THOUGHTS ON ETHICS, PSYCHOTHERAPY AND POSTMODERNISM

Sonja Snyman (DPhil) & Robyn Fasser (MA)

Abstract The purpose of this article is to describe some postmodern implications for the ethical conduct of therapists. In our opinion, one of the overriding implications is the increase in the ethical responsibility held by therapists. In a context that rejects objectivity, redefines boundaries and broadens the notion of the client, the buck stops with the therapist. Consequentially, with an increased emphasis on the ethical responsibility of therapists training, curricula and ethical codes have to be revisited. This article is a postmodern discourse. In deconstructing the text, the reader engages in and assigns meaning to, it. This process is an echo of the therapeutic relationship, in which therapist and client engage each other and assign meaning to the texts presented in therapy. All behaviour in this dynamic relationship has ethical implications that therapists need to manage. Thus, the postmodern therapist is the ethics.

From modernism to postmodernism As psychotherapists in South Africa, we are fortunate to have been knocked off our ivory perches. Unwittingly, we have been given the opportunity to experience, on an hourly basis, the dynamics of a postmodern world. From our consulting rooms, where our paradigms are challenged by the diversity of world-views that cross our thresholds, to the multi-theoretical content of seminars and conferences, to the multi-cultural emphasis in therapist training, we are forced to reconsider what we do and how we think. And, in the process, a different realm of understanding is bound to evolve. This process is running concurrently with changes in Western thinking (Simon, 1991). The question is: Are we experiencing a modern moment, namely a moment of crisis or reckoning in which it becomes self conscious as a period (Foster, 1985, p. viii), or have we entered a new period? According to Cantor (1988, p.401) the intellectual homeland that we seek can no longer be Modernism We have been, as it were, shut out of paradise by the cultural residue of the political, economic, and military upheavals of this [20th] centuryWe cannot return to it as a cultural entity, as theory for today Modernism is our past, not our future. Hence our Eurocentric assumptions are being tested. Throughout the Western world, previously unquestioned truths are being challenged, and new ways of thinking are emerging (Capra, 1982). These erstwhile unassailable truths intrinsic to the modern age, which was characterised by an incessant search for unity and absolute knowledge, were underpinned by the sovereignty of reason, rationality, objectivity and empiricism. Modernity created a singular perspective and a legacy that has shaped the indisputable principles that guided Western thinking and relating. A particular set of rules directed what is called Cartesian/Newtonian,

Occidental or Western thought. Based on a system of logic developed in the Age of Reason, this paradigm hinges on three rules of thought: the Rule of Linear Causal Process, the Rule of Pejorative Dualism and the Rule of Certainty (Auerswald, 1992). In this model, there was certainty about the one reality: objects and objective ideas existed substantively in an infinite and separate time and space; space was three-dimensional and time linear. Also, objects and ideas were ordered hierarchically according to form, activity or some set value (Auerswald, 1992), resulting in inherent power relations in all spheres of reality, society and interpretation. Furthermore, in this thinking, there was an acceptance of an everyday reality that was reducible to quantifiable, provable elements that were experienced, in exactly the same way, by everyone. In the 1950s and 1960s, the critical discussions within the field of philosophy of science spearheaded the challenges directed at modernistic, foundationalist thinking. This was underpinned by discoveries and developments in modern physics, technological advances such as cybernetic networks, and the proximity of change in the shrinking of a previously disassociated world into a globally interconnected one. The certainty of the modern epoch has given way to change and relativity; uncertainty and unpredictability have become the order of the day. Ultimately, the Western Weltanschauung is moving away from a linear, reductionistic, mechanistic and absolutist view towards a postmodern discursive reality (Hare-Mustin, 1994). While modern discourse strives towards a rational explanation of the world, assuming that rationality has a universal validity which enables us to develop a Grand Theory about reality (Degenaar, 1994, p. 2) postmodern discourse manifests itself in an ironic relationship towards all claims to finality whether based on myth or reason. (Degenaar,

1994, p. 2). This implies that postmodern thought assumes that there is a plurality of ways of understanding. Hence, postmodernity refers to an age which has lost the Enlightenment ideal of progress and emancipation, through meta-narratives and increased systems of knowledge (Kvale, 1992). It indicates an era in which society has become decentralised, heterogeneous, local and flexible. Postmodernism is more interested in a process, in the interpenetrative experiences that weave contemporary culture. Postmodernism is a perception of relatedness that rejects reduction ... It is not a thing one can find out there, but a relation that runs through all things, in art, production, consumption, public policy, and in the minds of people. (Amiran & Unsworth, 1994, p. 5). Postmodernism is not a consciously directed movement. Wakefield (1990) attests that in the process of trying to define, describe and name postmodernist happenings, one runs the risk of building a structure that does not exist and in no way wants to exist. We run the risk of creating a coherence of what are elusive, nebulous and de-centred narratives in time. He goes on to state: "The semantic

complexity of the term 'postmodernism', its ability to elude or withhold definition, testifies not to any lack of meaning but rather to the fact that meaning has been dispersed or redeployed across a much larger site of struggle and contestation" (Wakefield, 1990, p. 20).

