thoughts on ethics, psychotherapy and postmodernism
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A paper by Sonja Snyman (DPhil) and Robyn Fasser (MA)TRANSCRIPT
THOUGHTS ON ETHICS, PSYCHOTHERAPY ANDPOSTMODERNISM
Sonja Snyman (DPhil) & Robyn Fasser (MA)
Abstract
The purpose of this article is to describe some postmodern implications for the ethical
conduct of therapists. In our opinion, one of the overriding implications is the increase in
the ethical responsibility held by therapists. In a context that rejects objectivity, redefines
boundaries and broadens the notion of the client, the ‘buck stops’ with the therapist.
Consequentially, with an increased emphasis on the ethical responsibility of therapists -
training, curricula and ethical codes have to be revisited. This article is a postmodern
discourse. In deconstructing the text, the reader engages in and assigns meaning to, it.
This process is an echo of the therapeutic relationship, in which therapist and client
engage each other and assign meaning to the texts presented in therapy. All behaviour in
this dynamic relationship has ethical implications that therapists need to manage. Thus,
the postmodern therapist “is the ethics”.
From modernism to postmodernism
As psychotherapists in South Africa, we are fortunate to have been knocked off our ivory
perches. Unwittingly, we have been given the opportunity to experience, on an hourly
basis, the dynamics of a postmodern world. From our consulting rooms, where our
paradigms are challenged by the diversity of world-views that cross our thresholds, to the
multi-theoretical content of seminars and conferences, to the multi-cultural emphasis in
therapist training, we are forced to reconsider what we do and how we think. And, in the
process, a different realm of understanding is bound to evolve.
This process is running concurrently with changes in Western thinking (Simon, 1991).
The question is: Are we experiencing a ‘modern’ moment, namely “a moment of crisis or
reckoning in which it becomes self conscious as a period” (Foster, 1985, p. viii), or have
we entered a new period? According to Cantor (1988, p.401) “ the intellectual homeland
that we seek can no longer be Modernism… We have been, as it were, shut out of
paradise by the cultural residue of the political, economic, and military upheavals of this
[20th] century…We cannot return to it as a cultural entity, as theory for today…
Modernism is our past, not our future.” Hence our Eurocentric assumptions are being
tested. Throughout the Western world, previously unquestioned truths are being
challenged, and new ways of thinking are emerging (Capra, 1982).
These erstwhile unassailable truths intrinsic to the modern age, which was characterised
by an incessant search for unity and absolute knowledge, were underpinned by the
sovereignty of reason, rationality, objectivity and empiricism. Modernity created a
singular perspective and a legacy that has shaped the indisputable principles that guided
Western thinking and relating. A particular set of rules directed what is called
Cartesian/Newtonian, Occidental or Western thought. Based on a system of logic
developed in the Age of Reason, this paradigm hinges on three rules of thought: the Rule
of Linear Causal Process, the Rule of Pejorative Dualism and the Rule of Certainty
(Auerswald, 1992). In this model, there was certainty about the one reality: objects and
‘objective’ ideas existed substantively in an infinite and separate time and space; space
was three-dimensional and time linear. Also, objects and ideas were ordered
hierarchically according to form, activity or some set value (Auerswald, 1992), resulting
in inherent power relations in all spheres of reality, society and interpretation.
Furthermore, in this thinking, there was an acceptance of an everyday reality that was
reducible to quantifiable, provable elements that were experienced, in exactly the same
way, by everyone.
In the 1950s and 1960s, the critical discussions within the field of philosophy of science
spearheaded the challenges directed at modernistic, foundationalist thinking. This was
underpinned by discoveries and developments in modern physics, technological advances
such as cybernetic networks, and the proximity of change in the shrinking of a previously
disassociated world into a globally interconnected one.
The certainty of the modern epoch has given way to change and relativity; uncertainty
and unpredictability have become the order of the day. Ultimately, the Western
Weltanschauung is moving away from a linear, reductionistic, mechanistic and absolutist
view towards a postmodern discursive reality (Hare-Mustin, 1994).
