Human Systems: The Journal of Therapy, Consultation & Training

Ethical Therapy: A Proposal for the Postmodern Era Marco Bianciardi1 and Paolo Bertrando2 1. Director of Training, Episteme Centre, Turin, Italy 2. Director, Episteme Centre, Turin, Italy

This article deals with the problem of ethical responsibility in psychotherapy. Any therapist, today, must consciously dismiss the illusion of being able to ob-jectively justify his/her choices in the course of her/his clinical practice; this does not lead to abandoning his/her ethical responsibility in professional prac-tice, but, on the contrary, leads to taking full responsibility regarding anything that may happen in the therapeutic process. We believe that clinical responsibility, today, should not be understood as it was within classical logic: the mod-ern clinician’s responsibility should be considered a second order responsibility. Taking such a responsibility means becoming able to monitor the relationship one is embedded in through second order operations.

From the very early days of psychotherapy, issues regarding ethical and deontologi-cal problems have been addressed by several authors from different viewpoints. We think that today we should consider psychotherapy as an ethical practice, rather than talking about ethics and psychotherapy, or ethics of psychotherapy. In this article, we want to justify such a proposal from the viewpoint of self-reflexivity.

The Ethics of Choice in Clinical Practice Let us briefly consider the characteristics of a demand for therapy. Bianca is 32, with big hazel eyes and brown hair. She is a young-looking woman, very talkative, well-dressed, with something of the polite adolescent about her. Her life is apparently the quintessence of normality: married for 4 years to a man who is a clerk, she is employed in a firm, likes painting on fabric, reads novels. She comes, though, from a story of hardships, and carries © LFTRC, KCCF & AIA

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with her a little big secret: although she wants it intensely, she never had sexual intercourse. After a long thinking, and with several doubts and perplexities, she goes to a community service. The psychotherapist that sees her immediately imagines, listening to her, the long days of an unhappy childhood and adolescence: after the untimely death of her mother, Bianca had lived in a sad and poor home, consuming endless afternoons of loneliness waiting for her father, an old stern man who, in his youth, was known as a play-boy, and had decided to marry Bianca’s mother only when his own mother had died. Thus, the silences of their evenings were filled by the hope of a better future. When, becoming of age, Bianca lost her father too, she thought her romantic dreams were on the verge of being realised, thanks to her en-counter with a good and generous youth she got engaged to. After a few months, though, he died tragically, and she remained, lost and ambivalent between finding a new family in his parents, or refusing them to escape the deadly doom that was apparently pursuing her. Bianca describes her subsequent marriage as a rational choice, that of a man still very close to his parents, sure of himself and his principles, who gives her some security; she hold him in deep esteem, although without the love she had for her first fiancée. Thus, after the first shy approaches, the couple’s sexual life is blocked in a knot of fear and regret, unfulfilled expectations and untold fears. This short account of a request for therapy illustrates an inescapable feature of the beginning of any therapeutic process. Since the very first words of any therapy, the therapist has before her several possible roads, alternative pathways to follow, which will disclose different stories and different realities. Being aware or unaware of it, she will immediately decode the demand according to her prejudices, and, step by step, she will choose among countless possible options. Obviously, each choice will have an in-fluence, sometimes decisive, on both therapeutic process and outcome. If we consider the above situation, we see that the patient’s story, her symptoms, her request for help, can be usefully understood both from a systemic or a psychoanalytic point of view. In the first instance, the clinician will use psychoanalytical concepts to understand the patient’s intrapsychic dynamics; in the second, she will use systemic ideas to make hypotheses about couple relationships, and how the patient’s symptoms evolved within them. Of course, a cognitive or a strategic approach could be useful too, and in this specific case also sex therapy approach could be fully justified. Pragmatically speaking, choosing a theoretical model usually leads to some preferred choice regarding the therapeutic setting. In this case, choosing a psychoanalytical model would lead to an individual setting, whereas a

