Excerpted from a presentation at the CICSW convocation on Ethics, June 2002

Introduction

I became interested in writing a paper about the subtleties of ethics in the psychotherapeutic process when I was on an Ethics Committee, having to adjudicate complaints in which there were no clear ethical violations, complaints that involved criticisms of what the therapist said, for example, that could not be understood as an ethical violation, especially out of the context of the experience that was occurring within the privacy of the therapeutic container.

In this presentation, I will attempt to define the ethical attitude which is applicable under these circumstances. I will address the origins of an ethical attitude, giving a brief overview of the theories of moral development and integrity, both of which are fundamental to an ethical attitude. I will then discuss qualities of the ethical attitude and conclude with examples of the use of an ethical attitude in approaching ethical dilemmas.

Definition of an Ethical Attitude

There is very little published material about an ethical attitude in psychoanalysis or psychotherapy in spite of the fact that an ethical attitude is an essential aspect of the analytic relationship. An ethical attitude encompasses the formal codes of ethics within the professions, but it is more complex than just following the rules. Ethics codes are needed in order to process dilemmas and complicated experiences and interactions. An ethical attitude is necessary because rules and regulations do not adequately cover the dilemmas that occur in the therapeutic relationship, issues that need to be considered and struggled with that often have no clear "right" answer.

Hester Solomon, a Jungian analyst in London, writes that an ethical attitude should be an intrinsic part of the therapist’s self. In the intimacy of the therapist’s relationship the protection of the development of the patient’s self is primary. The therapeutic attitude therefore must be an ethical attitude. An ethical attitude is based on our humanness, our need to act with humanity toward others in our professional lives as well as in our personal lives. We try to be decent to one another, listening to ourselves and to one another, choosing ways to respond after having reflected on what seems true and just rather than what is simply correct, maintaining an awareness of our humanness (p.443). An ethical attitude implies behavior toward the other that is altruistic. Concern for the other is not based on reciprocity, but rather on selfless behavior (p. 447).

An ethical attitude requires the ability to hold the opposites, to deal with ambiguity and paradox, not to split. It may mean suffering the uncertainty of having said or done something that was "against the rules," such as hugging a patient, not charging for a phone conversation — or even having a phone conversation, or disclosing personal information to the patient.

Ethical Dilemmas

Confidentiality

We are often in ethical dilemmas regarding confidentiality. Although reporting such things as elder or child abuse is now required, we still have to decide whether or not to report. In Jan Weiner’s paper "Confidentiality and Paradox: The Location of Ethical Space" (2001), she notes that Bollas and Sundelson (1995) believe that following the law to report is not therapeutic for the patient. They believe breaking confidentiality by reporting is betraying a central axiom of the analytic method. The analyst needs to protect confidentiality and bear the agony of this stance ( p. 436). This relates to Weiner’s idea of finding an ethical space to process issues that are more complex than ethical codes and regulations, a "third position" where the subjective and objective can have a space to give each its due (p. 431). She quotes a line from Rattigan’s (1946) The Winslow Boy "It is easy to do justice, but much more difficult to do the right thing" (Weiner, p.440).

There are always ethical and un-ethical forces at work within us. It is easy to turn to the rules for a decision; it is more difficult to consider the issues in a thoughtful way related to the care and concern we have for our patients. This involves depending on our integrity, finding what Weiner calls an "ethical space" in which we can combine our moral principles and ethical attitude, giving credence to both the objective and the subjective. Our personal subjective feelings can validly inform a decision about whether to break confidentiality (pp. 439-440).

Many of us break confidentiality when we talk about patients to close colleagues. We usually do this when we are in a complex or in a countertransference enactment and desperately need help. These breaches are done with care and concern for the patient; they are not about gossip, but rather occur because of our own inner conflicts in relation to the patient. We want to talk the problem over with someone we trust who knows us well. We want help so we and our patient can come to a better relationship with one another. Often when this occurs, there is guilt and worry about the process; sometimes it works well, and sometimes it does not, such as when two therapists each seeing one member of a couple take sides with their own patient. However, when this occurs it may be able to be understood in terms of the dynamics of the couple, helping both therapists to work more effectively with their patients. We are, however, breaching confidentiality and need to carry the struggle within ourselves.

What about when we write up a case for a paper presentation or journal? Some therapists will not write about patients, others ask permission, others disguise cases well or make up a composite case. Is getting permission from the patient really informed consent? I think of a time I asked permission and showed the people what I had written before presenting the material. Each of the people was very upset when they heard the presentation; it sounded different in public and was hurtful because it was revealing of the private space that was precious to our work together.

On the other hand, if we do not talk and write about our work how do we learn from one another and how do we develop our skills as therapists? Reading and hearing about how others work is an important way to learn about the process of the therapeutic relationship. It makes us better therapists. Talking about the problems we have in our work with patients helps the patient and us to solve difficulties we are having in the therapeutic relationship.

These are ethical dilemmas related to rules about confidentiality. They can only be resolved by thinking about the objective issues and the subjective experiences we each have about writing and speaking of our work.

