Science in Christian Perspective
Psychotherapy, Ethics and Faith
STANLEY E, LINDQUIST
Department of Psychology
California State University, Fresno
From: JASA 30 (September 1978): 124-127.
[Modified from a presentation to the American Association for the Advancement of
ScienceNational Science Foundation Seminar on "Ethical Issues and the Life
Sciences," Stanford, on March 17-20, 1976. Dr. Lindquist is also president
of Link Care, Fresno, California 93711.]
Psychotherapy is potentially a strong force, intimate and demanding, capable of influencing the beliefs and actions of other persons. Therefore, the use of psychotherapy must he examined from the same ethical, evaluative stance as other forms of behavioral control physical, mental or spiritual. Standards of ethics and religious beliefs are significantly involved in the use and ends of psychotherapeutic techniques.
Psychotherapy can result in the freeing of a person from the unrealistic neurotic or psychotic internalized demands of his conditioning experiences, allowing him freer choice for future behavior. On the other hand, it can be used as a tool by which the therapist subtly forces the client into new patterns of behavior acceptable to society or the therapist's own frame of reference. The latter procedure may substitute one type of bondage for another.
Foremost, ethics of psychotherapy involves the rights of the individual, but it also includes the rights of society for protection from the person who directs aggression against himself, against another, or against social institutions. For example, recent Court decisions indicate that if the therapist knows of a client's plans to harm another, the therapist has an obligation to inform the "other" of that threat. This sharing of information violates the long-standing concept of confidentiality of the therapeutic session material-a concept which is gradually undergoing a metamorphosis in terms of professional behavior but which has important ethical implications. The American Psychological Association's statement of the ethics of confidentiality suggest revelation, "when there is clear and imminent danger to an individual and society." Further, it states, "The client should be informer! of the limits of confidentiality." Ordinarily, with the above-noted exception, confidentiality of shared information is paramount.
There are several other ethical conditions that can be briefly described. For example, when a client has revealed himself intimately, there may be a tendency for him or her to want to become more involved in a physical relationship with the therapist, who appears to possess many of the desirable traits of the "true" human often lacking in others. During this period, the vulnerability of the client must be protected by the therapist.
The ethics of giving advice must also be recognized. What right does the therapist have to intervene directly in the belief system of the client, changing or even destroying it? What right does he have to intervene in the life-style of the client, drastically altering patterns of action, even if the client at the moment wants that direction?
The beliefs of the psychotherapist are very much present in therapy. To try to hide them would be foolish. Making one's beliefs clear enough to allow the client to make his own independent choice of allowing those beliefs to affect a behavioral change or not is important. The only statement from the Ethical Standards of the American Psychological Association that seems to hear on this point is, "Psychologists clarify the nature and direction of their loyalties and responsibilities and keep all parties aware of their commitments." This aspect is crucial for the Christian therapist. What place does "witnessing" have in therapy? Is it ethical? If so, what are the limits? Does the therapist force his views on the client without allowing free choice?
A most important aspect of the ethics of psychotherapy is the use or ends of that therapy. What is the purpose? How will that purpose be served? What will the end result be?
In brief, any purpose of psychotherapy which is manipulative, i.e., serving someone else's or purely societal ends, may be considered unethical. On the other hand, that therapy which clarifies the choice points and the potential effect that choices may have on the individual and society, allowing the individual to make more rational decisions, may he considered to be ethical.
The above statement may be clear and acceptable. In practice, the way clarification takes place and the procedures used are full of ethical implications. Can the psychotherapist be a dispassionate clarifier who never influences the decision-making?
Obviously the answer is, "No!" Therefore, a partial answer to the ethical question is related to how clear and honest the therapist is in recognizing how his own viewpoints and biases may affect choice. It also relates to how well he communicates these influences, thereby allowing the client to take these factors into consideration as he evaluates his choice of specific behavior patterns, and weighs the future implications and results of that decision.
The Client's Stance
There are, in addition, several factors which relate to the client's stance in entering the therapeutic relationship. Four classes of situations may he considered; 1) Does the client come willingly for help with his problem? 2) Does he come under the duress of the pain of his anxiety or depression, or is lie motivated by disagreeable pain of his anxiety or depression, or is he motivated by disagreeable effects of his past maladaptive behavioral patterns? 3) Is he coerced by anothers spouse, parent, lover or business associate? 4) Is he forced to come by Court or other social institutions?
In each case, the ethical implications are somewhat different. Long-term psychotherapeutic treatment, because it works slowly, may give the client more time to contemplate and conceptualize any proposed change, and thus evaluate such changes more carefully than with the more sudden intervention of chemotherapy or psychosurgery. However, behavior modification techniques also allow more rapid behavior change. If these skills can he utilized to help, they can conceivably be used to implant other behavior changes as well.
With this discussion as a background, we can now look at the four situations where treatment is indicated.
