Morality and Psychotherapy

[Studious]

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We had a grand rounds recently on the interplay of cultural issues between the therapist and the patient. The lecture centered on "cultural humility," or the idea that since you can't fully understand another person's culture, you are in no position to make a moral pronouncement upon them. Furthermore, judgment only inhibits therapy.

I certainly agree with the last statement. However, throughout the lecture, various psychiatrists/psychologists were invited to share a case which exemplified what was being discussed. One such example was a patient who thought corporal punishment to the point of leaving welts was okay. The psychiatrist disagreed vehemently, saying that whether a spank left a welt/bruise vs. some erythema was the dividing line between abuse and simply discipline. He finished his story by saying that, in retrospect, he realized he didn't understand how "honor cultures" worked and that he should have been more inquisitive.

My question is, if we're going to bring this morally relativistic attitude to therapy with individual patients, how can we ever say something is "bad?" What about the duty to report (e.g., Tarasoff), etc etc? Furthermore, does this mean that professional organizations or individual therapists cannot take a public stand in societal debates concerning moral issues? How do these things interact? I understand the therapist has certain duties imposed upon him by the law, but what role does morality play in the bigger picture of psychotherapy?

 

[whopper]

It's difficult to define what is acceptable or not in such a nebulous field.

I can tell you that I do think here are some guidelines psychotherapists should use.

1) Be honest about limitations: Don't promise that psychotherapy can do something it cannot per studies.

2) Don't make assumptions based on circumstantial evidence: E.g. don't tell the patient it's their own fault they can't get a job when the patient tells you they applied to three jobs and didn't get one yet. That's not enough information and if people operated on circumstantial evidence all the time, there'd be a heck of a lot more ignorance in the world. If you suspect the patient is the cause, a better way to bring this up is asking, "There's a reason why you didn't get the jobs. Help me to understand" as a start.

3) Be supportive or not, know when: It's not your job to always validate the patient. If the patient admits to raping someone, of course you shouldn't say something to the effect of "Oh that's terrible for you. Don't let it bother you."

As a forensic psychiatrist, I was placed in the position of literally telling patients who committed crimes not due to mental illness that I would in no way support their attempt to get an not guilty by reason of insanity defense, or basically say something to the effect of "You broke the rules, there's no excuse for this, you're getting an injection."

It's your job to be honest, and try not to let your personal feelings get in the way and react in the manner that is appropriate. For most patients that will be supportive, but for others it will not be. If you're going to give the patient a reality talk, make sure you got your Ts crossed and Is dotted because if you get harsh on them and you're wrong, you're likely causing harm, something doctors aren't supposed to do.

4) Don't recommend patients do something unless you have good reasoning behind it: I know a doctor that had a patient with PTSD, and he told her that to get over it, she had to face her rapist in a confrontational manner. The rapist was not in prison or in a hospital and she occasionally saw him in a local store. When I found this out I flipped out. What was to prevent this rapist from raping her again? What grounds did he have to believe this confrontation would actually therapeutic? Would the victim do something illegal such as shoot the rapist?

This guy obviously didn't know what he was talking about. I know who this guy is and he has an M.D. and knows really nothing about psychotherapy, but thinks his license gives him knowledge he doesn't have nor really had any training in.

5) Be able to diagnose the patient and at least have a direction where the therapy should go.

 

[Ibid]

We had a grand rounds recently on the interplay of cultural issues between the therapist and the patient. The lecture centered on "cultural humility," or the idea that since you can't fully understand another person's culture, you are in no position to make a moral pronouncement upon them. Furthermore, judgment only inhibits therapy.

I certainly agree with the last statement. However, throughout the lecture, various psychiatrists/psychologists were invited to share a case which exemplified what was being discussed. One such example was a patient who thought corporal punishment to the point of leaving welts was okay. The psychiatrist disagreed vehemently, saying that whether a spank left a welt/bruise vs. some erythema was the dividing line between abuse and simply discipline. He finished his story by saying that, in retrospect, he realized he didn't understand how "honor cultures" worked and that he should have been more inquisitive.

My question is, if we're going to bring this morally relativistic attitude to therapy with individual patients, how can we ever say something is "bad?" What about the duty to report (e.g., Tarasoff), etc etc? Furthermore, does this mean that professional organizations or individual therapists cannot take a public stand in societal debates concerning moral issues? How do these things interact? I understand the therapist has certain duties imposed upon him by the law, but what role does morality play in the bigger picture of psychotherapy?

Sure in some cultures a man can hit/discipline his wife as long as he does not leave a mark. Although I don't suppose that was what they were getting at.