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systemic choice would lead to a couple setting. Actually, though, even in proposing a setting the therapist is making her own choice, which is not mandatory at all, among several possible options. In this case, for example, the choice of a systemic individual therapy would be appropriate too (see Boscolo & Bertrando, 1996). On the other hand, a couple setting is admitted also in differ-ent traditions, such as psychoanalysis (Scharff & Scharff, 1987) or sex therapy (Bro-derick & Schrader, 1991). The methodological option and the choice of setting become in turn context and frame for further options, regarding, step by step, the evolution of the overall therapeu-tic process. Each word, each silence, each moment of participant listening and each in-tervention, both implicit and explicit, are the result of the therapist’s choice among the thousand possibilities opened by the evolving relationship. In the case we presented, Bianca’s therapist could only choose between systemic and psychoanalytic theories because those were the only possibilities within her professional repertoire: she had no training in cognitive or sex therapy, which means that those pos-sibilities were not available to her. Actually, no clinician has a range of possible choice as wide as it is theoretically possible. This also has a subtler consequence: often, the therapist is not aware that her clinical proposals or decision are “choices”. Many of the criteria that lead her choice are on the level of the implicit, untold premises that orientate her worldview. They can be seen as choices only from the perspective of an external observer, who does not share the clin-ician’s theoretical underpinnings. Somebody could say that such an emphasis on the therapist’s choices is superfluous, since any therapist knows she is making choices all the time in her professional endeav-our. We think, though, that this is a problematic knot, where epistemological and theo-retical issues are intertwined with ethical ones. Psychotherapy is considered as a form of cure (Freud defined his psychoanalysis as a branch of medicine). As such, we tend to believe that the subjective and tentative aspects of the therapist’s choices should be re-duced as far as possible, and substituted by “objective” and “reliable” criteria and methods – which are pursued by the “best practice” guidelines. At the same time, the speci-ficity of the therapeutic relationship is extremely difficult to reduce to the criteria of classic science. Here the problem goes far beyond professional deontology. It rather implies that it is impossible to escape ethical issue in psychotherapy because they are embedded at the core of each psychotherapeutic process. We must become aware that ethical issues characterise the very nature of a psychotherapeutic encounter (see Doherty & Boss, 1991; Doherty, 1996). Such

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awareness is absolutely necessary in postmodern times, when the therapist’s professional responsibility cannot be granted any more by objective criteria.

A practice without a “scientific” foundation Psychotherapeutic theories have been using for a long time – possibly since Freud gave form to his “talking cure” more than a century ago – concepts and terms derived from medicine. Generally, they have been looking for a scientific status, with an “objec-tive” foundation (Cushman, 1995). Such an aspiration was, of course, fully justified, for ethical reasons too: since psychotherapy is a professional practice, a scientific basis could guarantee, first of all, its clients. But the aspiration toward a scientific status soon entered a crisis, with manifold causes: the difficulty of documenting outcomes in a way similar to “hard” sciences (see for example Garfield & Bergin, 1994); the emergence, even in medicine, of a different concept of causality (Vineis, 1999); the ubiquitous crisis of professional knowledge (Schön, 1983); the growing difficulty for psychotherapy theorists of accepting positivistic models of science (Freedheim, 1992). The pathway of this crisis was neither linear, not simultaneous for all forms of psy-chotherapy. Freud, for example, came from neurology, and his Project for a Scientific Psychology (Freud, 1875) aimed at a biological theory of the psyche; later, though, even a positivist like Freud realised how hard it was to find objective proof of what he was discovering in his analyses (Freud, 1937). A similar path was followed in later years by most schools of family therapy (Bertrando & Toffanetti, 2000). On the other hand, forms of therapy that were born from an academic research matrix – mostly cognitive-behavioural therapies – remained faithful to an empirical template (see for example Fal-loon, 1991). This process generated an ever-widening gap between psychotherapeutic models. Some of them followed mainstream psychiatry in its evolution toward techniques and standardisation, as happened to cognitive-behavioural therapies (Wachtel & Messer, 1999). Others evolved toward a different way of conceptualising therapy, closer to her-meneutics and human sciences, as happened to most – although not all –psychoanalysis (Eagle, 1999). Systemic therapy, in its history, went all the way through: it was born as a very technical and scientific form of therapy, but it became in the last twenty years much closer to constructivism or social constructionism (Bertrando & Toffanetti, 2000). Of course, this is an approximation: there are family therapists who consider them-selves scientific (Selvini Palazzoli et al., 1998), just as there are cognitive

