Abstract
The psychotherapy profession as a whole has had and continues to have considerable difficulty with questions of regulation and accountability. The UKCP of which the IGA is an organizational member has been engaged in long and often fraught discussions with the government regarding how the profession should be regulated, and more recently has radically altered its complaints process to comply with conditions for continuing voluntary regulation. My reading of the debate as it has been reported is that it has aroused much persecutory anxiety. This is not surprising. What is more disturbing for our profession is that these have been allowed to lead to polarization of the debate in which the profession has felt itself to be under threat without taking sufficient account of our responsibilities to the public we serve. Of course we are not alone as a profession in any of this.
Many psychotherapists including group analysts work within the National Health Service in England and Wales. There is much anxiety about threats to jobs, which are frequently interpreted as attacks on psychotherapy. This is probably true to an extent but it ignores how other vital services within the Health Service have also suffered significant cuts. There can be little argument that the Health Service professions have to be accountable for the quality of the service provided and that there needs to be an adequate system of regulation. As a profession we cannot have it both ways. If we want to be part of a National Health Service we have to be accountable.
It is axiomatically true that the law is an ass. However no one suggests that society can function without the law even when problematic. We are living in an era where laws around regulation are causing serious problems. My experience in the National Health Service for example is that regulation has become so heavy-handed that people have become frightened, so that rather than taking responsibility and doing their best as they would in general like to do, they in fact end up frequently doing their worst through practising defensively. So I agree it is right that we should examine our Codes of Ethics to ensure as far as possible that they serve the functions they are intended for.
This leads me to my first argument with Dalal’s article. His view is that the Code of Ethics is there to police the membership. I contend that its primary purpose is to protect the public, in as far as this is possible to do. It follows from this that it lays out what therapists are accountable for. In order to practise as psychotherapists people who come to us need to know they will be safe. An important aspect of this is that the profession has a good reputation. It is an essential function of the Code of Ethics and of complaints procedures to maintain public confidence in the profession when things go wrong.
Dalal goes on to say that Codes of Ethics only state the obvious and that in some way we all know what they contain without actually reading them. This may be generally true but not necessarily specifically so. As a doctor there have been various times during my career when I have had recourse to my medical defence union or professional bodies to seek advice or clarify legal and ethical issues in cases where difficult decisions have to be made. As a single individual I cannot be expected to know all I need to know to practise appropriately ethically and legally. I need to know where to turn for advice when I do not know or have doubts. A Code of Ethics and the people who are experts in these matters are key resources I require for my work. Utilizing such resources has the effect of improving my knowledge base, providing an opportunity to discuss with experts and peers complex problems and contain my anxiety. The end result is that I can then make a decision with some confidence that I do so within an accepted professional framework.
Whilst it may be true that in general terms psychotherapists and other professionals have some grasp of what is written in a Code of Ethics even though they may not have studied them, what is also true is that most psychotherapists have little knowledge of the legal framework within which they practise. The majority when asked whether or not it is illegal to have sex with a patient simply do not know the answer. This is shocking. It forms part of the Sexual Offenders Act. Similarly very few will know the law related to vulnerable adults even though many people seeking psychotherapy will fall within the definition of the act.
Additionally there is no reason why members of the public should be aware of the contents of any professional Code of Ethics beyond very general ideas. One female patient telephoned me between sessions to ask me out on a date. Rather thrown I replied lamely that she must know this was not possible. She very obviously stated that if she had known it was not possible she would not have asked. Later when we were discussing her feelings for me I said that it was better for her to have me as a therapist than a lover. She thought otherwise. One aspect of the thinking that guided my discussions with her during this phase of therapy was the knowledge that it would be an act of professional misconduct on my part to have entered into the relationship she was proposing. There are times when patients can put considerable pressure on professionals consciously and unconsciously which can lead to confusion in the professional’s mind and possibly to act in ways that would be harmful to the patient. At those times it is often the obvious that needs reaffirming.
There have been too many instances of professionals including psychotherapists engaging their patient in a sexual relationship for the problem to be ignored. There is probably no psychotherapy organization in which this has not happened. It is only when you see the devastating impact on a patient, and indeed the therapist, of such a relationship do you truly understand why this is proscribed within our Code of Ethics and why these things need stating. It is the obvious that can easily be lost sight of.
To my mind there are several other serious problems with this article. They lie not so much with what it actually says than with what it leaves out. It would at first glance be good to live in a world where the Nordstrom rule was all we needed. It would by the by be interesting to know how Nordstrom discipline their staff and what grounds they use for dismissal. Nordstrom is a different type of organization from one working with human suffering where different strains apply and different anxieties are aroused.
It is necessary therefore for us to take account of the question of the particular types of anxiety that are a fundamental aspect of our work and the fate of those anxieties both in terms of how a Code of Ethics might aid us in containing anxiety and the defensive processes we employ individually and as a profession which might become the basis for harming our patients sometimes through breaches of our ethical code. One of the major sources of anxiety is the uncertainty that runs through our work. As Dalal points out we can have little specific idea about how any therapy will turn out. We have little evidence beyond our own experience, which is essentially anecdotal, to help us. As a profession of analytic psychotherapy we have not helped ourselves in this by failing to engage in research and indeed in many instances being actively opposed to it, often on defensive grounds. Too few psychotherapists know the evidence base for our work or know how to interpret it.
We need a range of ongoing training and reflective practices and other aids to enable us to contain these anxieties. These include organizational processes, e.g. requirements for Continuing Professional Development that are sufficiently diverse to help us think about our work from different perspectives. Amongst these are such bodies as Complaints and Ethics Committees, which provide guidance as well as accountability as to what constitutes good practice. We all know that if we make a complaint we want to be sure the complaint is effectively investigated. Sadly psychotherapy organizations have often lacked the knowledge and capacity to manage serious complaints. This is partly why the UKCP has moved to a centralized complaints procedure.