While modern discourse “strives towards a rational explanation of the world, assuming
that rationality has a universal validity which enables us to develop a Grand Theory about
reality” (Degenaar, 1994, p. 2) “postmodern discourse manifests itself in an ironic
relationship towards all claims to finality whether based on myth or reason.” (Degenaar,
1994, p. 2). This implies that postmodern thought assumes that there is a plurality of
ways of understanding. Hence, postmodernity refers to an age which has lost the
Enlightenment ideal of progress and emancipation, through meta-narratives and increased
systems of knowledge (Kvale, 1992). It indicates an era in which society has become
decentralised, heterogeneous, local and flexible.
“Postmodernism is more interested in a process, in the interpenetrative experiences that
weave contemporary culture. Postmodernism … is a perception of relatedness that rejects
reduction ... It is not a thing one can find out there, but a relation that runs through all
things, in art, production, consumption, public policy, and in the minds of people.”
(Amiran & Unsworth, 1994, p. 5). Postmodernism is not a consciously directed
movement. Wakefield (1990) attests that in the process of trying to define, describe and
name postmodernist happenings, one runs the risk of building a structure that does not
exist and in no way wants to exist. We run the risk of creating a coherence of what are
elusive, nebulous and de-centred ‘narratives in time’. He goes on to state: "The semantic
complexity of the term 'postmodernism', its ability to elude or withhold definition,
testifies not to any lack of meaning but rather to the fact that meaning has been dispersed
or redeployed across a much larger site of struggle and contestation" (Wakefield, 1990, p.
20).
The therapist in a postmodern world
Psychology, and with that psychotherapy, as historically practised in South Africa, is a
Western cultural enterprise. Psychology is a child of modernity (Kvale, 1992). As a child
of modernity psychotherapy forms an indissoluble part of the modern project in its aim,
which mirrors the modernist objective to liberate the creative forces of the inner person;
in its in-depth focus on the ‘psyche’ of the individual; in its clinically circumscribed
method; in its attempt at developing a comprehensive theory; in the therapeutic
relationship that emulates the modernist belief in a detached expert position; and in its
assertion that from such an expert position of knowing it is possible to uncover the
‘truth’ about the nature of the problem.
Given the above parameters, truth and its discovery then become a viable option for
therapists, provided they are scrupulous in their method of investigation. This
epistemological stance leads to what Keeney (1979, p. 118) calls “psychiatric
nomenclature and the classical medical model of psychopathology” which results in the
reification and labelling of human behaviour according to singular descriptions.
Under these circumstances, modern therapists have to present themselves as scientists,
and, as such, view themselves as independent observers with no expectations other than
to uncover what is an objective truth regarding the client. The assumption is that,
provided therapists apply the applicable theory correctly, the objective truth would be
discovered (Chaiklin, 1992). The existence of this truth, coupled with the therapist’s skill
(method) at uncovering it, was fundamental to the practice of therapy. Furthermore, it
was believed that such a truth would be uncontaminated by the personal biases of the
therapist. As a result, the erstwhile ‘expert’ position of the therapist was unquestioned.
Postmodern thought asks psychology whether these notions of objectivity, one truth, one
theory and expert position can be accepted unequivocally (Kvale, 1992).
At its most fundamental level, the paradigm shift (Capra, 1982) that has emerged in
Western thinking and culture encompasses a shift from notions of truth to those of
significance and meaning on the one hand, and from the notion of one reality to a
multiplicity of perspectives on the other (Howard, 1991). This shift has significant
implications for therapy. Today, many therapists believe that the art of therapy involves
deconstructing and reconstructing the stories that clients bring to therapy. The therapist’s
role of listening and responding to the client’s story is akin to the deconstructive reading
of a text (Derrida, 1986). Deconstructive thinking denies that there is a single fixed
meaning in texts (stories) and purports that texts can generate a variety of meanings. It is
furthermore acknowledged that meaning is not inherent in words and things. Meaning is
brought to things and situations through articulation and interpretation. An assigned
meaning is always the perspective of a perceiver. The known is always the by-product of
the knower. We therefore cannot speak of what we know as distinct from ourselves as
knowers. According to Bateson (1951), the perceiver imposes an order, on his external
world, that fits with his belief system. One might call this one’s epistemological stance. It
means that each time we make an observation, we choose an epistemological position.