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therapists who consider themselves constructionist (Guidano, 1987). All the same, in the span of one century, psychotherapy was forced to renounce (or, at least, problematise) its posi-tivistic ideal of science, seen as the pursuit of universal certainties, progressively con-structed, and aimed at knowing in a more and more detailed way its object of study. It became harder and harder to define univocally both psychopathologic theories and treatment procedures that are universally accepted. And the very wideness of the array of heuristic and operational choices that the practitioner has to face testifies to it. This implies that nobody can justify once and for all her clinical choices, inscribing them in a frame shared by a whole scientific community, or linking them to classical scientific criteria, such as reliability, predictability, falsification. Most of all, it is impossible for all psychotherapists to accept a common definition of the nature of their own discipline. Clinical practice must accept an absence of (hard scientific) foundations (McNamee & Gergen, 1992). This is the mark of the condition we commonly call postmodern (Lyo-tard, 1979). Such a problem impinges on clinical practice too. Let us consider, for example, the choices favoured by most strategic schools of therapy. In time, they have justified therapeutic choices many saw as reckless or manipulative, appealing to the criterion of efficacy: if a practice proved itself useful in reducing the clients’ suffering (of course, without violating obvious deontological norms), then therapy is ethically legitimate, and the therapist should not refrain from any means – within those limits (see Haley, 1976). But, if it is impossible to demonstrate in a way accepted by everybody the clinical effi-cacy of an intervention, such justification is not proper anymore. The therapeutic choice without foundation becomes personal responsibility of each therapist, in her unique in-teraction with each client in each moment. To lose foundations means to lose practical certainties for getting an orientation among therapeutic choices. At this point, there are two possible ways of conceptualising – both intellectually and emotionally – such awareness. The first accepts a classical logic, which sees the subject as distinct from the object of knowledge, and is founded on the hypothesis that such a distinction may lead to an objective knowledge of the object. The second is located within a self-reflexive logic, that sees subject and object as co-emerging and recipro-cally implicated, and it is founded on the hypothesis that cognitive processes constitute a “reality” that is a subjective, self-referential version of that reality which, in turn, dictates limits and potentialities of those cognitive processes themselves. In this respect, the difference between a constructivist and a social constructionist perspective is barely relevant (see Gergen, 1999).

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If we follow the former epistemological approach, accepting a logic of objectivity, the difficulty in finding objective certainties cannot but be seen as a defeat, and the fail-ure in satisfy the criteria of hard science as a (hopefully provisional) guilt. If we assume, instead, the logic of reciprocity and an epistemology of self-reference, the very same awareness can be seen as the emancipation from an illusion, maybe consolatory but vain, and as a possibility to join those “soft” sciences that, according to Heinz von Foerster’s (1982) formula, can deal with “hard” problems. What is important here is that the two approaches lead to different outcomes in re-gard to ethics, i.e., to therapist’s responsibilities in making clinical choices. Within the first perspective, not to find a foundation may mean a drift toward a complete clinical (we could also say: cynical) relativism, where every choice and its opposite are the same. On the contrary, within the second perspective, losing certainties puts to the fore the extent of the therapist’s personal responsibility.

The problem of professional responsibility We received Bianca’s case in supervision, in a moment when therapy had reached an impasse. In the first encounter, Bianca had appeared aware and motivated. She had said she wanted a personal therapy, aimed at a better understanding of her story, and at a possible modification of some aspects of her own personality, independent from her sexual problem. In short, she demanded an individual therapy, also stating that couple therapy was not easy to do, because her husband would have refused it. The therapist, who had had a psychoanalytic training, but had been interested for many years in the systemic approach, accepted the request, thinking that such a format could be useful for Bianca. After one and a half years, both Bianca and her therapist felt they were working properly. In some very intense moments, Bianca had dealt with her feeling toward her mother’s figure, and made significant steps toward her own individuation. Some mean-ings for her sexual symptoms emerged too, and the therapist judged them as potentially decisive for the resolution of such symptoms. Unfortunately, though, the sexual block, rather than being solved, was in a sense inverted: Bianca stated she was ready for com-plete intercourse, but that her husband was now withdrawing. Also, some of his person-

