A psychiatrist writes a letter to a journal explaining his decision to marry a former patient. Another psychiatrist confides that most of his friends are ex-patients. Both practitioners felt they had to defend their behavior, but psychoanalyst Arnold Goldberg couldn’t pinpoint the reason why. What was wrong about the analysts’ actions?
In Moral Stealth, Goldberg explores and explains that problem of “correct behavior.” He demonstrates that the inflated and official expectations that are part of an analyst’s training—that therapists be universally curious, hopeful, kind, and purposeful, for example—are often of less help than simple empathy amid the ambiguous morality of actual patient interactions. Being a good therapist and being a good person, he argues, are not necessarily the same.
Drawing on case studies from his own practice and from the experiences of others, as well as on philosophers such as John Dewey, Slavoj Žižek, and Jürgen Habermas, Goldberg breaks new ground and leads the way for therapists to understand the relationship between private morality and clinical practice.
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About the Author
Arnold Goldberg, M.D., is training and supervising analyst at the Institute for Psychoanalysis in Chicago, and the Cynthia Oudejan Harris MD Professor of Psychiatry at Rush University Medical School. He is the author of The Problem of Perversion; Being of Two Minds: The Vertical Split in Psychoanalysis and Psychotherapy; and Misunderstanding Freud.
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Moral Stealth How "Correct Behavior" Insinuates Itself into Psychotherapeutic Practice
By ARNOLD GOLDBERG
The University of Chicago Press Copyright © 2007 The University of Chicago
All right reserved.
Chapter One Setting the Stage
Paul Ricoeur, the French philosopher, defined ethics as "the wish to live well with and for others in just institutions." His is what he called a three-cornered definition, which unites the self, the other, and the third-party bearer in the judicial, social, and political planes (Hahn 1995, 51-52). For Ricoeur, morality concerned itself with the imperatives and prohibitions which thereby regulate ethics. For Ricoeur, ethics was more fundamental than any norm. It could be regulated by more than one set of rules.
Bernard Williams continues this line of thought with his suggestion that morality (the word derives from the Latin) should be understood as "a particular development of the ethical that has a special significance in modern Western culture. It peculiarly emphasizes certain ethical notions rather than others, developing in particular a special notion of obligation, and it has some peculiar presuppositions" (1985, 6). He states that ethical is the broad term, whereas moral applies to the narrower system. One special concept that belongs to morality is that of moral obligation. Williams says that this moral sense is the outlook of most of us and is directed at what to do in both general and particular situations. Once again, the moral is but one aspect of an overall ethical way to live.
The idea of duty encompassing prohibitions seems to make the moral domain a more useful way to think about the conduct of psychoanalysis and psychotherapy than the much broader field of ethics, which carries with it a good deal of the thinking of religious and philosophical concepts. It is certainly true that much talk about duties and obligations is subsumed under the so-called study of ethics, but a focus on duties, obligations, prohibitions, and imperatives might be better understood under the umbrella of morals and morality.
Morals can be considered as the aggregate of rules under which we live and under which we aim to live well. Living and working under rules and regulations often lend themselves to a set of customs which are taken for granted and may fade into the background. Not surprisingly, they only intrude into awareness at moments of uncertainty or in situations that lack clarity. A psychoanalytic focus on these rules would assign them either to a place in the superego if they are capable of eliciting a feeling of guilt if not properly followed, or else to a less affective experience if they are considered a function of the ego. This will be expanded upon in chapter 11. In the latter case the compromise formation formed by the varied agencies of the mind might well lead to a relative lack of distinctiveness of any such rule. Thus, one might feel that operating as an honest person is accomplished without thinking about it at all. This form of living well is automatic and never an object of self-scrutiny. If, however, it becomes a matter of examination and study, it can be singled out as a true example of a moral imperative. And once it is examined, the psychoanalyst needs to consider what, if any, unconscious determinants have contributed to this once silent but now openly delineated feeling of obligation. However, even beyond the noting of the unconscious contribution to this state, whether capable of producing a feeling of guilt or more comfortably functioning in the ego, there is a need to determine just how it fits in the rest of the personality. Honesty, for instance, may be accompanied by a feeling of pride, while dishonesty may be disavowed and not noticed at all. Thus, a failure to follow a rule, just as much as a submission to one, has a dimension that merits a separate psychoanalytic study. Of course, this form of inquiry should in no way, and by no means, necessarily be in conflict with the more far-reaching ethical considerations, but it may well result in questioning Ricoeur's insistence that ethics is fundamental.
