ETHICS IN PSYCHOANALYTIC PRACTICE
The drive to state regulation often appeals to the notion of ethics, but attempts by psychotherapeutic training and registration bodies to enforce ethical behaviour in line with the demands of the state, or what organisations imagine the state demands, may only serve to bind its practitioners all the more firmly to dubious unethical practices. To untangle the 'ethics' that is being assumed in these debates we can start by identifying some of the problems with theoretical vantage points on ethics in Western culture, then we might know better what assumptions we may unwittingly fall into when we attempt to formulate an ethics appropriate to psychoanalytic work. Then, against this background, we can outline some elements of ethics in psychoanalytic practice.
A first common approach is one that presumes that we can all agree what a 'Good' is that we should be aiming at and against which we can easily define what falls below it as the ideal standard. This is a notion of ethics that we find in Aristotle onwards. There are, of course, theoretical frameworks in psychotherapy that would be compatible with this notion of the Good and of ethics. Specifications of essential underlying human nature, perhaps deriving from the secular humanist tradition, for example, would presume that we do know what it is to do right and wrong. The idea that a therapist can have an objective sense of their qualities, both rational and irrational, for example, buys into this approach to ethics.
The problem is that once we start to take psychoanalysis seriously the perception of the Good is thrown into question. The Good is not something that already exists somewhere to be intuited and aimed at, but it is something that is constructed by us. First because it functions as an ideal which we set up ourselves based on our own idiosyncratic experience of what is delightful and alluring to us, an image of what we would like to be or a point from which we would like to seen as likeable. And second because every notion of the Good that we too easily conflate with what is beautiful to us, is suffused with fantasy. What may be good to us as an ideal that is suffused with fantasy, then, may turn out to be quite horrific to other people.
The second approach appeals to an imperative to follow the right course of action, which we assume to be potentially if not actually present in each individual human being. This is the way of Kant, and the categorical imperative, in which we are asked to assess our action according to the maxim that we should imagine it to be carried out by all other human beings, applicable to them; this maxim is designed to bring some measure of universality directly into the moral decision-making of any particular individual. Again, this is an ethical paradigm that we can imagine certain traditions in psychotherapy adopting with ease. The image of the person as containing within themselves a conscience by virtue of which they are able to participate in a society as a civilised enlightened human being can then even be translated into certain psychoanalytic models of the personality that psychotherapists sometimes draw upon. Here, images of 'the public', 'norms' and 'good practice' are compressed into the idea that there is some shared moral framework that we should all adhere to.
The problem with this approach, which operates according to some notion of the existence of conscience under law, is that some people who carry out the most horrific actions do themselves feel themselves to be following some version of a moral injunction and to be in conformity with what human nature is like.
The third approach is concerned with the calculation of goods, of costs and benefits of actions for different individuals. This is the universe of Jeremy Bentham, which presumes that it is possible to determine what will be good for people and bad for them and to arrange roles and responsibilities so that the greatest possible good is distributed among them. Again, psychotherapy includes enough models of human behaviour to warrant this version of ethics. Here, some of the strands of work in the cognitive-behavioural tradition, which seem to refuse to adopt a specific moral standpoint, do actually rest on notions of what healthy and unhealthy patterns of behaviour are and how contingencies of reinforcement might be set up to bring benefit to people. The assumption that a 'mapping document' could lay out the field of therapeutic practice in a clear and objective manner, and that we could draw up criteria for the 'evidence' that would make our activity understandable and predictable is part and parcel of this notion of ethics.
The problem with this approach is that it rather conveniently overlooks what the stakes are for the individuals or groups that arrange the distribution of goods. Some neutral position outside the system is presupposed so that decisions can be made which are not themselves affected by certain benefits. Psychoanalysis, which is one of the most intense reflexive conceptual frameworks, would ask what the individual who arranges things gets out of it. And the problem lies not so much at the level of particular decisions as at a deeper systemic level - structurally distributed powers - in the very position accorded to those who will decide.
Critical appraisal of these three approaches to ethics is a ground-clearing exercise. It is not possible to do psychoanalytic clinical work if you operate on some ideal image of the Good, if you intend to strengthen conscience and conformity, or if you try to calculate the costs and benefits of actions.
