Thursday, 20 August 2009

psychotherapy and the ethics of acknowledgement




For a talk at the forthcoming 'Fifth R. D. Laing Conference'...

1. In his paper Pat Bracken charts the unwitting suicide of the evidence-based medicine (EBM) paradigm in psychotherapy. Large-scale studies have found evidence that, when we consider the psychotherapy of people judged 'depressed', therapeutic success has far more to do with the putatively 'non-specific' - than with the specific, technical - factors in the therapist-patient relationship. What really matters, that is, are not so much the model-driven 'interventions' of the therapist - 'interventions' which the EBM paradigm has done so much to assess - but rather the quality of the therapeutic relationship, as well as client-specific factors. So: whilst so much of the evidence-based paradigm is concerned with documenting the efficacy of this or that specific intervention, the research as a whole itself shows us that it is not these technical interventions that are doing the majority of the work.

Perhaps I should start by voicing my own perspective on this. I want to note first that the research Pat cites is research on the therapy of patients judged 'depressed'. It is not concerned with patients struggling primarily with circumscribed anxiety difficulties, for example. My own clinical experience is that patients 'with depression' seem to benefit less from an approach in which therapeutic techniques are derived rationally from models of psychopathology than do patients diagnosable with discrete 'anxiety disorders' such as OCD or panic/agoraphobia or various phobias. My own limited experience is that (CBT and mindfulness) techniques can be very useful for a substantial majority of this latter group of patients, especially when they are otherwise secure and intact in their emotional functioning, whereas they seem to add little to a person-centred, dynamically informed, therapeutic stance - a stance characterised by the listening therapist's restrainedly making their own humanity maximally available to the patient - for those who struggle with depression.

In what follows I want to pursue a line of Pat's presentation further, and to consider whether - and if so in what sense - it may not be merely a fact, but a necessity, that good therapy often cannot be reduced to the performing of technically good interventions. I shall prosecute this through first considering the significance of the therapist's ability to recognise the patient's individuality. (The philosophers Raimond Gaita and Cora Diamond will be my philosophical guides in starting to unpack what such recognition and such individuality amount to.)

The patient's individuality is often put forward by psychotherapists as a reason for the inapplicability of therapeutic approaches based on the application to the individual of generalisations derived from research on groups of individuals. I think that such arguments, while (probably, usually) representing attempts to articulate a perfectly apt intuition, often end up making a mistaken empirical point (for the details as to why this point is indeed mistaken, see Gloria Ayob's (2008) Do People Defy Generalizations?: Examining the Case Against Evidence-Based Medicine in Psychiatry in PPP, 15, 2, 167-174). The articulation goes awry because the arguments have often already unwittingly conceded too much to the EBM paradigm - conceded too much through making use of what I shall call 'empirical' rather than 'ethical' conceptions of the patient's individuality and its recognition by the therapist. What this all means will be explained later in my presentation.

2. The standard 'but everyone is unique!' argument against using an EBM approach in psychotherapy goes as follows: "You want me to apply this research-based bit of advice in my clinic. But in my clinic I see a lot of individual cases. As such they have their own unique difficulties and their own unique historical trajectories. Therefore it's meaningless to try and treat this person as an instance of a general type. That misses out what is particular about them - and their psychopathology is inevitably bound up with their particularity. To understand the individual person we must use an idiographic mode of comprehension, to see how they uniquely have been formed, and how they uniquely can be helped. It would be unethical to apply EBM approaches since these are not tailored to the individual, and as such would just not be effective in helping them achieve their own goals."

I will come on to the question of ethics later on. For now I want to note that the argument as presented depends upon a (to-my-mind dubious) empirical premise: People are just too dissimilar to one another in their personalities and in their troubles to warrant the application of general methods. But is this true? And how often is it true? After all, the EBM pundit is not claiming that using their technique for someone who meets a particular diagnosis will always lead to success. What they are claiming is that it will lead to success often enough - let's say, 7.5 out of 10 times. Unless we can claim better success rates for our idiographically derived treatments, then we should just shut up and practice evidence based therapy.

Furthermore, if this really is the argument, then why not just compare a version of therapy designed to tackle particular problems against a version which relies on individual clinical judgement derived purely from particular case formulations? The idea that one would come out tops is a perfectly empirical postulate, and readily testable. What it isn't is something that should just be evident from argument alone - something that can just be said by way of defence of one's own practice, for example, during a conference.

