Friday, 30 January 2009

moral treatment

Pinel unchains his inmatesEarly psychotherapeutic endeavours were known as 'moral treatments', the category of the moral being drawn on primarily to contrast with that of the medical. The French alienist Pinel freed his psychiatric patients from their manacles and recruited helpers who would treat their wards with respect and kindness using a 'traitment moral'.Whilst 'moral', as Pinel uses it, seems to have more to do with the 'psychological' than the 'ethical', the fact remains that treating the patients kindly, with respect, as real people, remained an important part of that admittedly imperfect evolution of the human madhouse into the humane asylum which he helped to institute.

In this post I want to start to think about the relation between the moral and the psychological. It strikes me that many psychotherapeutic endeavours and psychological schemes treat the category of the moral as merely externally related to the therapeutic encounter. Psychological theory and technique can then (it is supposed) be developed and practiced as something intrinsically separate from - even if always necessarily contextualised by - ethical concerns. So, to be a therapist I must of course be a kind and warm-hearted person who abides by the code of ethics and conduct of my professional body. These are, so (what I believe is) the prevalent conception would have it, (merely) essential preliminaries, practical preconditions, for the therapeutic endeavour. But this endeavour can (it is supposed) be theorised in purely psychological terms which, as such, need make no further essential reference to the moral order. The two goals - to be a (morally) good clinician, and to be a (psychologically) good clinician - are two enterprises which accordingly may (allegedly) be thought to merely run in sequence or in parallel. And whilst the former may influence the latter externally (i.e. be a practical precondition for the efficacy of, but not be actually constitutive of, the psychological therapy), the practice of morality is nevertheless typically theorised as external to the therapeutic action.

There are I believe some exceptions to this from what might at first appear some quite unusual quarters. Kleinian theory, for example, and despite some of its occasional darkness, has particularly powerful things to say about the complex and interwoven relationship of moral factors, goodness, love, envy, etc., to psychological functioning and the development of the self. And Rogerian theory and practice, despite some of its occasional naievity, holds to a view of therapeutic endeavour which makes moral authenticity and openness into a primary therapeutic virtue. But on the whole the rule of a separation of the moral and the psychological seems to hold. One thing that strikes me is that (what I believe is) the typical psychological approach seems to view the moral factors as quite easily instantiated. Follow the BPS Code of Conduct - keep confidentiality, show respect, don't bring the profession into disrepute, don't sleep with the client, don't abuse your position of power - and you'll be alright.

The first 'argument' I wish to make is that this appears to be a very simplistic position on what it is and what it takes to morally relate to another. It seems to make out that it is far easier than it really is to be moral. It seems to take a particularly Old Testament, decalogue-ish, view of morality. Don't: murder, be adulterous, forget to pray, lie, slander etc., stick to the rules - and you're doing alright. (I don't mean to slander through absurd simplification the Jewish faith, and am not at all concerned with making a religious point, only with borrowing a certain, probably false yet popular, Christian conception of the relation of New to Old Testaments to make the ethical point at issue.) But the New Testament tells us it's not so simple as obeying principles such as not coveting your neighbour's wife's ass. Love your neighbour as yourself: is that an easy task? Can we even be confident what is to do it, or know when we've done it? Practicing open-heartedness is, instead, a never-ending challenge, whilst not stealing or murdering or sleeping with the patient is hardly such a burden. Christian writers, such as Rowan Williams, make clear how the spiritual life, understood in its moral dimension - as the cultivation of 'un-principled', un-conditional love - is something we have to continually work at, not simply through effortful self-discipline, but through the never-ending practice of openness, prayer, and humility.

So what about, say, respectful listening in the consulting room? Is it really so obvious when we manage to achieve respect? Is it just a matter of, say, not interrupting? Of course not! And what about treating the patient as a person. Is that an easy matter? To really, fully, acknowledge the otherness of an other? To not project one's own values or beliefs onto them? To achieve true humility in our listening? To locate the humanity in the most challenging of their endeavours or attitudes? To practice with integrity, to fully empathically respond to them, to convey to the client our recognition of their personhood - not in an interpretation but in, say, a spontaneous smile?

This kind of morality clearly speaks not to what massive abominations we refrain from doing, nor of or to a set of procedures or codes of conduct as to what is generally befitting of a psychologist. It speaks to what or who we are as human beings. Open-heartedness, genuine kindness, true compassion are character traits we have to work on, constantly, throughout our lives. It's often only when I'm back in touch with my better self that I realise the darkness in which I've been living - both inside and outside the clinic.

So my counter to a contrary temptation to say 'To be a good therapist it's not enough, you know, to be a nice person' is to ask: 'Are you so very sure that you have really appreciated, really tackled in understanding, the sheer amount of un-ending work it takes to manifest moral courage in the consulting room?' 'Are you sure that morality can be tidied away into injunctions and niceness, leaving the field open for a more purely 'technical' endeavour called, for example, psychoanalysis?'

Let me be honest: I think I can, truthfully, imagine a truly not-very-kind cognitive therapist, who in their personal life lacks integrity, nevertheless helping a patient to overcome their social phobia in the course of working their job through, say, both providing them with some knowledge about the maintaining influence of safety behaviours, and also by putting them through the paces of a desensitisation regime. (Computerised CBT also provides a good example, as do self-help books, of therapeutic strategies that lack any obvious moral dimension.) Or a hopelessly immoral psychoanalyst who nevertheless serves as a useful object for me to become conscious of the extent of my own disposition to project and of my typical unconscious assumptions about the way others will or should treat me. And I can imagine too that someone who happens to be nicer than the aforementioned therapists, and who has an equivalent merely technical capacity, will effect better results because they may, say, be just that good bit more approachable.

But it is also clear to me that, whilst the above-mentioned patient may have been freed from his phobia, he will not have achieved any change in who he is as a person. He will not have grown through the encounter; his self will not have changed. He will 'be better' in one sense only - in a quasi-medical sense of symptom-relief or change in underlying non-moral beliefs.

And I do not want to say, either, that the psychotherapist ought to be positioning themselves as a moral guide, or view their patients as wishing primarily to make moral progress. To simply collapse the psychological into the ethical would seem as misguided as trying to separate them out from one another in the manner I've been criticising above. What I am claiming is simply that, to help the patient to become themselves - to achieve some of their inmost potential and, through that self-becoming, to be able to relinquish their defences - it may perhaps be necessary for the therapist to be fully morally engaged in the encounter with the patient and for this moral engagement to be in no way be exhausted by, say, simply not being immoral. Achieving recognition of the other - through the receiving of which the other may now be able to change - is I believe not something we - those of us well educated in the theory and techniques of psychological therapy - can afford to take for granted as a straightforwardly cognitive endeavour. The depths of my own humanity are rarely readily accessible, and plumbing them seems to require a constant invocation of humility which, if I am honest, I frequently find hard to muster.