Against these common taken for granted ideas about ethics, psychoanalysts make some quite different assumptions about the nature of the person we see in our clinical practice and the nature of the work. The human subject is divided between conscious experience and the unconscious, and the unconscious is itself divided and resistant to being understood. We can identify here six elements of ethics in psychoanalytic practice.
First, the individual subject is complex rather than 'integrated'. While the illusion that integration of the self may be a comforting one, it is one that we question in our work. The nature of the unconscious, and its presence in every conception that a person has about themselves, not least in psychotherapy, is crucial to all forms of psychoanalysis.
Second, dignity for the analysand may not correspond to society's ideals. The contradictory ideas that someone has about 'dignity', and for who they may or not be dignified, are powerfully at work in the unconscious, and particular to each person's history.
Third, the analysand will mostly not want to know about their suffering. Psychoanalytic work attends to defences against knowledge of the unconscious, which includes complex and painful desire for the very suffering that the analysand may declare themselves to want to be released from.
Fourth, the demand for happiness needs to be put into question. Not only do we not know what happiness really is for each different person, but each person is all to ready to conform to the happiness that others demand them to enjoy, and this introduces a dynamic in the therapeutic relationship that we must attend to rather than simply confirm.
Fifth, psychoanalytic work engages with the painful nature of suffering rather than aiming to remove symptoms. The symptoms speak of deeper more wide-ranging issues, and it is only by approaching those unconscious issues that it may be possible for someone to be able to question the way symptoms give some consistency to their lives.
Sixth, the process is a long one that does not aim to patch things up quickly. The most immediate solutions are the ones that precisely lock most neatly into already existing patterns, and it is only by exploring the way a hope for certain kinds of 'patch' functions that we can begin the psychoanalytic work.
These six elements have implications not only for how we approach the clinical work, but also for how we respond to regulatory bodies who would like psychoanalytic practitioners to respond to their demand that we provide them with unambiguous answers about what we do and how will guarantee that what we do is right. There can be no such guarantee, and to pretend that there is such a guarantee would risk endorsing the worst commonsensical approaches to ethics that are usually invoked in this culture.
Psychoanalytic reflection on ethics outside clinical practice, reflection that takes a critical position with respect to the approaches that flow from Aristotle, Kant and Bentham and rests upon the critical elements outlined here, can help us think about the implications of state regulation for our work. One example is to be found in the work of Alain Badiou, in a book first published in French in 1998 and then in English in 2001 titled Ethics: An Essay on the Understanding of Evil. Badiou develops a critique of dominant paradigms in ethics and sets out some coordinates for rethinking what the relation is between ethics and evil. This relation does not presume that people will be evil unless they are regulated, but explores the way in which certain conditions, including certain notions of ethics, set the stage for evil to appear. For Badiou, evil arises in three ways.
First, through 'simulacra' (fake copies of events which close things down, as when the ethics committee replaces the careful thoughtful deliberation of the researcher with its own bureaucratic procedures), Second, through 'betrayal' (giving up and turning against what was opened up, as when the early ideals of the research are abandoned because they are too difficult and when awful reports are produced which normalise and pathologise behaviour). Third, through 'absolutization' (enforcement of an overall scheme to force agreement, as when interpretations are made which pretend to apply to all those involved in the research and which are extrapolated to all the others who are assumed to be like them).
The state does offer a framework for ensuring quality control that will guarantee that we will never be abusive, but while this framework uses a rhetoric about 'ethics' it is actually a simulacrum, it relies on the betrayal of those who have become disappointed with the attempts to resist and will now turn against those who are sceptical about the benefits of regulation, and it instates one framework that will apply to every practitioner.
We cannot, and should not pretend that there is one simple answer to the questions we are posed, that we know exactly what it is that best for the analysand, or that the analysand will simply tell us what is wrong with them so that we can put it right. We cannot make people happy, and we cannot remove the obstacles to happiness. The answers that we provide to inquiries about our practice will necessarily be difficult to formulate, and it is not possible to provide quick formulations to statutory bodies that fill in all the gaps in their understanding about what we do. Holding open that space for those complex issues is to hold open an ethical space against state regulation.
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