I want to note too that it had better not be the case that idiosyncratically tailored treatments - treatments designed to accommodate this particular individual with his or her particular difficulties and particular history - function just as well as, but no better than, the EBM treatment. If our argument is that the EBM techniques do not attain to the requisite level of specificity to meet the individual needs of the individual client, then it ought to be the case that an individual-case-formulation-based approach should meet those needs better. That is a direct implication of the above argument which treats what it is to be an individual to be an individual case - even if a case of a class which has only a few - perhaps only one - member.

On this 'empirical' approach to the individuality of the patient - this approach which takes the form of individuality which matters to us here to consist in the idiosyncrasy of the patient's history, character, beliefs, etc. - the connection between the ethics of the psychotherapy relationship and the patient's individuality can only be construed as 'external'. What I mean by this is that the only significant reasons why it would be considered morally better to treat the patient 'as an individual' are, on this approach, to be located in the prior framework for, and the posterior upshot of, the therapy.

First the framework: follow your professional code of conduct, be respectful to the patient, do not abuse your power, and treat them as you would treat anyone. This provides a background moral framework against which treatment is to be provided: it isn't itself typically understood as a piece of distinctly clinical advice.

Second the upshot: treat the patient in such a way that their presenting problems will be most speedily and successfully remitted. Here the best analogy would be with medical practice: provide that treatment which has the best chances of success. The therapy is morally good or morally bad depending on how it leaves the patient. A doctor or therapist who practices forms of therapy that don't work, or don't work very well compared to ones which do, is practising in a straightforwardly unethical manner.

I do not wish to criticise either of these moral principles: of course we should be generally humane, and of course we should not provide treatments with less than optimal outcomes. What I wish to say, however, is that this 'professional ethics' reading of the connection between ethics and psychotherapy is banal. It fails to explore the possibility that there is a more intimate connection between therapy and ethics - fails to explore the possibility that it might be illuminating to consider whether there is a sense in which one might meaningfully and truthfully say "therapy is ethics".

There is, I believe, something very convenient about this exclusion of the ethical from the heart of psychotherapy for the practitioner. The convenient implication is that to act ethically all one has to do is to act professionally (follow your professional body's code of conduct, aim for optimal outcomes, and there you are). Therapy itself now becomes all technique - practised in a humane way, of course - and the moral probity of the practitioner becomes a straightforward matter requiring little or no reflection. Knowing that we have met the ethical standards of the code of conduct and the technical standards of the therapy manual is knowledge that is not too hard to come by. (Good therapy, I want to suggest by contrast, constantly has the practitioner calling him or her self into question. Did I really understand, did I really offer acknowledgement, did I really make myself available or take myself out of the way? If anyone thinks such questions can be answered with any confident certainty they have probably just missed the trick about what it is to live an examined life.)

I shan't pursue the following thought in detail here, since I believe it better honours Laing's memory to use a paper at an 'R D Laing conference' to pick up his themes anew than to retrospectively mull over his thought or his person. But - briefly - it strikes me that much of R D Laing's work and thought can be seen as an enacted repudiation of this professionalised approach to the ethics of psychotherapy. (Importantly, Laing also repudiated the idea that therapy consisted in any set of techniques - I shall ***???*** return to this in the final section.) Laing's trickster identity led him to counter the banalising effects of professionalism by acting in deliberately unprofessional ways. This, I believe, served to highlight - for those with ears to hear - what I am arguing is an aspects of the ethics of therapy which professionalised approaches leave untouched: the ethics immanent in the authentic therapeutic encounter itself, an encounter which professionalised approaches tend to render merely humanely and technically managed. For those without such ears, all that was heard in Laing was his unprofessional manner, the GMC investigation, and so on. (This, it seems to me, is the danger of deploying the trickster approach - its failure to save those who most need it - those damned by their own institutionalised banality.) At any rate, in what follows I start to unpack the 'who' of this authentic ethical therapeutic encounter.

