concerned about individual well-being than about the wider community (MacIntyre, 2007).
Ethical issues are rarely straightforward and disagreement is part of the process. A useful starting point that I would recommend is for us to begin, individually and collectively, by considering the concerns or criticisms about what we do, or do not do, with a view to establishing a sound ethical foundation for contemporary psychotherapy which can ensure the profession, and the community it serves, can flourish. In the meantime, there is much work to be done, and, as Aristotle said, “one swallow does not make a summer”. (Aristotle, 1984: 1735 1,7, 1098a 18).
This year marks the 21st anniversary of the Irish Council for Psychotherapy. This symbolic ‘coming of age’ indicates that we ought to be able to deal adequately with our responsibilities (ICP, 2012). But have we established yet what our responsibilities actually are? We have had decades of psychotherapy at this stage, yet society, here, as well as elsewhere has not improved – it could be regarded as even more problematic. Are we, as psychotherapists making any noticeable contribution to society?
Aristotle would argue that the capacity for an individual to flourish is linked to society – to the common good, where the ultimate purpose of all practical decisions is the well-being of citizens, both as individuals and as a community. If we could understand how to achieve that goal, we might then see how the actions of every individual can both be good for that person, and also contribute to a flourishing community. Ethics can show us how to find answers. However, this can only happen by each of us considering what it is that is ultimately important to us as a community. Then, together, we will need to discuss, and argue, the various perspectives until we come to a consensus about the main focus for psychotherapy which in turn becomes our ethical foundation, which can serve to shape and inform our work while including the bigger picture of our role in society as individual psychotherapists, and as a profession.
Mary Stefanazzi has an MA in Ethics and runs a private practice as a psychotherapist, Clinical Supervisor and Ethics Consultant in Dublin and Westmeath. www.psyche.ie.
Aristotle. (1984). ‘Nicomachean Ethics’ in Barnes, J. (ed) The Complete Works of Aristotle. Princeton: Princeton University Press.
Have, H.T. (2009) and Michele S. J. The UNESCO Universal Declaration on Bioethics and Human Rights: Background, Principles and Application. Paris: Unesco Publishing.
Irish Council for Psychotherapy Newsletter (2012). January edition: editorial.
MacIntyre, A. (2007). After Virtue. London: Duckworth.
MacNamara, V. (2010). The Call to be Human, Making Sense of Morality. Dublin: Veritas.
Nussbaum, M. (2009). The Therapy of Desire. Oxford: Princeton University Press.
Tjeltveit, A.C. (1999). Ethics and Values in Psychotherapy. London: Routledge.
Vision for Change (2006). Report of the Expert Group on Mental Health Policy. Department of Health and Children, Stationery Office, Dublin.