Meaning is created through the interaction between self and world, writer and reader,
observer and observed as well as therapist and client (Gergen, 1994; Degenaar, 1986). As
‘carriers of meaning’, therapists bring certain meaning structures to the field of therapy.
This means that their preconceptions and assumptions will inform and structure the
content and process of therapy - and thereby edit it. As such, therapists need to be
attentive to their personal and cultural assumptions, which are in turn informed by their
taken-for-granted Weltanschauung and by their way of thinking about reality. How we
hear, how we listen, what we understand as well as the questions we ask are all informed
by our basic belief system. This implies that the underlying world-view inherent in a
therapeutic approach will determine the parameters within which a therapist will assign
meaning. In practice, meaning is deconstructed in the therapeutic ‘language’ of the
therapist. For example, using constructs like false self, idealisation, projection and part-
objects will unwittingly guide therapists towards ‘understanding’ and interpreting their
clients’ behaviours in terms of the notions of splitting, phantasy and projection.
By taking responsibility for our thought systems, by questioning our presuppositions
and by acknowledging our epistemological positions, we further acknowledge the ethical
basis of our therapies. Ethics and the ethical code of conduct in the healing professions
are now more important than ever. However, as Wassenaar (1998, p.140) points out
“with the growing national and international diversification of psychology, no single code
of ethics will anticipate all of the contexts in which psychologists will work, particularly
in a rapidly changing South Africa”. In such a context therapists are compelled to engage
the field of ethics in a dynamic and personalised manner so that the therapist “is the
ethics”.
The ethical implications of a postmodern reality for therapy
With the acceptance of an expert/learner position and with no singular standardised
method in which to ground psychotherapy, the role of postmodern therapists is far more
complex than that of their modern counterparts. The complexity of the role translates into
a ‘the buck stops here’ responsibility and accountability on the part of the therapist. The
onus of circumscribing therapeutic practices, on the one hand, and ensuring that ethical
parameters are adhered to, on the other, rests with therapists more than ever. This
discretion necessitates an ongoing ethical self-monitoring and evaluation.
The following discourse on objectivity, boundaries and ‘who the client is’, looks at
some of the ethical implications for postmodern therapists.
Objectivity and ethics
Keeney (1982) describes the indivisible world as one of form and pattern. For
postmodern therapists, this means that a system (or problem) is the function of a
distinction drawn by an observer (therapist). It also implies that a system does not exist in
reality, but that it exists in the ‘world of form’, and that it comes into being through the
act of languaging. In Brian McHale’s words, the post-modern “exists discursively in the
discourses we produce about it and in using it” (in Amiran & Unsworth., 1994, p. 5)
Such a conversational domain is an ecology of ideas and exists through dialogue,
distinguished by linguistic markers. It is, therefore, a meaning system that evolves from
our shared, cognitive and linguistic discourses (Anderson & Goolishian, 1988, p. 372). A
therapy system is similarly one that is “coalesced around some ‘problem’” (Anderson &
Goolishian, 1988, p. 372): it is a meaning system created by a problem (Hoffman, 1985),
a problem-determined system. The therapist is an observer-participant and co-creator of
such a therapy system. The implication of this for therapy is that there are no set facts
about the individual or family that exist independently of the therapist’s observations.