Theoretical Frameworks

What about the implications for our patients when we are devoted to a particular theoretical framework? What are the ethics of trying to fit a person into a theory because the theory is meaningful to us and fits our own subjective experience? We are most vulnerable to being wedded to a particular theory when we are new in the field and are trying to hold onto something that is knowable; when we are learning about a new theoretical approach, especially when in a training program, or an analytic program in which a theory has to be learned in order for the therapist to become an analyst; or when in a training program such as the Institute’s and we are writing a paper about a particular theoretician, needing to relate the theory to a case. Another time is when we are teaching, especially when we are new at it and feel we need to have something to impart to the student or supervisee. It is also possible to interfere with a patient’s development when a supervisor insists on a particular theoretical view, especially because the student obviously knows the patient more intimately. In some circumstances the student is not able to strongly disagree with the supervisor because his or her successful completion of a training program or of licensing hours requires a positive evaluation from the supervisor. Both student and patient may be traumatized when the supervisor is unable to be curious about a different point of view from his or her own.

We also may become locked into a stance with a patient we have seen for many years, unable to register changes that have occurred, thereby causing us to continue to relate to the person with old theoretical ideas about their problems. This may also occur when we are stuck in a theoretical approach into which the patient does not fit. We continue to understand and interpret to the person based on theory that is no longer relevant to the person. An example is when a patient has been angry at the therapist for a long time. When the anger dissipates due to the development that has occurred, the therapist may continue to treat the person as though there is still anger underneath the communications toward the therapist. The anger remains the subject of interpretation when it is no longer appropriate. The imposition of theory blocks the therapist’s view of changes in the patient.

An ethical attitude involves continued learning and continuous examination of one’s ideas and reactions in the therapeutic relationship. There is no one right way to be with everyone or even with one person. The therapeutic process needs to be seen as ever-changing and rife with uncertainty and awe. No one theoretician has the answer, though it behooves us to be curious and learn about theory in order to have a basis on which to think about the therapeutic process.

Self-disclosure

Self-disclosure presents another ethical dilemma. Many of us are self-disclosing to one degree or another. Having an ethical attitude means using self-disclosure for the benefit of the patient; such disclosures come from a deep connection with the patient, involving a resonance and knowledge of their relevance to the patient. When I have told a patient about my own vulnerabilities, it has usually been when I was trying to help the person understand the humanness of his experience, when the patient is feeling that he or she is horrible because of certain thoughts or feelings for example.

When we are self-disclosing in a way that is not helpful, it is important to examine ourselves and to ask if the patient may have heard something that felt intrusive. There are also self-disclosures that come from our own need to talk and be seen. These are times when an ethical attitude brings us to an examination of the process and curiosity about what may be occurring between the patient and analyst in the moment as well as what has stirred the analyst’s narcissism in the moment.

Current thinking about the psychoanalytic relationship with its emphasis on mutuality has opened the door to self-disclosure as an important aspect of the healing process. Some of the thinking includes considering the patient’s comments about the therapist’s self-disclosure as part of the patient’s development. For example, if a patient has said or done something that angers the therapist, the therapist may acknowledge the anger toward the patient as a way to help the patient understand the patient’s impact on others. There are also notions that the patient is an observer of the therapist and needs to be able to comment on the therapist’s disclosures about him or herself as a part of the relationship, and that the therapist needs to validate or clarify the patient’s ideas about the therapist as a way for the patient to become more trusting of his or her inner experiences. An ethical attitude means the therapist participates in this process with uncertainty, with an openness to critical review of the process and with self-scrutiny so that care and concern for the patient remain primary.

Personal Relationships

In his book, Love’s Executioner, Irvin Yalom (1989) gives an example of a patient of his who had previously been seen by another therapist with whom she had had a sexual relationship. Throughout the treatment with Yalom he tried to "help" her realize the sexual relationship was exploitive of her. She believed, and continued to believe, that it was good for her. The first therapist was concerned and caring about her and she experienced him in that way.

Many of us know of marriages between therapists and their former patients that are now against the rules. Some have been lasting and successful. How do we understand this? What is an ethical attitude in relation to these situations? It is easy to be critical and think there must be unresolved transferences and countertransferences. Many ethics codes and California state law say that sexual contact with a patient or former patient within two years following termination of therapy is considered unprofessional conduct. Also, the therapy may not end for the purpose of having a sexual relationship. Even when therapy or analysis has been terminated for two years, there is skepticism about these relationships, or, more likely, negative judgments these days. How would you think about this with an ethical attitude?

Miscellaneous Ethical Dilemmas

Here are other situations that pose ethical dilemmas. What about when the patient talks about something he or she is doing that is illegal? If I question the patient’s integrity, I am judging rather than holding a neutral stance. My decision to question the behavior may come from my own over-scrupulosity rather than integrity, or from my fear of getting caught, or fear of my patient’s getting caught. What is an ethical attitude in relation to this kind of situation? For example, what if the patient steals, or uses illegal drugs, or is a drug dealer?