The Willing Client
The first condition is that in which the person consents to receive or even seeks out the help. While in some ways this category of clients presents the least problem, in other ways this condition may present the most subtle and complex ethical questions.
Alleviation of immediate psychological distress (shortrange goal) may compromise the ultimate end (longrange goal). This statement assumes the functional value of a presenting problem or symptom.
The classical example is illustrated by the parable of the ugly duckling who was therapized, accepted himself as an ugly duckling and never became aware that he had become a beautiful swan. His solution for a short-range goal resulted in the loss of his long-range potential.
Treating the depressed client with mood elevating drugs without discovering the etiology of the depression, or use of drugs in anxiety states to help the client tolerate difficult situations, may be thought of as similar
Any purpose of psychotherapy which is manipulative, i.e., serving someone else's or purely societal ends, may be considered unethical.
problems. In each case, there is less likelihood that the person involved will be motivated to change his problem presenting behavior constructively. Therefore, the ethical question facing the psychotherapist is to determine how alleviating the immediate symptom will affect the client's long-term motivation to change behaviors which may need changing. If the therapist reduces or alleviates the effects of those signals of depression or anxiety, he may neutralize the client's attempt to work out a more comprehensive change in his behavior. Another example is the client who has "sinned." He is aware of that sin, feels guilty about it and is impelled to make the necessary changes in his life. Psychotherapy can alleviate the guilt feelings, which may reduce the motivation to change and the client may continue in the "sinful condition." The ethical issue relates to making the client aware of the significance or implication of his symptoms.
Another ethical factor relates to the potential imposition of the therapist's value judgments on the client. When the client accepts the therapist's value judgments, he is relieved from becoming the responsible person he needs to become (Classer 2, p. 300-1). When the therapist does the client's work, he may erode that client's acceptance of responsibility, not just for the immediate situation, but for other situations as well.
The psychotherapist aids the client to evaluate his own set of values to discover the effects that holding those values have on his decision making, how he perceives himself, and his attitudes toward his own past. When this is clarified, the client can then take appropriate action, supported by the psychotherapist, to assume personal responsibility. If the client is unable to do so, due to his emotional problems, the therapist continues to strengthen him until he is ready to do so. Helping the client gain information about himself in every aspect of life including his religious goals can give him the tools by which he then can responsibly and effectively act on his problems.
The general principle has been stated by Halleck (5 p. 385), "I am convinced that the usefulness and reasonableness of the patient's choice will be positively correlated with the amount of accurate information he has about himself and about the stressful factors in his environment."
The Willing "Hurting" Client
When the client, under the duress of pain, anxiety, depression or feelings of failure, comes into the psychotherapeutic relationship, his freedom of choice is restricted. He looks to the therapist as a healer, and expects him to act as such, implying, "I have pain. You know how to help me. Do so as quickly as possible."
Often, due to the pressures of the moment, such clients are not willing to explore the meanings of their reasons for coming to therapy. They want relief, and anything that postpones that relief is looked upon with disfavor,
regardless of the short or long-range effects. Most people, at this stage, are not particularly interested in learning lessons from the immediate situation which could influence the future. They want relief, and want it now.
The therapist may be seduced into doing what the active client wants. He also may yield to the subtle temptation of trying to alleviate suffering, of playing benefactor, of trying to he the powerful, healing person the client wants and short-circuit the treatment plan. This situation is difficult to cope with ethically. Should one immediately rush in with the hand-aid of symptom reduction, or should one withhold treatment Of it is available) because it is better in the long run to do so?
There can creep in an element of sadistic pleasure in withholding
it is "for the client's ultimate good." Most psychotherapists cannot
give medication or provide surgical intervention, so to them, this
aspect is not
a question. However, all of us can provide sympathy, allow
ventilation of feelings,
and offer reassurance which can give immediate, partial relief to the client.
While we cannot forgive "sin," we can effectively remove the distress
of the guilt feelings created by the sin. Should we or should we not?
One solution is analogous to that of providing a crutch to the person with a broken leg. The crutch allows mobility, and helps the person to do what needs to he done. The crutch gives immediate relief, but also aids in the continuing growth of the person by helping him accept responsibility to help himself, so that he may eventually abandon the crutch when it is no longer necessary.
Similarly, in pschotherapy one can ethically help the person remove' the immediate crippling effects of the problem, so that he can deal with the long-range implications more effectively. The pain continues to motivate the client to do something about rearranging his life style and behavioral pattern so that such pain will not continue to occur or recur.
In the theological sense, confession of the sin and acceptance of forgiveness allows the person to deal with the causes of the sin, and to make restitution for the sin if it involves another person. If the treatment encourages or allows the client to withdraw or become overly dependent, or if it removes the effects of the maladaptive behavior without constructive direction, the therapist may be considered in an unethical position. Each treatment procedure should be aimed at making the client as self directing and problem solving as possible.