For postmodern therapists, this lack of objectivity and its concomitant uncertainty
results in the increased importance of ethical choice. As observer-participants, therapists
in a relationship with their client, are ethically obliged to acknowledge that their
observations and interventions are as much personal edits as they are a function of the
client’s presenting problem. For example, a therapist may describe the aetiology of a
presenting problem as either neonatal or anxiety based, depending on how he/she makes
sense of the problem. This understanding will guide the therapist to ask certain questions,
respond non-verbally in particular ways and in so doing unwittingly and regularly
identify specific problem descriptions. Furthermore, Polkinghorne (1992, p. 158) points
out that “successful therapy is carried out by practitioners who give allegiance to various
theoretical systems … treating them as models or metaphors”.
A lack of awareness of these therapeutic influences in steering the therapy has ethical
implications in that therapists may make assumptions that result in a label being treated
as ‘the truth’. For example, a child who presents with scholastic problems and sees an
ADHD specialist may exit the therapy with a confirmed diagnosis of ADHD. Although
the diagnosis of ADHD may well be valid within the framework within the DSM IV
diagnostic categories, the fact that the fathers of four of his school colleagues were killed
violently in the past year was not factored in constitutes an ethical transgression. The
ethical implication is that a singular description presented as the truth will lead to a
singular solution, which may be limiting. The client in this instance may not be afforded
all the appropriate solutions that could maximise his/her improvement.
Aside from the influence of being observer-participants, the ethical challenge is further
complicated by the fact that therapists’ perceptions are underpinned by personal values
regarding gender, sexual orientation, class and ethnicity, etc. According to Bateson
(1951, p. 176), “the network of value partially determined the network of perception”.
For example, therapists who value family over the individual may inadvertently focus on
promoting the continuation of the marriage rather than the specific needs of the
individual. Another example is White’s (1995) stance on accountability that is elucidated
in his approach to working with men who abuse. He believes that as a male therapist he
needs to, with his client, accept accountability for the abuse that men perpetrate against
women. For him ethical accountability means that the therapist makes “it clear to the
clients that he sees himself as being basically part of the same culture from which the
abuse has taken place” (White, 1995, p. 158). The implication is that therapists who are
members of a dominant culture need to take responsibility for the power relations and
subjugation, associated with that group, and for what these associated marginalized
clients may experience, or may have previously experienced. In this regard Freedman and
Combs (1996, p. 266) speak of “a ‘margin-in’ approach to ethics – one which values the
experience of people at the margins of any dominant culture … [by] making space for
such people’s voices to be heard, understood, and responded to.”
Boundaries and ethics
In a dualistic and hierarchical reality, clear distinctions are drawn between categories and
classes, and the relationship between such categories is often defined by power.
Psychotherapy was conceived in a world where clear power differences circumscribed
the relationship between therapist and patient. Therefore, the inherent power
differentiation in the therapeutic relationship was further confirmed and entrenched by
the modern worldview. In practice, therapists maintained their therapeutic stance of
interpersonal distance by endorsing these power differences. This made the therapist-
patient boundary virtually impermeable. By contrast, in the interconnected postmodern
world power relations have become contentious and with that the clearly circumscribed
power differentiation between therapist and client. In the absence of a hierarchical
external structure, on the one hand, and as learners who define themselves as part of the
therapeutic system, on the other, postmodern therapists need to set boundaries more than
ever before. However, these boundaries should be based on functional role differences
and not on power. For example, such differences may entail using expert knowledge to
facilitate the process of therapy while at the same time being a learner in terms of the
client’s story.
In a world woven together by networks and connections, boundaries are permeable and
the possibilities of crossing such boundaries in interpersonal interaction abound. Blurred
boundaries can distort the professional nature of the therapeutic relationship and impair
therapists’ judgement. This can lead to a potentially exploitative situation and in turn
bring ethical issues into play. For example, the ethical management of a properly bound
therapeutic relationship would preclude socialising with a client or consulting with
acquaintances or relatives.
