When treatment might cause harm

When treatment might cause harm Exploring ethical dilemmas related to diagnosis, drugs, and other possibly iatrogenic aspects of mental health care.

Presenters and Overview • Run Unger, LCSW • Pamela Birrell, PhD • Goals of the seminar • Ethical behavior is not the display of one’s moral rectitude in times of crisis, it is the day-to-day expression of one’s commitment to other persons and the ways in which human being’s relate on one another in daily interactions

Ethics Philosophy and Practice

What is (are?) Ethics?? • 1. ( used with a singular or plural verb ) a system of moral principles: the ethics of a culture. • 2. the rules of conduct recognized in respect to a particular class of human actions or a particular group, culture, etc.: medical ethics; Christian ethics. • 3. moral principles, as of an individual: His ethics forbade betrayal of a confidence. • 4. ( usually used with a singular verb ) that branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions.

Ethics and morals • So clearly ethics has to do with doing what it “right”? • Who is to determine what is right? • Is it the mental health system and the respective codes of ethics? • Is it our own moral compass? • What about when the ethics code conflicts with moral principles? • These were questions I began to ask…

And I also began to question things going on around me… • State Hospital • Community mental health—drug cocktails • Clients being lied to, not respected • “Ethics” workshops • Need to question the medicalized, paternalistic system that we have inherited

And I saw things that didn’t feel ethical to me… • Ethics Workshops • Parts of the Ethics Codes • Risk management without relationship. • Let me explain…

Things that aren’t ethical • “Ethics” Workshops and how ethics has come to be all about the law and breaking rules and how we can get into trouble • The fact the we think that it is possible to be certain about ethic, and finding the “right” answer is more important than careful discussion of assumptions, power and concepts of disorder • The lack of questioning of the ethics code itself • The fact that ethics is most often thought of as separate from clinical work, almost as an afterthought, rather than the core of clinical work

Here’s what I think… • Ethics must be the core of our work as psychotherapists. • We have too often been taught that ethics are merely an abstract set of rules that tell us what to do in difficult situations. • But every moment is the ethical moment, an ethical position is the way we position ourselves with the other. (Birrell, 2006b)

What about risk management? • There is of course a place for risk management, but we must be aware that if it is played out in a manner that only increases the power-over position of the therapist, it can be harmful • Much (but not all) “risk management” can be avoided by good relationships

Where do we go from here? • Let’s look at how we got to where we are • the western philosophical roots of Ethic Codes, • And then extrapolate how some other, more modern ideas about ethics might apply to the psychotherapeutic and ethical situation. • I will also introduce a relational approach to ethics that we will expand on for the rest of the day.

The Vignette The classic approach to teaching ethics

Case 4-15: Robert Bumble, Ph.D., began treating a troubled young woman in an office at his home. Dr. Bumble failed to recognize increasing signs of paranoid decompensation in his client until she began to act out destructively in his office. At that point, he attempted to refer her elsewhere, but she reacted with increased paranoia and rage. Dr. Bumble terminated the relationship, or so he thought. The ex-client took an apartment across the street from his home to spy on him, telephoned him at all hours of the day and night with an assortment of complaints and explicit threats, and filed ethical complaints against him. • (Koocher and Keith-Spiegel, 1998, p.89)

This is a typical case study presented as a training model to teach ethics in psychotherapy. In these vignettes, as in much of the writing about ethics, ethical problems are most often presented as separate from clinical work.

You are on the ethics board • What kinds of things do you think about? • How do you come to make decisions about Dr. Bumble? • The “answer” from the Ethics book: • 2.01 Boundaries of Competence(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

Articulating the Standard Approach Where do Ethics Codes come from, what are their uses, and when we must question them

The View from a Distance: The Standard Approach • What is the basis for this approach? • In Western philosophical views the basic idea is that we can reason our way to the ethical ideal • So we talk about “ethical” situations, decide which ethical principle applies, ruminate about what to do, and never question the assumptions underlying the ethical codes.

Characteristics of this View • Universal Principles • Do no harm, Justice, Respect • These are good and wonderful principles, but the question is how we apply them • Autonomous self—relationships are not important and total objectivity is possible • Generalized Others in formal relationships • In other words, particular situations and people don’t matter • People are therapists or clients • Clinical and ethical issues are separate • Ethical principles are not integrated into the healing work

A Closer Look Care Ethics: The Ethic of Dialogue, Care, and Immediacy

A re-framing of the Vignette • Standard vignettes contain the assumptions of the standard approach: • Individuals are interchangeable (e.g., “clients” and “therapists”) • Ethics codes are universally applicable • Ethical situations are separable from the therapeutic context • What if we look a little closer at how things might actually be happening?

Care Ethics—Noddings, Gilligan • Care ethics portrays the moral agent as a someone who is embedded in webs of relations with others, not autonomous and abstracted. • Care thinking is generally described as narrative, contextual, and particularistic, as opposed to abstract, autonomous and universalistic. • The concept of the “generalized other” is incomprehensible. Instead uses the concept of the “Concrete Other”, arguing that the generalized Other is a stereotyped Other, denying the uniqueness of human life.

