Blurts & Spasms

Thanks for the question, Jeff.

I’d say “that depends.” It depends on the the training of the therapist, their level of moral development, their own personal ethical praxis, and the system within which the therapist is practicing. This introduces a lot of variables. For a client-centered practitioner who is forced to maximize client load and minimize interaction time in service to group practice profitability, corporate cost-saving mandates, or a paucity of insurance coverage for their chosen modality, all but the most bare-boned moral and ethical assumptions can practically be followed. And even then, it may only be according to the letter of the law, rather than its spirit. That said, the APA has developed a very robust Ethical Principles and Code of Conduct: https://www.apa.org/ethics/code/

Given that some methods like CBT and DBT have a mountain of evidence to support their efficacy, one could conclude that “all that really matters is to effectively teach these helpful cognitive behavioral tools, and the rest is up to the client’s willingness and compliance.” And there are certainly many therapists who either lack the internal psychosocial makeup to transcend this position, or who become exhausted enough by the constraints of for profit practice, that they arrive at this pragmatic distance from their clients.

But there are many therapists — and I would argue the really “good ones” — who recognize that their practice is really about relationship. That relationship has boundaries, to be sure, but it is deeply empathic, deeply committed, deeply involved in the client’s well-being. It is authentically engaged in the client’s perspective and felt reality, rather than merely prescriptive. And it is actively adapting to the client’s individual needs, rather than treating them as another cookie-cutter application of proven principles. In short: it embodies love.

In this latter, and arguably rarer, case, the unspoken moral and ethical assumptions run much deeper that the APA guidelines. The relationship isn’t just about client benefit, avoiding harm, and navigating a maze of laws — that’s a given. It is also about compassion, attentiveness, empathy, and a profound honoring of the client’s agency and personhood. And why is this considered important — if not critical? Because most “good” therapists know that a client’s trust, openness, and empowered agency are not just sacred and precious in the abstract, but are also primary factors in healing, growth and transformation itself. These features of the client relationship will contribute to potential outcomes in much more enduring and arguably richer and more fundamental ways.

So on the one hand there is the efficacy of technique, and on the other there is the efficacy of relationship. Whether this position is a common or not I will leave for others to judge and comment upon. I would say, however, that it is essential.

My 2 cents.

Comment from Jeff Wright:

I wonder if you’d be interested in taking it another step (because I could not make this more explicit in the original question)—

What are the unspoken moral and ethical assumptions that delimit what is and is not in the APA guidelines (since they represent a kind of social consensus reality orthodoxy about the relevance or absence of such themes within mainstream practice)? What would “run much deeper”?

This involves your highlighted themes of client, agency and personhood, so there are embedded implicit ideas about the nature and extent of those notions. And I believe those are the key points in any (deconstructive or reconstructive) inquiry into the sociology or philosophy of psychology and its practical applications. I was going to say “clinical applications” but that is a good example of a relevant tacit assumption.

And to put this in a less abstract frame, are you aware of ways that practicing therapists engage these questions in their own work, with or without the ability to articulate them?

To further answer the deeper, tacit moral and ethical assumptions question, here are some possibilities — perhaps not universal, but I suspect pervasively involved once again with the better/best therapists:

Client independence from care. That is, a level of health, wholeness and harmony that allows the client to be free of any form of mitigation or ongoing clinical support.

Client happiness and equanimity. Beyond mere increases in function, a desire for the client to feel fulfilled, at peace, etc.

Client momentum towards emotional growth and moral maturity. There are inevitably more profound evolutions in people when they engage thoughtfully in self-aware therapy. The hope is that they will really “grow up” beyond the infantilized and/or traumatized state in which they first presented. More than independence from care, this is about self-transformation.

Most importantly, that the therapist does not interfere with any of these liberating processes and conditions, but actually facilitates them earnestly and devotedly.

Comment from Jeff Wright:

Thanks. These are good statements of the main positive ideas of humanistic psychotherapy, the ideals of the “better/best therapists”.

However, tacit ethical assumptions are not limited to positive and aspirational ideals, the traditional moral focus on virtues, the “this is our best version of who we want to be”. They also embody negatives or shadow features. It’s possible I think that practitioners who work in public service settings are probably both more embedded in these and more aware of them, compared to those in private practice who work with voluntary, aspirational clients (“improve my life” or “suffer less”, or “be happier”).

There are assumptions that are widely operative within psychology and psychotherapy that express a “medical model” (based on various forms of scientism) pathology, disease, mechanization, depersonalization, individualization, disconnection and isolation of the person from their family, world, depoliticization, a turn away from social issues, and so on.

To understand some of these themes, one thing we can do is look at what gets initially emphasized and more easily carried forward through a paradigm change. For example, there were attempts at spiritualization in psychotherapy (a.ka. “transpersonal”), which never became mainstream, and more successful attempts to import ideas from Buddhism (e.g. “mindfulness”), and now more recently, “positive psychology”, which seems more successful at gaining traction in research-oriented psychology.

All true. I think what you’re touching on becomes much more specific with the modality/philosophy of care involved. Some are more somatic while others focus on relationships; some incorporate transpersonal considerations while others focus on cognitive-behavioral tools. With so much variation, it becomes difficult, I think, to make broad generalizations about pervasive moral and ethical assumptions. But it’s worth a try nonetheless!