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ality traits appeared now worsened, hinting at a mild obsessive-compulsive symptoma-tology. The therapist was perplexed. Had she been right in accepting the individual setting? Was the evolution of the case maybe showing that it would have been better to work for a couple setting? And had she worked properly? Maybe she relied too much on her psy-choanalytic competences, leaving her systemic ideas in the background; or were those new ideas interfering with her approach to the clinical situation? The group of colleagues participating in the supervision proposes different under-standings of the clinical impasse. Some follow the former hypothesis: the setting was wrong from the beginning, and the therapist colluded with the patient’s requests to be-gin a dyadic relationship excluding the husband (this hypothesis is apparently corrobo-rated by the observation that the therapist immediately accepted Bianca’s statement on the husband’s availability, taking for granted his refusal of couple therapy). Others pre-fer the latter: the therapist was right in accepting individual therapy, but probably she was not consistent with the theoretical model she had chosen (for example by privileging relational aspects and overlooking intrapsychic ones). As it happens, a therapeutic impasse leads to wonder where, or how, the therapist did wrong. We think that such a question is legitimate, but at the same time we feel that the problem should not be dealt with in terms of right versus wrong. We want to look at it according to a different frame. We cannot elude the risk of clinical relativism by accepting a responsibility similar to the one which works for hard sciences, i.e., a criterion of rightness. If we accept the problematic nature of objective foundations, we put into question the very possibility of building “right” or “correct” models. We cannot refer to them in considering our profes-sional responsibility. Now, we have to consider the possibility of a drift toward a complete justification-ism, at least because in our professional practice we must, first of all, respect and guar-antee our clients. But our professional practice is extremely peculiar, since its character does no rely on aspects such as setting, technique, or timing (which in themselves can be considered as repeatable, verifiable, falsifiable), but rather on its nature: a human, historical, contextual encounter - a life encounter.

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Now, we could think that in medical practice human as well as relational factors may be considered accessory to the actual factors of cure (diagnosis, drugs, etc.) – although good physicians probably would not agree with such a technical view of their work (cu-riously, today we tend to mistake medical research for medical practice). Anyway, no-body could deny that, in psychotherapy, human factors are central to good practice. In this sense, the therapeutic encounter should be considered an existential experience, and, as such, unrepeatable. It is, anyway, a life encounter which is also a professional encounter. Its paradoxical nature – a professional encounter which makes sense only if it is, first of all, an authentic intersubjective encounter – makes the issue both problem-atic and intriguing. In our life, there are few relevant choices that rely on objective criteria. Nobody would try to found on criteria of objectivity, demonstrability, falsifiability, her choice of a partner, her decision on giving birth to a son or daughter, or any other existential choice. This does not mean, however, that we consider such choices as free from sub-jective responsibility: on the contrary, we live them as choices we must accept full re-sponsibility for, and choices we are ethically engaged with. Although we are aware that no objective criterion can justify once and for all our life choices, nobody would accept a complete relativism in them. These considerations imply that, actually, if we remain within the logic of objec-tivity, we locate our practice in a domain which is different from the domain of life ex-perience. Within the logic of objectivity, any practical choice should be based on certain and repeatable protocols, whose outcome should be fully predictable. This is the logic, for example, of the American Psychiatric Association, which imposes standardised di-agnoses (American Psychiatric Association, 2000), and standardised treatment protocols for “optimal practice” (Kutchins and Kirk, 1997). If we assume a different logic (the recursive logic of reciprocity), we must recognise the full therapist’s responsibility, not only in clinical choices, but, first of all, in the very choice of the modality for approaching, understanding and decoding what clients pro-pose: each of us is responsible for the world she builds – since each of us participates in the processes that define its contours, its characteristics, and its properties. The therapist, therefore, must accept responsibility for the very modes through which she enters the therapeutic encounter, since they participate in defining