Raimond Gaita3. I now wish to outline an account of individuality - I shall call it an 'ethical' account - an account of 'individuality' as an ethical concept - which lies in contrast to the above-described 'empirical' concept of a numerically distinct individual with qualitatively distinct psychological attributes. (It is here that I shall be drawing heavily on the work of the above-mentioned philosophers Cora Diamond and Raimond Gaita.) I shall start by considering philosophical considerations before moving on to consider psychotherapeutic ramifications in section 4.

To rehearse a point made above, what it isn't to be an individual human being, in the (ethical) sense of 'individual' which concerns me here, is to be a particular member of the species homo sapiens, nor is it to have empirical characteristics which serve to distinguish one from one's conspecifics. Neither my numerical identity (I am this singular person here, not you, that one over there) nor my biological or psychological qualities (I have such-and-such skeletal or postural attributes, such-and-such a profile of neuroticism or extraversion, an IQ of 80 or 130, weak or strong ego boundaries, a poor self-image, this or that profile on the BADS or WIMS or TAT or Rorschach, these beliefs and those desires, etc.) constitute my individuality. But what then is it to be an individual in the ethical sense? What is it that we recognise when we show recognition of someone's essential individuality, and what is it to recognise this?

One unhelpful way to answer this question is to search for objective facts about people which constitute their individuality and which warrant our ethical recognition of one another. This is not to say that certain facts about us do not condition our practice of acknowledging individuality. Take the living bodies and faces of others, physiognomies capable of embodying character, faces capable of expressing emotion, faces which can show moral as well as physical wounds - - without these we should struggle to ethically encounter one another. (We struggle to show instinctive solicitude for those creatures which least embody the human form.) A certain unity of experience and memory - both autobiographical factual memory, and the 'memory' of sedimented habits of motion and emotion - provide some foothold for our ethical appreciation of one another. Yet there would seem to be nothing in such objective facts about us that compels us, in the way in which a demonstration of right- or wrong-headedness would wish us to be compelled, to offer one another recognition. (That, perhaps, is why ethical recognition is offered - it neither consists in, nor rests upon, our exercise of extra-ethical cognitive skill.)

Philosophers have tried various idioms for articulating our ethical individuality. For Kant it was an essential part of a viable (i.e. non-consequentialist) ethics that we treat one another as ends in ourselves, and not merely as means to ends. "Act in such a way", he said, "that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end." To recognise another's individuality, then, is not so much to become acquainted with some fact about them, but rather to act towards them in a particular way - to treat them not merely as means to ends, but as ends in themselves.

Gaita tells us that to see someone as an individual is, in part, to see them as an intelligible object of someone's love. We may not be able to love them ourselves (perhaps they have terribly hurt someone we do love), but we must at least, if we are to be able to acknowledge their individuality, be able to see them as lovable by someone. Gaita also draws out internal relations between the concepts of an ethical individual and friendship; to see a man as an individual:
he must be seen as someone who is subject to the demands which are internal to friendship, as someone of whom it is intelligible to require that he rise to those demands, no matter how often he actually fails to do so. That is compatible with him being such a nasty fellow that nobody could befriend him, for it is to see his nastiness from the critical standpoint of what is required for friendship. He is not like a bad-tempered dog.
Our offering recognition to one another shows itself in a range of further facts such as (those noted by Diamond:) that we give our children names and not numbers, and that we have respect for people, and treat them in a particular way, even when they are dead. It may also be brought out in talk of the moral preciousness of any individual's life, or of the essential irreplaceableness of any true person. By 'preciousness' here I mean the 'infinite preciousness' of a person - the fact that their worth is necessarily immeasureable. Individuality is reflected in the fact that if I wrong you, then what I feel remorse for, if I do, is not that I have broken some general moral rule, nor that I have decreased the stock of happiness in the world, but rather that I have hurt this particular person - you. Similarly with grief: a mother who grieves the loss of one of her four children may have grieved equally deeply if she lost any of the others. Nevertheless, in this instance, it is precisely for this particular child that she grieves - she does not grieve for her loss, but for this child. (Such examples bring out the meaning of Kant's above-cited categorical imperative far better, it seems to me, than any abstract formulation regarding 'ends' and 'means'.)