The Coerced Client
The coerced client is motivated to come to the therapist by someone external to himself. Separation of the differing clinical situations does not imply that the categories are discrete. Each category has most of the elements of the previous ones, plus some additional, which add a different dimension to he considered.
The ethical question in this ease becomes one of deciding whether you should work with the person at all, or how do you do so without becoming the "cat's paw" for the one who sent him to you? Obviously, there has to be some motivation on the part of the coerced client to come for help. The most common incentive is to maintain a relationship with the person who originally persuaded the client to come into therapy. Therefore, there call he value in the therapeutic relationship, provided this feeling of coercion is replaced or reinforced with his own desire to grow.
The first step is to explore how he feels about being there-the negative aspects. Usually, ventilation of feeling allows the client to look at his anger at being coerced, his relationship with the significant "other" and why it may he important to change in some way to improve that relationship.
Another step is to look at the nature of the external pressure on the client. Threats of loss of love or the relationship itself are common. If the client feels that his main hope in life is the continuation of the relationship of the one who coerced him, he may fear the potential loss and be forced into unacceptable adjustments as a result.
Coercion may come from a referring source, physician, minister, or friend. The fear that, "If you don't do something about the problem now, you will get worse and eventually lose control totally," may be the threat used.
In any case, ethical considerations require that the client he informed of the procedures of counseling as is noted in the APA Code of Ethics. For psychotherapy, the statement of the methods and goals should he adequate. The potential effects of psychotherapy should be described, along with alternative methods that can be used if the practitioner is skilled in them,
The "Forced" Client
The "forced" client differs from the "coerced" client in that he is not necessarily motivated to maintain a relationship with the one who has persuaded him into therapy, but comes under the threat of severe consequences if he does not cooperate. Usually it is a judge who applies these pressures with jail as the only alternative. For the mental patient, whose "jail" is less tangible but nonetheless threatening, the alternative is continuing in his negative state, being chided by other patients and staff for not cooperating.
Ilaileck (5, p. 382) suggests some other conditions which might call for forcible intervention: 1) The client is judged dangerous to himself or others-usually sufficient reason for commitment. 2) The treatment is of potential benefit. 3) The client is incompetentm to evaluate the treatment.
Decisions about each criterion relate to societal and personal values, and are often arbitrary. In the first ease, the diagnostician is limited in determining the dangerousness of the client. In a relatively recent case the Court decision, based on expert testimony, freed a person who then went out and killed seven additional persons. One must face his limitations honestly.
The second consideration, "potential benefit," may center only n making the client calmer or more tractable for the home or hospital without taking into account that client's own long-range goals. Ethical consideration in such cases, emphasizes that the goals and ends of therapy should he as similar as possible to those the client would have chosen had he made the decision himself. The ones who disapproved of his initial behavior must not he the only people whose desires are considered.
When one assesses the third condition of incompetance, one faces a tendency on the part of all psychotherapists to overdiagnose. The "doctor knows best" idea is pervasive, becoming a subtle pressure on both the therapist himself and the client.
When all three conditions are present, psychotherapeutic treatment would appear to be ethically acceptable regardless of the client's permission. However, a peer therapist group may he the most effective ethical decision-maker for treating the "forced" client when fewer than the three criteria are met.
A brief review of some of the ethical implications in psychotherapy indicate the complexity of the subject. The Christian psychotherapist is involved in unusual ethical considerations, viewed from the framework of responsibility to himself and his client, possible manipulation of the client through machinations of
therapeutic devices, and his dedication to a cause, a belief and a way of life. There are no easy answers. Each decision and procedure can he evaluated by our professions' ethics, our own internalized frame of reference and by God's Spirit dwelling in us.
1Eonis, B. Prisoners of Psychiatry: Mental Patients, Psychiatry and the Lose, N.Y. Harconrt, Brace, 1972.
2Halleck, S. The Politics of Therapy, N.Y.: Science House, 1971.
3________"Legal and Ethical Aspects of Behavior Control," American Journal Psychiatry, 131; April 4, 1974.
4Kieffcr, George (Ed.) Ethical Issues and the Life Sciences. AAAS Guide on Contemporary Problems, 1975.
5Londou, P. Behavior Control, N.Y.; Harper, 1970.
6"Revised Ethical Standards of Psychologists," APA Monitor, March, 1977, pp. 22, 23.
7flieff, P. The Triumph of the Therapeutic: Uses of Faith After Freud. N.Y. lHarper, 1966.
8Szasz, T. Psychiatric Justice, N.Y.; Macmillan, 1965.
9 Low, Liberty and Psychiatry. N.Y. MacMiBan, 1963.
10Wenck, E.; Robinson, 0.; Smith, C.; "Can Violence Be Predicted?" Crime and Delinquency. Chapter 18, pp. 393-402, 1972.