Caveat emptor comes into play here. The patient has some responsibility to decide if the therapist is the right therapist for them as well.

 

[billypilgrim37]

I certainly agree with the last statement. However, throughout the lecture, various psychiatrists/psychologists were invited to share a case which exemplified what was being discussed. One such example was a patient who thought corporal punishment to the point of leaving welts was okay. The psychiatrist disagreed vehemently, saying that whether a spank left a welt/bruise vs. some erythema was the dividing line between abuse and simply discipline. He finished his story by saying that, in retrospect, he realized he didn't understand how "honor cultures" worked and that he should have been more inquisitive.

In most locales, you would have a legal obligation to report suspected child abuse. I've talked to some private practice psychodynamic MDs who say flat out they would not do this (i.e. would break the law), and I believe the American Psychoanalytic Association basically says it's better to go to jail than to violate patient confidentiality. So, people disagree about these things. I think you're better off using a little common sense and a little bit of thoughtfulness about moral relativism. This would be less of an issue in a less psychodynamic psychotherapy, as I don't think there's really any part of CBT that says that you have to be open to your patient abusing a child.

Being culturally sensitive is one thing. Being permissive of things that our culture thinks are dangerous, criminal, etc. are another.

 

[Studious]

Good points. Thanks so far for clarifying.

However, where do we draw the line? Flagrant crimes (e.g., murder, child abuse, etc) are obvious, but what about more controversial areas of personal morality (e.g., abortion, homosexuality, racism, terrorism, religion)? Should the therapist simply act as an agent of the law but in all other areas remain morally neutral (if such a thing is possible)? Or is there a separate morality that actually supersedes the law - and thus that's why we report a patient if we find out he's abusing his daughter but not if he's regularly smoking pot (i.e., the relevant morality in this case would actually be harm of others, not necessarily any and all law-breaking). If the ladder is true, how does this mesh with law in general? Who decides?

 

[whopper]

The APA doesn't endorse negative attitudes against things such as homosexuality, religion or race, however, they are a professional organization and cannot force people to practice in a specific way, so a psychiatrist could pretty much do anything so long as state boards don't take away their licenses.

State medical boards tend to be reluctant to take action against doctors,even ones that are flagrantly violating professional ethics, so you really could practice within a wide berth. (Not that I agree with that....it's actually something that bugs the heck out of me).

But to not sidestep the question, and to give you a more direct answer, issues like this are tackled within residency training. The APA and AMA also provides guidelines on several ethics and those are the ones taught in residency and considered norms that are usually used in court should it get to that point.

 

[Studious]

But to not sidestep the question, and to give you a more direct answer, issues like this are tackled within residency training. The APA and AMA also provides guidelines on several ethics and those are the ones taught in residency and considered norms that are usually used in court should it get to that point.

I'm certainly looking forward to these types of conversations in residency. Does this mean that the AMA and APA guidelines can actually overrule law? Going back to my previous example, what makes it required that we should report a child abuser but not a drug abuser except that harm of other persons is involved in child abuse, and therefore law-breaking in general isn't the primary standard?

I'm not trying to find a reason why we should avoid reporting child abusers, or a reason why we should report all minor infractions of the law, but I just wonder how this is philosophically and legally consistent.

 

[cleareyedguy]

"Cultural humility" strikes me as deskilling, unprofessional, and actually a sort of faux-humble arrogance. I know there are major medical centers where they seem to spend as much time on cultural humility, paperwork, and/or pedagogy as they do on psychopharm and psychodynamics, but that just strikes me as wrong headed and dumb.

I MUCH prefer to view my perspective as culturally curious, whether my task is psychotherapy, an evaluation, or whatever. I do have personal biases about a whole range of things, and I'm fairly well versed about the law, and so I think I'd know that I'd have a responsibility to clarify the law with the welt-giving spanker (and not just be passively humble that the spanker lives in a different subculture from my own), but I'd also believe it should be done with timing and tact rather than an attitude of knee-jerk condescension/criticism.

I'm also actually a therapist who prefers to spend 45" a week or more with each patient, which allows for greater depth of connection, which can allow for greater understanding and trust so that when I make a fairly subtle inquiry about spanking (or an affair or unscrupulous work behavior, etc), our alliance allows that to be grist for the mill rather than an inquisition. Further, in most cases (the rapist example is one I've never seen in real life; most of my "offenders" haven't done anything a cop would care about), I AM genuinely curious about developing an understanding of the patient's perspective, in developing empathy, and then trusting that the patient will figure it out. A few things trump the whole process (child abuse, a planned act of violence), but they are rare. Further, there is a legitimate concern that if we report people for their fantasies, then they won't reveal their fantasies; that's where judgment comes in, and it's sometimes not easy to tell what it means when a patient says he (it's usually a he) is going to do something bad to someone else.