Psychotherapy in comparison to psychoanalysis casts a wider net in its varied ways of functioning and thereby in its wider set of rules and regulations. Some of the suggestions made in the conduct of what is often called psychodynamic psychotherapy in contrast with cognitive-behavioral or other forms of psychotherapy are believed to either stretch or break the rules of psychoanalysis. Indeed, a debate frequently ensues when a suggestion for a particular modification in treatment is made, and the claim is raised that this modification has so broken the rules that it can no longer be called psychoanalysis. Here is an example.
In the words of Lichtenberg and colleagues, "A theory of deficit holds that for the patient to be able to progress developmentally, the analyst gives to the patient what the patient did not get. That is, the analyst 'provides' in response to the need the patient indicates. This provision can be in the form of verbal responses or other new relational expressions" (2002, 177). We shall have occasion later to examine the implications of this form of therapy, but it may be noted here that some argument could be formulated as to whether such "providing" qualifies as a proper technique for psychoanalysis. That, of course, is a definitional question, but it highlights the fact that disciplines and categories are often delineated by their rules and regulations.
If a psychotherapist champions the value of physical contact with a patient, regardless of the efficacy of such an act, it would probably either be classified as a countertransference problem or placed in a category outside analysis. Lichtenberg and colleagues write: "Susan and I held hands, face to face. We sat in silence, feeling the connection. I felt warmth, caring, and affection toward her.... Hand holding powerfully communicated that I cared for and valued her, an experience she sorely needed" (2002, 102). Earlier these authors had stated that this was a patient in analysis (p. 101), a characterization with which most analysts would probably take issue. This should serve to demonstrate that breaking the rules that might apply to one sort of activity may be considered perfectly acceptable under a different title. Indeed, jurisdictional disputes are not uncommon in the gray area between psychoanalysis and dynamic psychotherapy, and no agreed-upon referee seems available to settle the argument.
Of course, touching Susan would not in itself be thought of as an ethical or moral breach in most disciplines, but it does fall into the "slippery slope" danger (Gutheil and Gabbard 1993) that is somewhat variable from psychoanalysis to other forms of psychotherapy. At some point in this slope, the consensus imputes a moral mistake. At a certain point, that is, almost all would distinguish between what therapeutic conduct is defensible in terms of efficacy, such as that of touching, and what is morally prohibited, such as sexual intercourse. At times the distinction is made between ethical concerns and technical ones (Dewald and Clark 2001, 102-4), a good example of which might be a case of the analyst falling asleep. For some this is a moral breach, for some a countertransference problem, for some an enactment warranting an inquiry into the patient's participation in the event. The clear difference between the rules and regulations of ethics and the imperatives of morality is often subject to individual choice and preference. Rules are related to procedures, while morals regulate right and wrong.
There may therefore be an alternative position to the one proposed based on technical versus ethical, as in the possible debate between touching and more overt physical intimacy. That stance would insist that there are only technical actions to be reckoned with, and as long as an intervention works, it warrants a technical acceptance that takes it out of the ethical domain. This sort of argument could well open the door to a myriad of actions that would appear questionable or unacceptable to some, but it highlights the fact that the application and contents of "the moral" are idiosyncratic and dependent on a multitude of factors.
The idiosyncrasy of the moral system as it enters into psychoanalysis and psychotherapy is not always recognized as such. Rather, it leads to a variety of efforts to formulate a simple, standard way of behavior that applies to every therapist everywhere. This standardization of psychotherapy and psychoanalysis is in sharp contrast with a position that is more utilitarian, focusing on the effectiveness of what one does. Perhaps most therapists and analysts live and work in the space between these poles: one of certainty about moral correctness and the other of behavior that subserves the desire to help one's patients. This ambiguous space is the subject matter of the chapters to follow. The lack of certainty about morals coupled with the ongoing arguments about proper technique also offers an opportunity to avoid the entire controversy. That, too, is a call for clarity.
