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|Ethical Dilemmas in the Analytic Relationship|
|Congresses - 2004 Barcelona|
|Written by Claire Allphin|
Definition of an Ethical Attitude
An ethical attitude encompasses the formal codes of ethics within the professions, but it is more complex than just following the rules. Ethics codes are needed in order to protect patients from exploitation. An ethical attitude is necessary because rules and regulations do not adequately cover the dilemmas that occur in the analytic relationship, issues that need to be considered and struggled with that often have no clear “right” answer.
Hester Solomon (2001), a Jungian analyst in London, writes that an ethical attitude should be an intrinsic part of the analyst’s self. In the intimacy of the analytic relationship the protection of the development of the patient’s self is primary. The analytic attitude therefore must be an ethical attitude. An ethical attitude implies behavior toward the other that is altruistic. Concern for the other is not based on reciprocity, but rather on selfless behavior (p. 447).
An ethical attitude requires the ability to hold the opposites, to deal with ambiguity and paradox, not to split. It may mean suffering the uncertainty of having said or done something that was “against the rules,” such as non-sexual physical contact with a patient, not reporting a threat a patient makes against another person, taking goods such as artwork instead of money, for treatment.
Origins of the Ethical Attitude
The importance of ethics is a theme throughout Jung’s writings, though he did not write much explicitly about the subject (Proulx, 1994). Jung considers the struggle to become conscious of the shadow aspects of oneself as essential to an ethical attitude. Moral development involves working to become conscious, to withdraw projections from others. (Solomon, p. 446).
Hester Solomon (2001) suggests that the environment of the infant may be basic to the development of an ethical attitude. When the infant is held without fear of retaliation or without too much need to placate others in order to survive, it develops securely, developing toward a self that has the freedom for authentic expression of complete humanness. When these conditions are not present, development of an ethical attitude may be impaired. Solomon also thinks the capacity to develop an ethical attitude may be partly innate. The development of the capacity for an ethical attitude is influenced by the environment and the caregiver’s ability to respond meaningfully to the self of the infant (p. 447). This suggests that achieving an ethical attitude depends on having had the experience of being related to ethically.
Qualities of the Ethical Attitude
Working as a analyst requires an ethical attitude. This is a challenge because it involves unsolvable dilemmas, uncertainty, suffering, and shame. It involves feelings that must often be suffered and held, sometimes never erased. An ethical attitude means questioning decisions, being respectful of the views of others, and doing no harm. But, how do we know when we are doing harm? How can we be sure in our work that we are not influencing people in ways that are not helpful, and may even be harmful?
Jung writes in his introduction to Erich Neumann’s book, Depth Psychology and a New Ethic (1969), that when someone has a strong sense of what is ethical and important in life, the person is likely to come into conflict with others and perhaps with oneself. The conflict is what brings a person to a greater sense of what is and is not ethical. When there is conflict we are forced to look within, thereby learning more about the negative sides of ourselves and becoming more related to what is unconscious (p. 17).
Solomon argues that there is a need for a written code of professional ethics when we or our colleagues are charged with unethical behavior, but being human means not just blindly following a code of ethics. It requires the pursuit of truth, justice, and the development of imagination which one develops through reflecting philosophically using internal resources that lead toward making a choice to speak or not, or to do or not (p. 444).
According to John Beebe’s description of integrity in his book, Integrity in Depth, (1992) integrity is a fundamental quality in an ethical attitude. He writes that the psychoanalyst has two basic obligations; to protect the patient’s self-esteem, and to protect the setting as a place where healing can occur (p. 20). His description of what he calls “the dialectic of integrity,” (p. 24) depends on endless self-questioning that is driven by uneasiness in the questioner. Uneasiness is signal anxiety alerting one that the self is in danger, that a vital relationship is threatened. He notes that integrity is standing up to the shadow and also dealing with emotions of uncertainty (p. 35).
Integrity’s relationship to an ethical attitude is clear. They seem synonymous. However, the idea that the capacity to develop an ethical attitude may come from having been treated ethically in infancy seems less probable if we think about ourselves and all the people we know who have had very bad early life experiences with primary caregivers. That the capacity for an ethical attitude is innate may be so. Not infrequently people who have been badly treated are especially skilled at taking good care of others, seeming to know what others need by what they did not get themselves as children. We all know people who were terribly mistreated as children that are very understanding, attuned, and helpful to others.
We are often in ethical dilemmas regarding confidentiality. Certain reporting is now required, but we are still in an ethical dilemma; we still have to decide whether or not to report. In Jan Weiner’s paper, “Confidentiality and Paradox: The Location of Ethical Space” (2001), she notes that Bollas and Sundelson (1995) believe that following the law to report is not therapeutic for the patient. They believe breaking confidentiality by reporting is betraying a central axiom of the analytic method. The analyst needs to protect confidentiality and bear the agony of this stance (p. 436). This relates to Weiner’s idea of finding an ethical space to process issues that are more complex than ethical codes and regulations, a “third position” where the subjective and objective can have a space to give each its due (p. 431). She quotes a line from Rattigan’s (1946) The Winslow Boy: “… it is easy to do justice, but much more difficult to do the right thing” (Weiner, p. 440). This comment is in line with the difference Carol Gilligan (1982) proposes between a morality of care and a morality of justice. Following the rules is the most obvious way we “do justice.” A decision based on concern for the other is related to the idea expressed in “doing the right thing.”