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the characteristics of the encounter itself, and of the patient the clinician will get in touch with. In therapy, as in life, there are no certain criteria to justify clinical choices – which have, anyway, relevant consequences for defining ongoing relationships: the therapeutic process is co-defined, in time, through the participants’ choices. And the therapist has a surplus of re-sponsibility, since her responsibility is professional. The therapist cannot blindly follow any protocol: if she follows a protocol, she is anyway responsible for the choices within the protocol, as well as the very choice to follow that specific protocol. Although we cannot go deeply into the issue of the therapist’s power, clearly the therapist – like the parent – is, within the relationship in some power position. In our logic, the therapist’s power is that of defining the ground where the encounter is sup-posed to take place: setting, models, methods, techniques, that can be made explicit, and most of all, the theoretical premises, which will remain, up to a point, implicit. The point where the two epistemologies we have outlined differ is this: the former sees the “reality” the subject can know (subjective reality) as a potential representation of objective reality. The latter is based on the assumption that the reality known to the subject is first of all congruent to the characteristics of the subject itself, and should be considered as emerging from the interaction between the subject, the characteristics of objective (i.e., external) reality, and the relational context the subject is embedded in. If we consider reality as independent from us, the lack of objective certainties leads to a lack of responsibility (reality is independent from me, and its characteristics cannot bother me). We are responsible, within this frame, only for the correctness of our know-ing procedure, and for the outcome of our actions – therefore, we must obtain criteria for maximising predictability. If we consider reality as connected to our knowing prac-tice, I am responsible for a reality that “exists” (for me as well as the others) only since I am participating in its definition. Even if I have no certainty, I am responsible of every-thing that is going on, since my knowledge and my actions are not separated: to know is to act on reality, and vice versaThe ethical responsibility of a clinician who operates within the logic of objectivity is a pragmatic responsibility. The responsibility of a clinician who operates within the logic of reciprocity is a logical and epistemological responsibility, in the sense of a re-sponsibility related to the heuristic options, and the epistemic quality of our know-ing/acting.

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Responsibility of responsibility Let us go back, once more, to Bianca’s case and supervision. Step by step, through discussion, the supervision group begins to accept that, if Bi-anca “seduced” her therapist in a dyadic relationship that excluded her husband, maybe this is useful information to understand the present impasse. In other words: there are no “strong” methodological criteria, external to the therapeutic relationship, for under-standing what the “right” option could have been, concerning the choice of both setting and theoretical model. The group now strives to understand the characteristics of the re-lational story, independently from the right/wrong dichotomy. Within this new frame, the group reasons about the therapeutic relationship and its evolution in time. Bianca asked the therapist for a sort of affiliation, and this seems con-firmed by the many contents emerging during the therapy that related to a deep dissatis-faction toward the mother, who in turn had been always considered the only positive pa-rental figure. The therapist had immediately accepted such a request: this was her choice, which, as such, was neither right nor wrong. This awareness allows the group to consider it as one of factors that in time became part of the problem. The therapeutic relationship is described by both parts as positive, useful, happy. The sexual symptom, though, remains untouched. Within the group, the hypothesis emerges that the sexuality-death equation, typical of the patient’s life, has been transferred to the therapeutic relationship too. Since the passionate love toward her first man was de-stroyed by a tragic and early death, Bianca is aware of a strong, albeit irrational, feeling that a complete sexual life could lead to her present husband’s death. The therapist had thought that acquiring such awareness could be decisive for symptom resolution. But this had not been the case. Other group members turn their attention to another issue: Bianca could feel herself as a woman, and get in love, only after both parents’ deaths. Within such logic, it is ne-cessary for the therapeutic relationship to “die”, in order to unblock the sexual symp-tom. But how can Bianca renounce a relationship so positive and deep? The group build hypotheses that connect a relational reading (the difficulty of leav-ing the symptom, thus losing the positive relationship with the therapist)

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to a symbolic one (the unconscious equation between sex and death, that the therapy allowed to bring to consciousness and put into words). The setting, proposed by the client and accepted by the therapist, and the subsequent evolution of the therapeutic dialogue, are now the basis for a hypothesis that eludes the trap of a right/wrong evaluation. To remind ourselves that taking responsibility of our choices within a therapy means to question ourselves all the time about such choices is not new in itself. What we want to emphasise is that it is not professional responsibility in the classical sense of the word. It is a responsibility involving not mere acts, but rather the frame in which such acts make sense, a frame that, on the other hand, is recursively defined and redefined in time by those same acts. Such a responsibility is intrinsic not just to the therapeutic ac-tivity, but also to therapeutic theories. It might be regarded as a way of declining within our domain the “responsibility principle” put forth by Hans Jonas (1979). The therapist must take full responsibility for her pragmatic choices within a reality she defined within the domain of her choices. She is responsible in the first person for her own ac-tion, within a reality she is (co-)responsible for in the first person. And she cannot ap-peal to external criteria, since any criterion, for her, is defined by her choices. In this sense, professional responsibility, for the therapist, is a second order responsibility, a re-sponsibility of responsibility. To accept a second order responsibility means to remember that the impossibility to get an “objective” world vision, that everybody could share, makes us responsible first for our premises, and, on another level, for the operational choices that, within our epis-temology, appear sensible, proper, useful. For a clinician, this means that no book, no school, no ideology can lift from her the responsibility not only for what she does (which is obvious, and is part of any elementary professional deontology), but also for how she decides the reasons and the sense of what she does, and of the consequences that stem from it. For a therapist, after all, the very fact of drawing the first distinction (Spencer-Brown, 1969) within the first session, is already an ethical choice. But what does it mean, practically speaking, to take second order responsibility? Al-though this is not the place to go further into the subject, we suggest that we can take it if we ask (second order) questions about the therapeutic process itself. Let us consider two of them. The first is the