Ilham Dilman memorialThere is a further feature of our individuality to which I wish to draw our attention. This is reflected in the necessary limitations of the scope of psychological discourse, and has been expressed most cogently by the philosopher Ilham Dilman. If I am treating someone as an individual, then I am treating them as someone with an inalienable authority over their own motivations and intentions. This is not to doubt the applicability on occasions of explanations in terms of unconscious motivations or emotions or intentions, and not to doubt that, on occasion, we may be in error regarding our own desires. Nor - I believe - need acknowledging this authority saddle us with implausible theories of mind, such that we start to take it (as an 'epistemic realist' might) to arise either from putative direct introspections of our inner motivations and intentions, or (as a 'constructionist' might) from an alleged constructive power that the act of avowal has to shape the contents of our hearts. (Avowals neither report nor construct - but rather avow! - that which they express.) However it does require us to suspend the hermeneutics of suspicion that would have us see every utterance or action as a function of someone's psychology, and instead to see a good part of them as a function of their person.

To see someone as a person is, I suggest, to see her as somebody who, at least in part, or at least potentially, has her sight set on the true and her heart aligned to the good. To see someone as a person is to see their thought and action as (to redeploy some of Donald Davidson's terminology) potentially 'regulated by the constitutive ideals' of the good and the true. Hearts and minds may be corrupted, but what it is to have a mind or a heart is to be someone who seeks out the true or the good. To be able to offer someone recognition is to be able to hear what they say as a sincere expression of what here they have to say - as a sincere expression of their thoughts and feelings. Acknowledging their individuality is, then, acknowledging the necessary limit here to explanations of their behaviour which reference unconscious desires and motives.

None of this is to say that, were we to fail in this endeavour, the cause of the failure need be all our own. Perhaps we are confronted with such a despicable psychopath that we cannot - to use Gaita's criterion - discern how to view them as an intelligible object of anyone's friendship or love. Their heart and mind are so perverted and corrupt that we struggle to locate their humanity, struggle to know even how to offer them recognition. The above brief sketch of what it is to offer someone acknowledgement does however lay out the task ahead of us, in any encounter worthy of the designation of 'ethical'. In what follows I shall consider the extent to which a pursuit of the ethical, thus understood, lies at the heart of the therapy relationship.


Carl Rogers4. In his paper, Pat Bracken describes how it is that what the EBM paradigm purports are the 'non-specific' factors have been found,time and time again, to be by far the most significant therapist contributions to therapy for people diagnosed with 'depression'. In what follows I shall suggest that these factors - which are I believe often thought of rather vaguely as something to do with the warmth of the therapist's manner - how friendly they are, for example - can be better understood as reflecting the therapist's capacity to offer ethical recognition to the person who is their patient.

Such a perspective suggests itself in the writings of Carl Rogers, who provided us with a set of ('non-specific') factors concerning the attitude that the effective therapist takes towards his or her patient. In fact he considered these to both be essential elements of any genuine human and humane relationship, and he considered too that the formation of such a relationship was the key to therapeutic success.

The factors Rogers cited were:
  • congruence: ‘It has been found that personal change is facilitated when the psychotherapist is what he is, when in the relationship with his client he is genuine and without “front” or fa├žade, openly being the feelings and attitudes which at that moment are flowing in him.’

  • acceptance / unconditional positive regard: ‘when the therapist is experiencing a warm, positive and acceptant attitude toward what is in the client, this facilitates change. It involves the therapist’s genuine willingness for the client to be whatever feeling is going on in him at that moment – fear, confusion, pain, pride, anger, hatred, love, courage, or awe. … he prizes the client in a total rather than a conditional way. … without reservations, without evaluations.’

  • empathic understanding: this is ‘when the therapist is sensing the feelings and personal meanings which the client is experiencing in each moment, when he can perceive these from “inside”, as they seem to the client, and when he can successfully communicate something of that understanding to his client’
Now there were elements of humanistic psychology at which Laing baulked, and at which I find myself baulking too. (It's version of self-realisation, for example, as well as degenerate versions of empathy (i.e. parroting what the patient says back to them).) But, so long as we do not offer an uncharitably trite interpretation of what 'unconditional positive regard' amounts to, nor demand that it should be present more than the therapist's 'congruence' could allow, then I suspect that there is little that could reasonably be said against these factors as significant elements in what makes therapy therapeutic.