The question is how is this different from the position of the modern therapist? Where
the boundary was previously predetermined by the definition of the power relationship
between therapist and client (which served as a static professional standard), postmodern
therapists have the onerous responsibility of employing their discretion regarding
professional boundaries. Hence, ethical decisions become a dynamic part of the
professional conduct of therapists in every therapeutic engagement. For example, modern
therapists would seldom self-disclose. However, self-disclosure for postmodern therapists
could serve to help to normalise the client’s perception of his or her problem. The ethical
decision in choosing to self-disclose would be at the discretion of the therapist and would
rest on what he or she felt was in the client’s best interest.
In multi-client therapy, the ethical dilemma of managing boundaries becomes an issue.
For example, in couples therapy, the decision to see the individuals, parallel to the
ongoing couples’ therapy, requires an understanding of changing boundaries on the part
of the therapist. The potential exists for the boundary that forms around the couple to be
diluted by the intervening boundary that occurs around the therapist and the individual in
the parallel therapy. Hence, there should not be an assumption that any of the therapies
are immune from bias, alliances and collusion. The result of this understanding compels
therapists to be even more aware of their own position in order to maintain an ethical
stance.
The client and ethics
The individual and his or her psychological well-being has been the nucleus of traditional
psychotherapy. Freudian psychoanalysis, which was conceptualised at the height of
Western individualism, focuses on individual personality dynamics. The primacy of the
individual was further endorsed by the pervading acceptance of Kantian ethics,
emphasising the needs and rights of the individual. The question arises whether in
therapy, by prioritising the individual over his/her relationships and family, the welfare of
these relationships is not subjugated and thereby negated. And more specifically, for the
purposes of this article, what the ethical implications of the modern/individual approach
are.
Since the 1950s, clinicians and theorists, looking beyond the individual in their
endeavour to understand behaviour, have found that behaviour can be better understood
when seen in context (Bateson, 1978). The advent of systems and relational perspectives
has brought about a contextual view of the client. This is a movement away from seeing
an isolated individual to seeing the individual in context, couples, families and
organisational teams (Hoffman, 1985).
This raises certain critical ethical questions, for example: Who is the client and whose
interest must the therapist serve in multiple-client therapies? Does the therapist have an
ethical responsibility to those partners or members not partaking in the therapy?
Ethics of relationality may serve to address some of these emerging issues. In a survey
conducted on the issue of individual versus relational morality, Wall, Needham, Browing
and James (1999) found that although the dignity, worth, needs and autonomy of the
individual were recognised by the majority of the marital and family therapists
interviewed, a preference, for what the researchers call ‘relational ethics’, was evident.
In the research, the therapists “less frequently endorsed an ethic of ‘being true to the
unfolding potential of one’s inner self’ than they did an ethic of ‘creating and fostering
loving and caring relations’ ” (Wall et al., 1999, p. 144). These results imply a morality
that not only commits individuals to self-actualisation but also to their attachment to
others.
Given the above developments, it is helpful to compliment the Kantian individual ethic
with an ethic of relationality. This means that one would prioritise and value
relationships, act towards others as you would like them to act towards you, maintain
responsibility not only to oneself but also to others and understand the interpersonal
consequences of one’s behaviour and in so doing foster caring relationships. These
considerations could help inform ethical decisions regarding the relationships inherent in
multi-client therapies.
Ethics as a dynamic process
Ethics is about confidentiality, the right to privacy, informed consent and clients’ rights.
However, it is also inherent in the dynamic relationship between therapist and client.
Because therapists are aware of their ethical responsibility the onus must rest on them, in
this relationship, to ensure that this process be ethically managed on an ongoing basis.
In the diagrammatic representation below (Figure 1), the client enters the therapeutic
relationship with a problem and the need for an intervention. The therapist, in turn,
engages his or her client informed by his or her training, values and personal bias. If, in
this meeting, the therapist’s responses, behaviour and interventions are calibrated by
individual and relational ethics based on a professional code of ethics, the client will in
turn trust him or her and commit to the therapeutic process. Such a dynamic relationship
will provide an optimal context for psychotherapy. In this context, where the ‘therapist is
the ethics’, the ethical principle of ‘benefit to the client’ will be fulfilled.