Many of us break confidentiality when we talk about patients to close colleagues without permission from the patient. We usually do this when we are in a complex or in a countertransference enactment and desperately need help. These breaches are done with care and concern for the patient; they are not about gossip, but rather occur because of some agony we are in, in relation to the patient. We want to talk the problem over with someone we trust who knows us well. We want help so we and our patient can come to a better relationship with one another. Usually when this occurs, there is guilt and worry about the process; sometimes it works well, and sometimes it does not, such as when two analysts each seeing one member of a couple are each taking sides with their own patient. However, when this occurs it may be able to be understood in terms of the dynamics of the couple, helping each of the analysts to work more effectively with their patient. We are, however, breaching confidentiality and need to carry the anguish about this, as Bollas and Sundelson say about carrying the anguish when confidentiality is tightly held to the point of not reporting what the law requires us to report.
What about when we write up a case for a paper presentation or journal? Some analysts will not write about patients, others ask permission, others disguise cases well, or make up a composite case. Is getting permission from the patient really informed consent?
However if we do not talk and write about our work how do we learn from one another and how do we develop our skills as analysts? Reading and hearing about how others work is an important way to learn about the process of the analytic relationship. Talking with colleagues about our work with patients helps us understand and resolve difficulties in our analytic relationships.
In her paper, “What Comes Out of the Consulting Room? The Reporting of Clinical Material,” Barbara Wharton (1998) suggests that a too-rigid stance against publication of clinical material may have to do with the analyst’s anxiety about self-exposure rather than anxiety about exposing the patient. She concludes her paper about her experience of re-reading what she has written: “The act of looking again at what I have revealed of myself, and the way in which it falls short of the ‘perfection’ I had hoped for, puts me in touch, very painfully, with a narcissistic vulnerability which may be concealed in many of us.” (p. 222)
Glen Gabbard writes in his paper, “Disguise or Consent,” “… the more I have studied the problem, the more I am struck by the [irresolvable] nature of the challenges posed by presenting and publishing clinical material. Tuckett (1998) emphasized that psychoanalysts must frequently confront [irresolvable] conflicts that can only be negotiated on a highly individual and moment-to-moment basis. Such is the case with dilemmas involving disguise and/or consent” (p. 1084).
Self-disclosure presents another ethical dilemma. Many of us are self-disclosing to one degree or another. Having an ethical attitude means using self-disclosure for the benefit of the patient. Some self- disclosures arise from our own need to talk and be seen. These are times when an ethical attitude brings us to an examination of the process and curiosity about what may be occurring between the patient and analyst in the moment as well as what has stirred the analyst’s narcissism in the moment.
Current thinking about the psychoanalytic relationship with its emphasis on mutuality has opened the door to self-disclosure as an important aspect of the healing process. Some of the thinking includes considering the patient’s comments about the analyst’s self-disclosure as part of the patient’s development. For example, if a patient has said or done something that angers the analyst, the analyst may acknowledge the anger toward the patient as a way to help the patient understand the patient’s impact on others. There are also notions that the patient is an observer of the analyst and needs to be able to comment on the analyst’s disclosures about him or herself as a part of the relationship, that the analyst needs to validate or clarify the patient’s ideas about the analyst as a way for the patient to become more trusting of his or her inner experiences. An ethical attitude means the analyst participates in this process with uncertainty, with an openness to critical review of the process and with self-scrutiny so that care and concern for the patient remain primary.
Owen Renik (1995), writes in “The Ideal of the Anonymous Analyst and the Problem of Self-Disclosure,” “… an ethic of candor, implemented via self-explanation, applies as an overarching technical attitude (alongside whatever other criteria an individual analyst brings to bear when making decisions about self-disclosure)” (p. 495). He considers self-disclosure, which he defines as the analyst saying what his/her experience is of the patient, to be central to the healing process in psychoanalysis.
Miscellaneous Ethical Dilemmas
Here are other situations that pose ethical dilemmas. What about when the patient talks about something he or she is doing that is illegal? If I question the patient’s integrity, I am judging rather than holding a neutral stance. My decision to question the behavior may come from my own over-scrupulosity rather than integrity, or from my fear of getting caught, or fear of my patient’s getting caught. What is an ethical attitude in relation to this kind of situation? For example, what if the patient steals, or uses illegal drugs, or is a drug dealer?
When a patient wants to end analysis and the analyst does not think he or she is ready this is often an ethical dilemma. Does the analyst want the patient to continue because he or she needs the money? Does the analyst want the patient to continue because the analyst will feel abandoned if the patient leaves and the analyst cannot tolerate that feeling? All of these may be issues at the time the patient wants to end about which the analyst needs to be conscious and struggling, which is having an ethical attitude.
Owen Renik, in his 1995 (p. 470) paper about self-disclosure, and Jan Weiner in the book she edited Supervising and Being Supervised (2003 p. 227), point out another area to be thought about as an ethical dilemma; the tendency in contemporary psychoanalysis to view all that is occurring within the analyst as relating to the patient’s experience rather than considering the analyst’s inner experience as related to his/her own individual psychology.
An ethical attitude often involves struggle, shame, uncertainty, anguish, and other feelings that are hard to tolerate, but must be embraced. A balance between subjectivity and objectivity has to be part of an ethical attitude. Rules and regulations, though very important to follow, are not always adequate for the complex situations of the analytic relationship. Integrity and morality are basic to an ethical attitude. Morality (knowing right from wrong) develops through relationships; integrity involves struggling with complex issues within ourselves.