Robert Bumble, Ph.D., was treating a troubled young woman named Angela Jacobs in his office at his home. The relationship between Dr. Bumble and Ms. Jacobs had been uneasy. Dr. Bumble felt that Angela was “putting him through his paces”, as he told his colleagues. He had diagnosed her as Borderline Personality Disorder. During one particular session, Angela started asking questions about his personal life that Dr. Bumble found intrusive. He was somewhat uncomfortable and angry, and it had been a long day in a busy practice. He was tired of dealing with Angela. He fell back on his ethics training about boundary violation and deflected her questions. He then attempted to educate her on the topic of boundaries in psychotherapy.

Angela was indeed “troubled”. She had a history of difficult relationships, never feeling a sense of acceptance and love from others. She felt some hope with Robert Bumble. He had treated her kindly and seemed attentive to her. As her hopes rose, she also felt a sense of rising desperation. What if things weren’t as they seemed? What if this relationship turned out like all the others, with rejection, leaving her more hopeless than before? She tested Robert Bumble. She wanted to know. On the day he gave her the lecture on boundaries, she felt humiliated, lost and angry. However, she could not allow herself to feel the hopelessness—the emotion threatened to swallow her up. Instead, she comforted herself that he really did love her, and if she only was able to stay close to him, things would work out. (My own extension of Koocher and Keith-Spiegel, 1998, p.89)

The Ethic of Responsibility, Face and Voice Emmanuel Levinas

Closer Yet • Care ethics adds an important dimension to how we think about ethics. It begins to question the idea of the autonomous self and speaks about selves-in-relation. • Yet, there is further we can go. • There is another strand of modern ethical theory that emphasizes not only the importance of the immediate and caring relationships, but also begins to deeply question the nature of the autonomous self and its roots in responsibility to the Other.

Emmanuel Levinas • Lithuanian Jew who lost his family in the Holocaust and was himself a German prisoner of war • Ethics prior to ontology—that is, ethics must be prior to “knowing” • Ethics is situated in an "encounter" with the Other in which the Other cannot become an object of knowledge or experience, but must remain subject. • The demand of the Other, according to Levinas is “Do not kill me”—not necessarily in the physical sense, but in the sense of “Allow me to be. Do not make me an object.”

Levinas attempts to undermine Western philosophy and its insensitivity to the Other • Characterizes most of Western philosophy as egology, and prefers instead of “love of wisdom”, the “wisdom of love” • “Saying” vs. “Said” • The content of speech strives for universality and solidity. Yet, in the failure of that striving, the Saying is revealed - conversations continue and are not discreet exchanges of information.

Totalization • “Totalization“, according to Levinas, occurs whenever I limit the other to a set of rational categories, be they racial, sexual, (diagnostic) or otherwise. • Indeed, it occurs whenever I already know what the other is about before the other has truly spoken. • If ethics presupposes the real other person, then such totalization will, in itself, be unethical.

Another go at the vignette • What would the vignette look like from a Levinasian framework? • Here’s a modest proposal…

Robert Bumble, Ph.D., was treating a troubled young woman named Angela in his office at his home. The relationship between Dr. Bumble and Angela had been uneasy. During one particular session, Angela started asking questions about his personal life that Dr. Bumble found intrusive. He was somewhat uncomfortable and angry, and it had been a long day in a busy practice. He was tired of dealing with Angela. Yet he recognized the total responsibility that he owed her. He knew that he must not “totalize” her, or make her part of his story, as though she was a “type” or class of patient; he must not make their living “saying” into a concrete “said”.

Among other questions, Angela asks, “Are you married?” Robert acknowledges that he does not know where this question comes from, but he recognizes the plea, “Do not kill me” (in other words, “Allow me to be”). Instead of remaining in his safe autonomy, he knows he must risk, open himself to her. He knows he is called into question by her plea. He recognizes his reluctance to engage with her, and his desire to withdraw behind professional boundaries. In this response, he realizes that he is also afraid. He also recognizes that his response must be immediate, honest and authentic, and he answers, “Yes, I am, and this is uncomfortable for me to talk about”.

Angela is frightened by his reply. How is it that Dr. Bumble has feelings like she does? How is it that he is uncomfortable? Angela’s self that is constituted in her responsibility to Robert is mobilized, and she is not sure what to do or say. She wants to totalize him, make him one of the many rejecting figures in her life, but somehow his vulnerability stops her. Nevertheless, she does respond with anger and feels betrayed by him. He acknowledges her feelings of loss and tries to understand them. As he does so, he finds he understands Angela at a much deeper level than her “pathology” and feels that in doing so, his universe is expanded. Angela also, although she is at first frightened, finds that she can expand how she thinks of Robert—not just as a therapist, but as a person.