Chapter Two Positioning Psychoanalysis and Psychotherapy for Moral Concerns
The true injustice is always located at the place from which one blindly posits oneself as just and other as unjust. -Zizek 2004, 79, quoting Adorno
From stem cell research to the experimental cloning of humans, from debates over abortion to the selection of offspring by genetic screening, from sex-change surgery to the casual use of human growth hormone, science is hard-pressed to disentangle itself from moral and ethical issues. Psychoanalysis is an active participant in the debate, inasmuch as it has been variously condemned as an activity intent on undermining morality, as having nothing whatsoever to do with morality, or as itself offering a cogent ethical theory. The first position is represented by Ian Gregory, who says, "Man may achieve a certain guile in pursuing his satisfaction, i.e., he becomes subject to the reality principle, but his end is always the same, his own gratification. He is, in short, wholly self-absorbed, utterly selfish, not capable of forswearing instinctual satisfaction" (1979, 102). Gregory feels that Freud was committed to a narcissistic position that embraced the thesis that everyone pursues his or her own self-interest. Heinz Hartmann (1960) took a slightly different position with his contention that moral evaluations are beyond the analyst's competence and task, and so moral values when they enter into treatment must be accorded the same status as any other facts. Ernest Wallwork is equally convinced that Freud, and so too all psychoanalysis, has a moral psychology that "suggests a social ethic in which the individual is committed to social life, first by an extended egoism in which reasonable social rules are viewed as a long-run practical benefit to the self, and second by an understanding that participation in the community ... is experienced as a good and pleasure in and of itself" (1991, 29). From one extreme to the other, psychoanalysis is unable to definitively position itself in terms of its ethical status, although this uncertainty is by no means due to a lack of scholarly opinions.
From the perspective of the first group, the practicing analyst would be pursuing an essentially immoral position by encouraging or enabling patients to pursue their own selfish and hedonistic desires. The "guile" that Gregory refers to is but the ego's better way of adapting to the demands of civilization, but that adaptation is in no way to be credited with any sort of altruism. The second group, much supported by many practicing analysts, would sidestep both the accusation and the responsibility of a moral stance. These therapists belong to the "we just work here" contingent and so might claim that analysis may lead to selfish behavior in some patients but may also result in a number of more socially aware and caring persons. This group feels that the process of analysis is not a linear pursuit with a predictable result, and therefore one cannot adopt a particular end point of optimal functioning applicable to everyone. Yet the third perspective challenges this escape from culpability, and insists that morality is built into the system. This last group concludes that there is a mature view on the workings of the pleasure principle so condemned by those who merely stress hedonism. This view takes happiness as the general aim of life, and recognizes that the Freudian position is not a simple one of drive gratification, but a more complex one involving self-scrutiny. Drive sublimation takes into account the demands of society and one's own conscience. Morality here is the very business of psychoanalysis.
The ways that morality and psychoanalysis relate to each other intersect with considerations of theory and practice: is a moral factor applicable to both how one functions as an analyst and how one's own moral proclivities may free or constrain one in theory and in practice? If a particular analyst has firm ideas about how people should or should not behave, it is unlikely that he or she would embrace the first or initial position that espouses selfishness, but it may be equally unlikely that "happiness" would be considered a proper aim for the good life by this or any other analyst or therapist. Indeed, it is one thing to dissect a Freudian take on ethics, as Wallwork (1991) has so eloquently done, and quite another to encompass the variety of personal views about ideal behavior espoused by psychoanalysts, ethicists, and philosophers.