But what I wish to urge here is that these factors are precisely what it means to offer ethical recognition to the patient. In other words, to be in touch with a patient as a unique and 'infinitely precious' individual, to do genuine justice to their individuality, just is to engage with them with the kind of solicitude outlined by Rogers' three factors of empathy, honesty and unconditional acceptance. The unconditionality Rogers mentions, for example, might at its worst be merely a suspension of judgement where judgement is due. This, it could be said, is a way of taking 'unconditionality' as an empirical feature of a therapeutic relationship: I think you're being unreasonable but I prevent myself from saying it. Or I would think that you were being unreasonable were it not for the fact that I've learnt to suppress my own judgements, shut down my own critical faculties, to the supposed - and misguided - end of 'being therapeutic'. But at its best, 'unconditionality' will not represent any such merely empirical function, but rather function transcendentally to constitute whatever it is to acknowledge another's individuality. The question is: can I allow myself to view you under this aspect - under the aspect of a uniquely and infinitely precious human being? Can I find this in you - but more importantly, can I find what allows for this perspective in myself? Can I bring myself to be fully alive and present - to bring myself spontaneously and unguardedly online - in this moment, to offer a recognition of your humanity by means of drawing fully on my own? Offer recognition of what you spontaneously offer me by responding from my own capacity for spontaneity?

Rogers acknowledged that when he put aside all thought and especially all theory, and approached the patient with wholehearted devoted attention, his therapeutic powers were enhanced (. He talked of his 'complete subjectivity', of how he 'let my self go into the immediacy of the relationship where it is my total organism which takes over and is sensitive to the relationship, not simply my consciousness. I am not consciously responding in a planful or analytic way, but simply react ... based on my total organismic sensitivity to th[e] other person. I live the relationship on this basis.'). Martin Buber, reflecting on what it is to meet someone as a 'you' - as another subject rather than as an object, comments that
The relation to the You is unmediated. Nothing conceptual intervenes between I and You. No prior knowledge, and no imagination. And memory itself is changed as it plunges from particularity into wholeness. No purpose intervenes between I and You, no greed and no anticipation. And longing itself is changed as it plunges from the dream into appearance. Every means is an obstacle. Only where all means have disintegrated encounters occur.

Bion put it more pithily: our task, he suggests, is simply to 'listen without memory or desire'. This mode of listening was, for him, a way of affording himself a faith in his own unconscious - in its capacity to respond directly to the unconscious of the patient. By 'unconscious' here Bion meant not a sphere of repressed desire, but rather, and amongst other things, a mode of mental functioning which dares to be playful and associative.

For all three authors, albeit with their different understandings of the work of healing in therapeutic relationships, therapeutic listening involves: listening with one's whole being, attentively, in a manner unmediated by thoughts of case formulation, without deploying special techniques, without explicitly trying to recall what was said before, in the absence of desires to have the patient reach a certain goal. It means meeting the person of the patient in that moment, and meeting them from a point of maximal involvement with them rather than with one's own thoughts.

In characterising the nature of that meeting it is far easier to say what it doesn't involve than to say what it does. I think this is not to psychotherapeutic theory's detriment. When Rogers, for example, tries to be more explicitly positive in his characterisation of therapeutic listening, he tends to risk becoming off-puttingly, humanistically, cloying. Rather than simply having an unconditional regard for our patient, we are invited to have an unconditional positive and warm regard. (This appears to risk contradicting his own emphasis on the significance of 'congruence'.)

By sticking to Bion's 'listening without...' formula we do better. The goals of therapy involve being able to 'relate without...' i.e. to engage with others without using defences. They involve too being able to 'be oneself', which means, again, simply an absence of certain neurotic fears which incline us to the use of contrived self-presentations. Some of the means of therapy - the listening without: trying to be clever, trying to explain, keeping an ear out for the data which will confirm one's theory, theorising what is being said - have a similar logic. In the final section of this talk I shall discuss this logic further, and explore analytically how it resists codification.