Dalal, through some of the philosophical quotations, presents an optimistic view of human nature. Again it may be true that the majority know what is right and seek to live by it. But what of hate (Winnicott, 1958), envy, aggression and other destructive mental states we are all prey to? To this I would add ignorance and stupidity. Experience tells us knowing what is right by no means is the only determinant of our actions. There are all sorts of circumstances when we do what we know is wrong or fail to do what is right. I have seen many examples in cases of professional misconduct where from the beginning the professional knew what they were doing was wrong. Additionally there are those within our profession and indeed all other health and social care professions who for reasons of character pathology do not know what is right and behave entirely according to their own wishes, e.g. those with narcissistic character pathology. These people may be in the minority but they represent a serious threat to the people they purport to treat and to the reputation of the profession.
I am not sure that the application of cult thinking to describe processes that lie behind Codes of Ethics practice works as a critique. Cults suggests a religious fervour to which all members subscribe and actively take part does not seem to me to apply to this type of organizational problem. We already have within our lexicon group concepts, particularly those of basic assumption mentality, which provide a more relevant basis for understanding these processes. In particular Hopper’s work on traumatogenic processes as the fourth basic assumption (Hopper, 1998). Many health and social care organizations can reasonably be described as traumatized due to such factors as the overwhelming need, intimate contact with suffering and vulnerability to public criticism through the courts and the media.
Dalal raises the question of what happens to the transference after therapy stops in consideration of the code regarding sexual relationships with former patients. Let us remember that at a common sense level transference is a technical term describing the attachment between two people based on internal models laid down from experiences at crucial developmental periods of our lives. It is therefore not simply a matter of whether or not one believes in the transference and its vicissitudes but plainly obvious that like any other relationship patients may develop strong attachments to their therapists and vice versa, not all of which by any means will become conscious during the course of therapy and which may well be aroused many years later. This makes entering into relationships, particularly those of a sexual nature, with past patients a potential minefield.
Winnicott (Winnicott, 1951) reminds us of the profoundly uncomfortable responsibility which we carry as therapists because the dependency which patients exhibit towards us is absolute. Of course many therapists are not trained to work at this level and even when treating a patient who may present as needing to work in this way will avoid doing so both through ignorance of the necessary therapeutic attitude which is required to contain the anxieties inherent in such work and through the use of their own defences.
I have used the term patient throughout. I am a doctor but even when acting as a psychotherapist I continue to use the term patient. Dalal points to the difference between the terms patient and client citing that the use of the term client was brought about to reduce the power differential. I seriously doubt it has done so. One has only to think how much power a social worker has towards their clients in being able to deprive them of their liberty or remove their children. No term probably quite covers the psychotherapy relationship. Different terms carry different nuances but the power differential remains due to reasons of professional training, power of action, vulnerability, dependency and disclosure. The group has a democratic aspect embedded in its structure. Nonetheless it is only the group analyst who can make executive decisions and that when s/he does so excites persecutory anxiety in the group. Additionally the group as a whole is more powerful than the individual and therefore has the power to harm an individual. We can certainly act in ways, which reduce the misuse of our power but changing the terminology is not one of them. It does also raise the question of what we call ourselves. Dalal appears to dislike the retention of the term analyst which he equates to psychoanalyst and yet we are members of the Institute of Group Analysis. What else should we call it?
Dalal makes a somewhat caricatured description of the law, which to some extent we all recognize. However he is referring to the particular aspect of the law we tend to see most of through the media and leaves out for instance what happens in family courts which is of a quite different nature. The point here is that the family court has its focus as the well-being of the child. This is analogous to the Codes of Ethics of health and social care professions whose focus is the well-being of the patient.
Dalal takes issue that we are not in a position to inform clients about the nature of benefits and risks of psychotherapy before it begins. It is true that it is not possible to be specific about any particular advice. A patient who a year into therapy developed a gambling problem which has seriously undermined otherwise good work of the therapy is not something I could have warned him about. Nonetheless it is possible to talk in terms of what it is like to be in therapy, i.e. how frustrating it can be, how slow progress can be, how painful it can be, that it will bring to light difficult issues and may create tensions in relationships albeit hopefully in the service of creating a better adaptation to life. So we can say something about benefits and risks whilst reserving the right to revise whatever it is we have said in the light of later knowledge. This would appear to be a reasonable duty. A patient has a right to be given information on which to base their decision to enter therapy.
He concludes by challenging us to write a Code of Ethics that truly reflects the values of psychotherapy in general and group analysis in particular. It would perhaps have been helpful to have come up with some examples of what this might look like. I am not at all sure that a code of ethics for group analysis would look significantly different from other forms of analytic psychotherapy.
Dalal’s article overall raises concerns for me about how the profession of psychotherapy responds adaptively to the demands of regulation and accountability both within our health and social care organizations and society in general in private practice. In doing so we do have to ensure we do not lose the essential nature of what it is we do. What this constitutes is not clear. Group analysis holds a range of schools of thought under its banner as does the profession of psychotherapy as a whole. All too often it is the accretions to the therapeutic enterprise, which have come to be regarded as essential that are defended as if they have become the task itself.
As Dalal and I would I think agree writing, revising and putting into action a Code of Ethics is a complex task and never a finished article. I was disappointed at the number of people who attended the launch day. I think this in part reflects a lack of interest for defensive reasons in our ethical responsibilities. In this country as in many others there continues to be a blind eye turned to professional misconduct. It is now a matter of public concern regularly aired in the press. It is an important part of our professional responsibility to respond to these concerns with openness and at times contrition for our repeated failures in doing so.