As we move beyond the work of Sigmund Freud to the multitude of post-Freudian contributions, there are, inevitably, additional moral components to the theory and practice as well as to the theoretical positions of the persons involved. Ideas about narcissism that have been developed and put into practice drastically challenge claims about the inherent amorality of psychoanalytic theory. Burgeoning theoretical contributions having to do with countertransference and intersubjectivity barely allow for Hartmann's plea for the objectivity of psychoanalysis. But, perhaps most important, the modifications of psychoanalysis brought about by psychodynamic psychotherapy have forced an examination of the makeup of psychoanalysts and patients alike. We now worry not only about the personality of the therapist but also about what may be best for the wider variety of patients seen in therapy and analysis.
Both positive and negative considerations have an impact on the moral embeddedness of psychoanalysis. One example of the first is the assigning of certain qualities of character to analyst. Stephen Mitchell says,
We tend not to speak or write much of the analyst's hope as such, because that sounds too personal somehow. The analyst is portrayed as professional, providing a generic service that helps when applied properly. But we all know that it is much more personal than that, that the analyst's hopes for her patient are embedded in and deeply entangled with her own sense of herself, her worth, what she can offer, what she has found more meaningful in her own life. The more we have explored the complexities of countertransference, the more we have come to realize how personal a stake the analyst inevitably has in the proceedings. It is important to be able to help, it makes us anxious when we are prevented from helping or do not know how to help. Our hopes for the patient are inextricably bound with our hopes for ourselves. (1993, 207-8)
This moves a giant step away from the neutral position espoused by Hartmann by introducing the dimension of the analyst's self-worth and his stake in the treatment. We seem to have entered a world that enlarges and makes more central the moral dimensions of psychoanalysis.
Submitting to Morality
A negative aspect of our revised concern with morality is in our preoccupation with boundary crossings and boundary violations. By no means were ethical breaches absent or unknown in the psychoanalysis of Freud's time, but there can be little doubt that they seem to have remained relatively unnoticed or even dismissed in that era. Not so today. We have introduced courses on ethics in psychoanalysis, and we have formed boards and committees to deal with ethical violations. There are extensive guidelines developed as a Code of Ethics by the National Association of Social Workers and a list of Ethical Principles of Psychologists and a Code of Conduct by the American Psychological Association, along with The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry by the American Psychiatric Association and in parallel, the American Psychoanalytic Association Principles and Standards of Ethics for Psychoanalysts. These guidelines instruct one on how to behave with respect to issues such as confidentiality and informed consent, as well as on how to handle misbehavior ranging from plagiarism to sexual harassment. In a not so subtle way these guidelines all make it clear that moral issues and moral behaviors have a standing that is overriding and undeniable. Yet as Nietzsche has warned us, "Submission to morality can be slavish or vain or selfish or resigned or obtusely enthusiastic or thoughtless or an act of desperation, like submission to a prince: in itself it is nothing moral" ( 1982, 81). There can be little doubt that the mental health professions compel us to submit to morality. Our ethics casebooks state that their aim is to guide conduct, but typically invoke standards and expectations that are foundational. We are expected to be truthful and responsible, to avoid exploitation, and to protect the public. We have no choice, nor should we. But choice may not be the problem.
Excerpted from Moral Stealth by ARNOLD GOLDBERG Copyright © 2007 by The University of Chicago. Excerpted by permission.
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Table of Contents
PART I: THE CONFRONTATION BETWEEN CLINICAL PRACTICE
AND MORALLY CORRECT BEHAVIOR
1. Setting the Stage
2. Positioning Psychoanalysis and Psychotherapy for Moral Concerns
3. Moral Stealth
4. The Moral Posture of Psychoanalysis and Psychotherapy: The Case for Ambiguity
PART II: DIFFICULTIES IN RECONCILING
CORRECT BEHAVIOR WITH PSYCHOANALYTIC
AND PSYCHOTHERAPEUTIC PRACTICE
5. A Risk of Confidentiality
6. On the Nature of Thoughtlessness
7. I Wish the Hour Were Over: Elements of a Moral Dilemma
8. Psychotherapy and Psychoanalysis and the Problem of Ownership: An Effort at Resolution
9. Who Owns the Countertransference?
PART III: THE CONTINGENCY OF CORRECT BEHAVIOR
10. Another Look at Neutrality
11. Deontology and the Superego
12. Choosing Up Sides
13. Making Morals Manifest