5. I started this talk with an appreciation of Pat Bracken's critique of the idea that specific psychological techniques provide the means for treating individuals struggling with depression. Over against such techniques Pat stressed the importance of the non-technical therapeutic relationship. I now want to finish by considering what could be said to someone who wished to attempt to turn the provision of that relationship itself into a technique. I (perhaps inaccurately) recall a passage in a book on Treating Affect Phobia I have that recommends going 'mmm' at certain points in the interview to convey understanding and empathy. That will strike anyone with ears to hear as righteously absurd, but I wish to ask now why this is so. Is it merely because, if we are thinking about what we ought to be doing, then we are less likely to be really listening to them? That is, is the uncodifiability of relationship merely a function of the contingent limitations (in attentional resources) of human psychology? Or is there something more principled at stake here: that the provision of true relationship cannot be codified, as a matter of what it means to enter into such relationship?

This at any rate is what I should like to suggest. In Buber's words, to attempt to codify relatedness would amount to attempting to reduce an I-Thou relationship to an I-It one. (I do not mean to say that one should not engage in both forms of relationship with one's patients, nor that a certain kind of movement back and forth between the two will not be highly productive at times, nor that I-It thinking may sometimes be helpful to clear the way for I-Thou modes of relating which have become thwarted. What I am concerned with here, however, is with the question of whether human relatedness could itself be codified.) I suggest that this is impossible, and this is not because we can't imagine deploying some set of rules which if the therapist deployed them, the patient would feel recognised, but because to deploy such rules is just not to respond to the patient, but instead to respond only to what they say or do. It is not to meet them as a person, but to (somewhat immorally - cf Michael Morris, The Good and the True, p. 116) build an explanatory or predictive model of their behaviour.

Buber writes, in defining what it means to relate as to a Thou: 'The relation to the You is unmediated. Nothing conceptual intervenes between I and You. No prior knowledge, and no imagination.' By 'imagination' here I suggest that Buber means: no imaginative projection of myself into your shoes. When I listen to you qua Thou, I discern straightway what it is like for you to be you - not what it would be like for me if I were in your situation. I do not, that is, first imagine what it would be like to be me were I in your shoes, then ascribe the output of this 'simulation' to you. I stress this here because I do not believe for one moment that Buber meant to deny imagination an essential place in our understanding of one another - only to state that such imagination should not function as a mediating, intervening, step between listening and understanding. To suppose that it would do is just to view you as another instance of a being like myself - and to do this is to fail to respond to your individuality.

Again, the relevance for the present discussion is not the likelihood of any such imaginative simulation-gained understanding being true or false. I may be correct 100% of the time in my making of such sympathetic inferences. Or perhaps I rely instead on 'prior knowledge' of what people in situation Z who report X are likely to feel or think or do or say, and I use this to explain or predict your behaviour with perfect accuracy. Again, I do not believe for one moment that Buber meant to deny our accumulated knowledge and prior experience of humanity a role in our understanding of one another. The point is whether such knowledge is to function as an intervening or mediating factor in my relationship with you when, truly listening to you qua Thou, I hear the meaning of what you say. Rogers' point, to reiterate, was not that listening to someone as if to an It made for poor individualised formulations and hence poor therapeutic interventions. It was rather that listening to someone as to an It made for poor therapy, since good therapy just is in part listening to someone as to a Thou.

Let me follow up this point regarding the relevance of the accumulation of knowledge to the therapist's activity, as a way of concluding, and summarising some of the main themes of, this presentation. In his essay 'Paradox and Platitude' (quoted by Ilham Dilman in his essay Science and Psychology), the philosopher John Wisdom wrote of how

It is, I believe, extremely difficult to breed lions. But there was at one time at the Dublin zoo a keeper by the name of Mr Flood who bred many lion cubs without losing one. Asked the secret of his success, Mr Flood replied 'Understanding lions'. Asked in what consists the understanding of lions, he replied 'Every lion is different'. It is not to be thought that Mr Flood, in seeking to understand an individual lion, did not bring to bear his great experience with other lions. Only he remained free to see each lion for itself.
The same, I believe, can be said of the enterprise of therapy. Of course the therapist brings to bear his or her experience with other people in the encounter with a particular patient. This, however, does not mean that the encounter need be mediated by this knowledge. And if the therapist is offering genuine solicitude to the patient then, I suggest, the encounter cannot be so mediated. The accumulated experience has informed who the therapist is, in their spontaneous engagement with the client, in (to use Winnicott's term) their carrying-on-being and this, I have been suggesting, is precisely what makes possible the carrying-on-being of the patient. To really meet the patient out of who one is, and not from what one knows, is just what I have been calling 'offering them recognition'.