People frequently toss out the evidence based card for such therapy, but there is plenty of evidence for psychodynamic psychotherapy; it's odd that people seem to reject its relevance, but there's no question that it works. Perhaps one concern people on this board have is that psychotherapy is difficult to learn, generally improves with training beyond residency, and--unless you develop a niche or live in a place where people pay a premium-- pays less.

To get back to ethics, the AMA and APA do actually supersede governmental law. By joining our profession, you have signed on to obey our local laws, and if you transgress, you can be punished. Some of the laws are more strict because it's a privilege to be a physician. For example, you can sleep with any willing, capacitated adult human on the planet, unless you're a professional doctor, lawyer, etc. Of course, our punishments tend to be wrist slaps, but they are embarrassing.

Anyway, off the high horse and back to work...

 

[nitemagi]

"Cultural humility" strikes me as deskilling, unprofessional, and actually a sort of faux-humble arrogance. I know there are major medical centers where they seem to spend as much time on cultural humility, paperwork, and/or pedagogy as they do on psychopharm and psychodynamics, but that just strikes me as wrong headed and dumb.

I MUCH prefer to view my perspective as culturally curious, whether my task is psychotherapy, an evaluation, or whatever. I do have personal biases about a whole range of things, and I'm fairly well versed about the law, and so I think I'd know that I'd have a responsibility to clarify the law with the welt-giving spanker (and not just be passively humble that the spanker lives in a different subculture from my own), but I'd also believe it should be done with timing and tact rather than an attitude of knee-jerk condescension/criticism.

I'm also actually a therapist who prefers to spend 45" a week or more with each patient, which allows for greater depth of connection, which can allow for greater understanding and trust so that when I make a fairly subtle inquiry about spanking (or an affair or unscrupulous work behavior, etc), our alliance allows that to be grist for the mill rather than an inquisition. Further, in most cases (the rapist example is one I've never seen in real life; most of my "offenders" haven't done anything a cop would care about), I AM genuinely curious about developing an understanding of the patient's perspective, in developing empathy, and then trusting that the patient will figure it out. A few things trump the whole process (child abuse, a planned act of violence), but they are rare. Further, there is a legitimate concern that if we report people for their fantasies, then they won't reveal their fantasies; that's where judgment comes in, and it's sometimes not easy to tell what it means when a patient says he (it's usually a he) is going to do something bad to someone else.

People frequently toss out the evidence based card for such therapy, but there is plenty of evidence for psychodynamic psychotherapy; it's odd that people seem to reject its relevance, but there's no question that it works. Perhaps one concern people on this board have is that psychotherapy is difficult to learn, generally improves with training beyond residency, and--unless you develop a niche or live in a place where people pay a premium-- pays less.

To get back to ethics, the AMA and APA do actually supersede governmental law. By joining our profession, you have signed on to obey our local laws, and if you transgress, you can be punished. Some of the laws are more strict because it's a privilege to be a physician. For example, you can sleep with any willing, capacitated adult human on the planet, unless you're a professional doctor, lawyer, etc. Of course, our punishments tend to be wrist slaps, but they are embarrassing.

Anyway, off the high horse and back to work...

I'm with ya, cleareyedguy. There's many approaches. CBT I believe is a bit more of a concrete approach, which is why it appeals to so many.

 

[dl2dp2]

"Cultural humility" strikes me as deskilling, unprofessional, and actually a sort of faux-humble arrogance. I know there are major medical centers where they seem to spend as much time on cultural humility, paperwork, and/or pedagogy as they do on psychopharm and psychodynamics, but that just strikes me as wrong headed and dumb.

People frequently toss out the evidence based card for such therapy, but there is plenty of evidence for psychodynamic psychotherapy; it's odd that people seem to reject its relevance, but there's no question that it works. Perhaps one concern people on this board have is that psychotherapy is difficult to learn, generally improves with training beyond residency, and--unless you develop a niche or live in a place where people pay a premium-- pays less.

I would argue that cultural humility, "systems based practice" and "how to teach" are very important things to learn. And as to the evidence basis for psychodynamics, we can just agree to disagree my thesis: out of all of the psychotherapeutic modalities, long term psychodynamic psychotherapy probably has the weakest evidence basis.

I actually disagree with the assertion that psychotherapy is harder to learn than psychopharm. And I disagree that you make less money doing psychotherapy--it's just that you are willing to charge less.