Listening as an Ethical Act • Although the idea of listening is a very important one in psychotherapy, that listening has not been described in ethical terms. • Ethical listening has far greater demands on us than simply to “understand” or make sense of another person. • In fact, in the terms stated above, this is mere “totalization”—taking the Other into our conceptual system rather than allowing our ideas, our epistemology, and even our very selves to be brought into question.

This view of ethics has radical implications for our field • That is what we will be talking about much of today • What happens if we dare to not just follow “rules”, but to approach each moment as ethical and each person as unique?

RELATIONAL ETHICS How does this change things?

Stuff that gets left out of traditional approaches to ethics • We need to begin to question some deep assumptions that we have about what it is to be a person, the workings of POWER in our system, and to let go of “Knowing” • Facing Suffering • Towards a Relational Ethic • Mutual Respect and Power-With • Engagement and Suffering-With • Ethics as Uncertainty and Deep Listening

Personhood, Power, and “Knowing” • What persons can say about themselves, the sense of personhood that they can develop, will depend on the stories they can tell, as well as the stories that others are willing to listen to, acknowledge, and accept as viable and true. • Ethics begins here, with the face-to-face encounter, when we allow or resist our discomfort with uncertainty to influence our encounter with another human being.

Giving an account of oneself… • We can only give an account of who we think we are in relationship, and can only know who we are in relationship. • How do we become persons? • How do we give an account of ourselves? • Is this not the heart of ethics? • If we do not allow others to give accounts of themselves, and force our epistemology upon them, have we not committed an ethical breach?

In the ethical relationship, “knowing” is not about gaining certainty. • This is the dominant position of positivist science—power, prediction and control. • The true ethical relation resists rational certainty, and rests on uncertainty and the “perilous adventure of forever insufficient knowers sacrificing their certainty and even their control for understanding.”

Facing Suffering • We have medicalized human suffering, replacing the language of despair and anguish with the language of symptoms and diagnostic criteria. • Suffering as isolation without meaning • We who are witnesses to suffering of others must make a choice: We must choose whether to be there for them or allow their isolation to continue. It is an ethical choice.

The goal of therapy is not to preclude or eliminate human suffering, but to take it on in a radically ethical and responsive manner: as a suffering-with which is a “suffering-for” the suffering other. • When we suffer-with those who are suffering we enter into ethical relationships, responding to them with care and compassion. • Much of our therapeutic language of “cure” and “symptom reduction” can take us away from suffering-with

We no longer see ethics as a set of rules to follow, but as an attitude and a stance toward the suffering of others. • It is not an attitude of totalizing, controlling, and power-over (be it persons or symptoms); it is a stance of responsibility, of radical altruism or authentic giving in each and every moment. • It is an attitude of respect, engagement and uncertainty. • In contrast to the notion of ethics as known codes and rules, ethical knowledge cannot be known ahead of time; rather ethical knowledge must be developed in relationship

Mutual Respect and Power-With • Mutual respect: Mutuality, mutual empathy, mutual empowerment, mutual responsibility—all add up to mutual respect—seeing the other as worthy of our attention and our regard. • Mutuality and mutual respect mitigate power’s potential to damage. Mutual respect keeps power in its proper place, with each person able to live within her or his own position of power.

Engagement and Suffering-With • Mutual empathy, authenticity, relational awareness all add up to relational engagement. • To be engaged means to respond to the needs of others. In this moral response, one does not lose oneself, but could be said to find oneself—what one is capable of and the depths one can respond to. • Engagement, as a characteristic of ethical relationships, requires attention to the self, to the other and to the relational space in between. • What about boundaries?? More on that later today…

Ethics as Uncertainty • The ethical relation rests, instead, on uncertainty and the perilous adventure of forever insufficient knowers sacrificing their certainty and even their control for understanding. • Our challenge is living and being comfortable with ambiguity—not only in searching for control. • Relational space is an ambiguous space where certainty does not exist. Our challenge is living and being comfortable with ambiguity—and inviting others to join our web of ethical relations.

We need to practice negative capability • “I mean Negative Capability, that is, when a man [sic] is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason- • The ability to contemplate the world without the desire to try and reconcile contradictory aspects or fit it into closed and rational systems.

Discussion: What are the implications of this somewhat radical view of ethics? • Is diagnosis totalization? • How might this play out in clinical practice?

Information sources that are heavily biased How can we trust our information?

Where did our thinking come from? • We have begun to see that the quest for being ethical is not just about learning rules, but about beginning to question what we know and how we know it • We may accept some of the following just because it was taught to us • Diagnoses (even DSM diagnoses) are real things, scientifically established • We need to work to reduce symptoms that people bring to us and make them functional again • We need to refer for drug evaluation • We need to accept a subordinate position to psychiatry

Where did our current system come from? • We are taught to accept our current system—DSM, “medications”, “Empirically Supported Therapies”—as the “truth”, scientifically established by objective “experts” • But just how did we get to our current system? • Is it “true” or perhaps culturally constructed?

When treatment might cause harm