May Ethical Codes Be Unethical?
The focus of this brief paper is on the ethical issues raised by certain authors who argue that the rigid, unreflective implementation of ethical codes may unwittingly militate against good clinical practice when working with specific client populations, for example those with dissociative identity disorder (DID) or learning disabilities. This ethical issue has important implications, not only for the client groups alluded to above but also in clinical work with clients in general; that, on a continuum, these issues and dilemmas apply to all therapists involved in a therapeutic relationship.
It is generally acknowledged that ethical guidelines, limit-setting and the maintenance of the therapeutic frame are all necessary prerequisites for undertaking therapy in a safe and boundaried environment, both for the client and for the therapist. As therapists we work from the necessary injunction “do no harm”. But might this slide into a defensive mind-set of “take no risks”? As Feltham (2007) suggests, if the therapist plays everything by the book, employing a set of rigid prescriptions to maintain the frame, à la Langs (1988), the space to develop a humane, intersubjective relationship may be foreclosed, leaving the client with a sense of having been abused by a too rigidly correct therapist. The “take no risks” approach may end up breaching the “do no harm” injunction – in effect, the treatment becomes iatrogenic.
Following Feltham (2007), I think it helpful to openly acknowledge that every close relationship is potentially risky – that no therapeutic relationship can be guaranteed to be problem free. De Zulueta (2007) makes this point forcefully, stating that “. . . any caring relationship . . . is potentially vulnerable to being abusive (p xi).” Given this, professional regulatory bodies have a clear ethical duty to make policies and vigorously police practice to protect clients from abuse and boundary violations. Achieving a balance between professional hysteria and harsh policing and punishment on the one hand and a laissez-faire approach that would undermine the profession on the other is no easy matter. The tradition of built-in supervision is an added safeguard. But where do boundary violations start and finish on a continuum of seriousness, and who decides (Feltham, 2007)?
In this context, I recall Margot Sunderland musing aloud during her presentation at the Bowlby Memorial Conference on Touch in 2003 as to whether there may be an army of secret touchers out there! Does giving a distressed client a comforting hug at the end of a painful session constitute a boundary violation? For some therapists the answer would undoubtedly be “yes”, for others I suspect that it would be a resounding “no”. The theoretical orientation of the therapist may also be a pertinent consideration here, in that a body therapist is likely to employ touch as an ongoing part of his or her clinical work. All too frequently, the context is given insufficient weight. For example, the dilemma involving touch may become particularly poignant when working with a client who has a learning disability, as movingly described by Linington (2007). Flexibility about issues of confidentiality may also arise with certain clients, in terms of the need, at times, to liaise with other professionals and/or family members.
Similar taboos and controversies exist in the field, for example about the issue of disclosure. Mann (1997) writes about the therapist’s erotic desires for the client. While he is sceptical about the merits of disclosing such sentiments to the client, he nevertheless argues that the therapist’s erotic subjectivity needs to be openly recognised to lessen the risk of his or her sexual desires being enacted with the client. He suggests that it is precisely because both participants may, on occasion, experience the therapeutic relationship as a cauldron of intense emotions, fantasies and desires that therapeutic boundaries need to be studiously maintained.
Central to the questions raised by authors arguing for a relaxation of ethical codes is how professional bodies define abuse and the scope of boundary violations (Feltham, 2007). Are these set too rigidly, to the extent that they may constitute unethical practice? Is there a need for greater flexibility, particularly in respect of individual clients with specific needs and difficulties in living? Might the relaxation of the therapeutic frame unwittingly put vulnerable clients, such as those described by Linington (2007) and in the literature on DID, at greater risk of abuse?
There are no easy answers to these complex issues, but Herman (1992) points up some of the transference and countertransference enactments that therapists invariably become ensnared in when working with clients who have particular needs and a history of severe trauma and dissociation.
In ‘Trauma and Recovery’, Herman (1992) sets out what she calls traumatic or vicarious countertransference. She suggests that trauma is contagious and may overwhelm the therapist. One among several reactions to this situation is the therapist’s need to defend against unbearable feelings of helplessness. Thus, therapists who ordinarily are scrupulous in observing the limits of the therapeutic frame may find themselves violating the bounds of the therapy relationship and assuming the role of a rescuer, thereby disempowering the client. Under the intense pressures of the traumatic transference and countertransference, the therapist may take on an advocacy role for the client, feel obliged to extend the limits of therapy sessions, allow frequent emergency contacts between sessions and answer phone calls late at night or when on vacation. Herman (1992) points out that the therapist’s defence against feelings of helplessness may lead to a stance of grandiose special-ness or omnipotence, with the attendant risk of extreme boundary violations, up to and including sexual intimacy. Such violations are frequently rationalized on the basis of the client’s desperate need for rescue and the therapist’s extraordinary gifts as a rescuer.