What about when I become angry with a patient? Is it unethical to show this anger in a strong way, that may even escalate to what might be thought by some as yelling? Or is it unethical not to show the anger? For example, when a patient is not getting what I am trying to communicate, is being critical of me and angry, if I get angry when trying to communicate my concern and the point I am trying to make, can this be coming from an ethical attitude? I had been seeing a patient who was seriously bulimic and was refusing to be examined by a physician even though it was likely that the patient’s potassium level was dangerously low. I became angry insisting that the patient had to go to the doctor. She was furious with me, stomped out of my office; I slammed the door behind her. She left me a note saying she would not return to see me. We both calmed down within a few days. She went to the doctor, and returned to continue her work with me, eventually giving up the bulimia. When we are deeply involved with our patients, the intimacy of the relationship may include such reactions. The love and concern for the patient brings reactions that are very personal and vulnerable. How do I know if I am acting with integrity when spontaneous reactions such as anger are expressed by me? One way I think of determining this is the extent of concern and worry that such reactions bring with them. This is a time when the struggle with what is right or wrong is not easy to solve. There may not be a comfortable conclusion; it may remain as a question with perhaps the feeling of guilt that accompanies struggles within an ethical attitude.

Another example is working with a patient who is stealing or dealing drugs. We are being paid with the illegal money. Do you continue to see the person and work with them in the hope that you will be able to help them examine their behavior and eventually change? I did work with someone for many years who was stealing money. We talked about it and specifically about my taking money that was illegally gotten. I was uncomfortable and periodically in anguish about it, but my patient eventually changed and stopped stealing. Another example is refusing to see a patient because of his stealing and then years later feeling it was unethical to refuse treatment to the patient because the patient needed help and might have eventually given up the stealing in the process of being healed. In both cases the therapist is holding a feeling of guilt, in the first example during the analytic process and in the latter example, years after the decision was made not to work with the patient.

When a patient wants to end analysis and the therapist does not think he or she is ready, this is often an ethical dilemma. Does the therapist want the patient to continue because he or she needs the money? Does the therapist want the patient to continue because the therapist will feel abandoned if the patient leaves and the therapist cannot tolerate that feeling? All of these may be issues at the time the patient wants to terminate. The therapist needs to be conscious of and struggle with these issues.

What about seeing a patient who is on disability and then gets a job but does not discontinue the benefits? We can talk about the integrity of this with the patient, but what do we do if the patient continues the behavior? Or, what if the patient needs the benefits for a few months in order to pay necessary bills, including the analyst’s, until the first paychecks are received?

When we over-extend ourselves is another time that we may need an ethical attitude to help us think about the way we are relating to the patient. Resentment may build and we find ourselves being irritated or angry toward the patient who seems to be taking advantage of us. An example is a patient who does not show up for appointments or cancels frequently. When continuing to hold time for the person and talking about the meaning of the missed appointments does not change the behavior, the therapist may then become reactive, such as unconsciously scheduling someone else in the patient’s hour, being critical of them or sarcastic.

Conclusion

An ethical attitude often involves struggle, guilt, uncertainty, anguish, and other feelings that are hard to tolerate, but must be embraced. A balance between subjectivity and objectivity has to be part of an ethical attitude. Rules and regulations, in and of themselves, are not adequate for the complex situations of the therapeutic relationship. Integrity and morality are basic to an ethical attitude. Morality develops through relationships and integrity involves struggling with complex issues within ourselves.

Throughout the therapeutic process we are involved in an intimate relationship in which we model certain ways of being. Developing an ethical attitude involves relating with integrity. In the process of relating to the patient with an ethical attitude we are helping the patient to develop his or her own integrity and ethical attitude. We are committed to respecting the patient and paying attention to our own inner experiences in trying to understand and help. To have care and concern for our patients we need to have the courage to think for ourselves when issues arise that are not clearly solved by following the rules. The relationship is primary in the analytic process.

As therapists we are in relationships that give us the opportunity to use our own subjective experiences and to value the subjective experiences of our patients. When we struggle with issues of confidentiality, writing about patients, dealing with illegal situations that are spoken about to us, or the effects of our devotion to a particular theory, we need to maintain an ethical attitude which means struggling with our conscience about what is right and wrong for us and for our patients, not necessarily what is right and wrong according to the rules.

References

Bollas, C. & Sundelson, D. (1995). The new informants: Betrayal of confidentiality in psychoanalysis and psychotherapy. London: Karnac Books.
Rattigan, T. (1946). The Winslow boy. London: Nick Hern Books.
Solomon, H. M. (2001). Origins of the ethical attitude. Journal of Analytical Psychology 46(3) 443-454.
Wiener, J. (2001). Confidentiality and paradox: The location of ethical space. Journal of Analytical Psychology 46(3) 431-442.
Yalom, I. D. (1989). Love’s executioner. New York: HarperCollins.

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Claire Allphin, M.S.W., Ph.D., is a graduate of CICSW and a member of our faculty. She is in private practice in Berkeley.

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