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diagnosis of diagnosis, the formulation of relational hy-potheses about our cognitive processes, i.e., about the diagnostic criteria we are using (Bianciardi, 1999). Within our logic, it makes no sense to wonder whether a diagnosis is right or wrong, but rather to wonder how that diagnosis emerged within that encounter: how the relationship between therapist and patient created such a context to favour the emergence of that specific diagnostic criterion, instead of other ones? Why did not the therapist see other data? And how did the patient present him- or herself to the therapist as a patient who could be framed within those diagnostic criteria? (To answer such questions, of course, it may be useful or necessary to widen the context, considering the working team, the therapist’s personal training, her relationships with her masters, her earlier clinical experiences – and the patient’s ones –, the diagnostic fashion of the mo-ment, etc.) Another second order question is the care of cure, how to take care of the process of cure. Again, it makes no sense to wonder whether one did wrong, but rather to under-stand how the relationship has been defining itself in time. In this way, we can formu-late hypotheses about the relationship itself, in order to take the responsibility of decid-ing how to proceed (see Bianciardi & Telfener, 1995). In the clinical case we presented, the group, freed from the idea of an evaluation ac-cording to objective criteria, has been able to make hypotheses about the relationship (how the therapist constructed her hypotheses, and/or the patient induced the therapist to construct them), thus taking care of the process of cure (by constructing and proposing a reading that could widen the possible evolution of the relationship).

Conclusions The postmodern therapist cannot but accept her second order responsibility. Here we simply presented this thesis, aiming at showing that any theoretical position which tends to suppress the therapist’s responsibility from a constructivist epistemology remains within the logic of objectivity rather than assuming consistently the logic of reciprocity. Such awareness, in turn, opens clinical issue of great relevance that do not admit rushed answers. The first is that the worldview the therapist is responsible for involves her moral val-ues too. Feminist critiques, some gender issues regarding most of all

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couple therapy, divorce mediation, problems with violence or abuse, clinical intervention directed at persons and families coming from other cultures or ethnicities, well exemplify this is-sue. The clinician, as anybody, has her own personal moral premises, which are part of her logical-emotional premises. And she cannot but question herself about the ethical implications of her worldview and her premises. Here it is impossible to find easy an-swers: the therapist must start anew her self-questioning process in every new clinical situation. The second issue is even more difficult. The therapist is responsible for her premises, but she cannot be fully aware of them: premises by definition “come first” (pre-missae in the Latin language), and therefore come before our own self-description of experi-ence. This implies an impossible task for the therapist, to take responsibility for what she is not aware of. There is always an implicit level of one’s own premises, in regard to which the therapist can only know not to know (Larner, 2000). Such questions must be faced with cautiousness, prudence, and humility. They re-mind us of Bateson’s (1968) recommendations toward the “ecological” respect toward anything that stands beyond our personal individuality and conscious experience. Of course, the self-reflexive option is not the only one available to psychotherapists. Many of us work (and we believe, work well) without following, at least purposefully, a second order logic. We think, anyway, that to follow this vision in a critical way, allows us to operate with a better knowledge of ourselves and our limits, both human and pro-fessional, and also with increased flexibility and ability to fit with the situation. This is what any “good enough” therapist has been doing since the invention of psychotherapy. What we propose is a further step – if we can use this term – in being more aware of ability and competencies already present in ourselves. Please address correspondence about this article to: Marco Bianciardi, Episteme, via Ricasoli 4, Torino, Italia. E-mail: [email protected].

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