In a similar way to Herman (1992), Davies and Frawley (1994) delineate eight positions, as expressed within four relational matrices. These positions, roles or self-states may be alternately enacted by the therapist and the client in the transference-countertransference matrix. They include the uninvolved non-abusing parent and the neglected child; the sadistic abuser and the helpless, impotently enraged victim; the idealized, omnipotent rescuer and the entitled child who demands to be rescued; and the seducer and the seduced. The authors view dissociation as existing on a continuum, with DID representing the most extreme form of mental defence against severe, protracted trauma. Dissociated traumatic experience is particularly susceptible to being enacted in the intensity of the therapeutic relationship.
Davies and Frawley (1994), Herman (1992) and de Zulueta (2007) all argue that traumatic transference and countertransference enactments are inevitable and that these may interfere with the development of a good working relationship. Paradoxically, as the Relational literature shows, non abusive enactments may lead to profound therapeutic change, enhancing a sense of felt security and the capacities for affect regulation and reflective functioning or mentalization. Crucially, the outcome depends on how the enactment is worked with in the therapeutic relationship – can it be contained and collaboratively explored, validating the client’s subjective reality and, thereby, provide a shared, co-constructed emotional experience as the rupture to the working alliance is repaired, or will it replicate past abusive relationships and re-traumatize the client?
As Searles (1959) notes, successful work depends on the therapist recognizing and reciprocating the client’s transference love without acting on these feelings. Ogden (2004) makes a similar point in observing that the quality of intimacy developed in the real relationship between the client and therapist will include feelings of enlivening humour, camaraderie, playfulness, compassion, healthy flirtatiousness and charm. Given these considerations, Herman (1992) suggests that the two most important guarantees of safety for both participants are the goals, rules and boundaries of the therapy contract and the support system of the therapist. The latter should include a safe, structured and regular forum for reviewing the therapist’s clinical work, such as a supervisory relationship or a peer support group. This view is also emphasised by de Zulueta (2007).
So, to sum up, therapy is an inherently intense, intimate and risky business. Trauma, like madness, is contagious, that is, it is transmitted interpersonally. Mutual reciprocal influence on both a conscious and unconscious level of mental functioning is continuously in operation, for good or ill. Therapist and client get drawn into inevitable transference and countertransference enactments on a continuum of seriousness under the sway of non conscious internal working models, unresolved trauma and mutual dissociation. Enactments can be a force for therapeutic change or a vehicle for re-traumatization. This dichotomy is succinctly summed up by Kernberg (1995) who, in discussing the erotic aspects of the transference and countertransference, notes that “There is probably no other area of psychoanalytic treatment in which the potentials for acting out and for growth experiences are so intimately condensed” (p. 114).
Clearly, then, safeguards are required! The therapeutic frame includes an adherence to ethical codes and guidelines designed to protect the client from abuse and boundary violations. These are reinforced by regular supervision and membership of a peer support group. Maintaining the frame in a consistent and ethically boundaried way may allow the client to feel sufficiently safe and free to develop, explore and express erotic and aggressive feelings in relation to the therapist, thereby providing grist to the therapeutic mill. The frame, then, provides a containing structure and creates the conditions for attachment security and the symbolic elaboration of dissociated and unmentalized wishes, desires, fears and affects deriving from unresolved trauma, loss, neglect and abuse. Conversely, breaching the frame by, for example, adopting a position of omnipotent rescuer may unwittingly disempower the client and foreclose on opportunities for therapeutic change.
All of this is relatively clear, but legitimate questions about the way in which ethical codes are implemented remain open to debate, namely “How rigid or flexible should ethical guidelines be, and to what extent, if at all, should they differ for different groups of clients?” and “May the defensive adherence to ethical codes lead to practice that is not only unethical but also iatrogenic in respect of clients with particular individual needs and differences?”
Davies, J.M. & Frawley M.G. (1994). Treating the Adult Survivor of Childhood Sexual Abuse. New York: Basic Books.
Feltham, C. (2007). Ethical Agonising. In Therapy Today, Vol. 18, No. 7, 4-6.
Herman, J.L. (1992). Trauma and Recovery. New York: Basic Books.
Kernberg. O.F. (1995). Love relations: Normality and pathology. New Haven, CT & London: Yale University Press.
Langs R. (1988). A primer of psychotherapy. New York: Gardner Press.
Linington, M. (2007). Being Disabled: Psychotherapy with a Man with Cerebral Palsy and a Learning Disability. In Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, Vol. 1, No. 3, 259-268.
Mann, D. (1997). The Psychotherapist’s Erotic Subjectivity. In Psychotherapy: An Erotic Relationship. London: Routledge.
Ogden, T. (2004). The analytic third: Implications for psychoanalytic theory and technique. Psychoanalytic Quarterly, 73, 167-195.
Searles, H.F. (1965). Oedipal love in the countertransference. In Collected papers on schizophrenia and related subjects. Madison, CT: International Universities Press.
de Zulueta, F. (2007). The Perversion of the Professional Caring Relationship. In Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, Vol. 1, No. 3, vii – xii.
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