Figure 1: Ethics as a dynamic process
Individual & relational ethicsEthical Code
Therapist “is the ethics”
Therapist Client Training Benefit to the client Problem/s Values Need for
Personal biases intervention
Trust Commitment to the process
Diverse influences and ethics
In conclusion, the circumscribed theory, method and therapeutic practice of the modern
therapist has been moderated by an external ethical standard. This standard, if conformed
to, ensured that the therapist was practising in an ethical way. These rule were
“prescribed and enforced in a ‘top-down’ way” (Freedman & Combs, 1996, p 265).
Because of the movement away from a Eurocentric and calibrated psychotherapeutic
practice, ethical standards and practice now include a far greater internal emphasis. This
shift in emphasis is a result of the rejection of an objective truth, the linguistically co-
evolved descriptions of problems, the observer-participant status of the therapist, and the
changing definition of ‘the client’. This is concurrently reflected in various theories,
methods and therapeutic practices.
In order to discharge one’s ethical duty as a therapist, working in a diverse context such
as South Africa, aside from conforming to an external code of conduct, there is the added
responsibility of continuous self-monitoring by questioning and checking the ethical
implications of each therapeutic encounter, intervention and decision.
A helpful guide in this regard is what Karl Tomm (Freedman & Combs, 1996) describes
as ethical postures. He suggests that one becomes aware of how one is positioned in a
therapeutic relationship and that one’s ethical obligation is to make a choice vis-à-vis this
posture. He describes the range of postures as extending from manipulation through
confrontation to empowerment and finally succorance. Psychotherapy, in his opinion,
includes all four postures with the proviso that an ethical stance will ultimately lead to the
empowerment of the client.
Secondly, ethics in practice means that aside from choosing an ethical stance, one takes
responsibility for the effect of one’s actions. This translates into a feedback relationship
where the calibration of an ethical action is the implication of that action for the client.
For example, a manipulative intervention such as prescribing the symptom may leave the
client unheard and therefore have an undesirable effect on the client.
Thirdly, the postmodern notion that everything exists as relationship subsumes
openness. This means that to hide or non-disclose infers an element of disengagement or
negation of that relationship. Transparency therefore must be the ethical choice. A way of
monitoring this choice would be to question if a conversation about a client with a
supervisor could be conducted in the presence of that client.
Recommendations
In light of the above it is essential that the South African therapist take cognisance of the
movement away from a Eurocentric top-down view of ethics. In order to be ethically
accountable ethics must be seen as integral to the therapeutic encounter. The therapist
therefore needs to take responsibility for all therapeutic choices and interventions made in
the therapy and the inadvertent messages these may hold for the client. In view this the
following recommendations are suggested:
1. In order to be “the ethics” the therapists should self-monitor. This means that
cognisance of the content and process of each therapeutic encounter and the ethical
implications of every intervention should be considered. This ethical awareness needs
to be inculcated through discussion and training. This could be implemented by
expanding post-therapy notes to include questions such as whether the therapist
performed from an expert position; whether the therapist took cognisance of
dominant and marginalized power relations; whether the therapist acknowledged the
effects of his/her interventions; and whether the relationship was open and
transparent.
2. In the training and supervision of psychologists, ethics should be integrated into all
modules offered rather than presented as a free-standing component. Beyond the
inclusion of ethics in curricula and discussions the application of ethical
accountability needs to be modelled by trainers and supervisors so that the trainee and
supervisee are experientially exposed to an ethical stance and behaviour.
3. In continuing training, the above principle should also be adhered to. All courses
offered to psychologists should take cognisance of the ethical implications of the
material presented. Furthermore, because of a previously held assumption that
meaning and truth are the same for all people, discussions in continuing professional
education need to further awareness around differences in meaning so that South
African diversity can be ethically accounted for.
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