The therapist in a postmodern world Psychology, and with that psychotherapy, as historically practised in South Africa, is a Western cultural enterprise. Psychology is a child of modernity (Kvale, 1992). As a child of modernity psychotherapy forms an indissoluble part of the modern project in its aim, which mirrors the modernist objective to liberate the creative forces of the inner person; in

its in-depth focus on the psyche of the individual; in its clinically circumscribed method; in its attempt at developing a comprehensive theory; in the therapeutic relationship that emulates the modernist belief in a detached expert position; and in its assertion that from such an expert position of knowing it is possible to uncover the truth about the nature of the problem. Given the above parameters, truth and its discovery then become a viable option for therapists, provided they are scrupulous in their method of investigation. This epistemological stance leads to what Keeney (1979, p. 118) calls psychiatric nomenclature and the classical medical model of psychopathology which results in the reification and labelling of human behaviour according to singular descriptions. Under these circumstances, modern therapists have to present themselves as scientists, and, as such, view themselves as independent observers with no expectations other than to uncover what is an objective truth regarding the client. The assumption is that, provided therapists apply the applicable theory correctly, the objective truth would be discovered (Chaiklin, 1992). The existence of this truth, coupled with the therapists skill (method) at uncovering it, was fundamental to the practice of therapy. Furthermore, it was believed that such a truth would be uncontaminated by the personal biases of the therapist. As a result, the erstwhile expert position of the therapist was unquestioned. Postmodern thought asks psychology whether these notions of objectivity, one truth, one theory and expert position can be accepted unequivocally (Kvale, 1992). At its most fundamental level, the paradigm shift (Capra, 1982) that has emerged in Western thinking and culture encompasses a shift from notions of truth to those of significance and meaning on the one hand, and from the notion of one reality to a

multiplicity of perspectives on the other (Howard, 1991). This shift has significant implications for therapy. Today, many therapists believe that the art of therapy involves deconstructing and reconstructing the stories that clients bring to therapy. The therapists role of listening and responding to the clients story is akin to the deconstructive reading of a text (Derrida, 1986). Deconstructive thinking denies that there is a single fixed meaning in texts (stories) and purports that texts can generate a variety of meanings. It is furthermore acknowledged that meaning is not inherent in words and things. Meaning is brought to things and situations through articulation and interpretation. An assigned meaning is always the perspective of a perceiver. The known is always the by-product of the knower. We therefore cannot speak of what we know as distinct from ourselves as knowers. According to Bateson (1951), the perceiver imposes an order, on his external world, that fits with his belief system. One might call this ones epistemological stance. It means that each time we make an observation, we choose an epistemological position. Meaning is created through the interaction between self and world, writer and reader, observer and observed as well as therapist and client (Gergen, 1994; Degenaar, 1986). As carriers of meaning, therapists bring certain meaning structures to the field of therapy. This means that their preconceptions and assumptions will inform and structure the content and process of therapy - and thereby edit it. As such, therapists need to be attentive to their personal and cultural assumptions, which are in turn informed by their taken-for-granted Weltanschauung and by their way of thinking about reality. How we hear, how we listen, what we understand as well as the questions we ask are all informed by our basic belief system. This implies that the underlying world-view inherent in a therapeutic approach will determine the parameters within which a therapist will assign meaning. In practice,

meaning is deconstructed in the therapeutic language of the therapist. For example, using constructs like false self, idealisation, projection and part-objects will unwittingly guide therapists towards understanding and interpreting their clients behaviours in terms of the notions of splitting, phantasy and projection. By taking responsibility for our thought systems, by questioning our presuppositions and by acknowledging our epistemological positions, we further acknowledge the ethical basis of our therapies. Ethics and the ethical code of conduct in the healing professions are now more important than ever. However, as Wassenaar (1998, p.140) points out with the growing national and international diversification of psychology, no single code of ethics will anticipate all of the contexts in which psychologists will work, particularly in a rapidly changing South Africa. In such a context therapists are compelled to engage the field of ethics in a dynamic and personalised manner so that the therapist is the ethics.

The ethical implications of a postmodern reality for therapy With the acceptance of an expert/learner position and with no singular standardised method in which to ground psychotherapy, the role of postmodern therapists is far more complex than that of their modern counterparts. The complexity of the role translates into a the buck stops here responsibility and accountability on the part of the therapist. The onus of circumscribing therapeutic practices, on the one hand, and ensuring that ethical parameters are adhered to, on the other, rests with therapists more than ever. This discretion necessitates an ongoing ethical self-monitoring and evaluation. The following discourse on objectivity, boundaries and who the client is, looks at some of the ethical implications for postmodern therapists.

Objectivity and ethics Keeney (1982) describes the indivisible world as one of form and pattern. For postmodern therapists, this means that a system (or problem) is the function of a distinction drawn by an observer (therapist). It also implies that a system does not exist in reality, but that it exists in the world of form, and that it comes into being through the act of languaging. In Brian McHales words, the post-modern exists discursively in the discourses we produce about it and in using it (in Amiran & Unsworth., 1994, p. 5) Such a conversational domain is an ecology of ideas and exists through dialogue, distinguished by linguistic markers. It is, therefore, a meaning system that evolves from our shared, cognitive and linguistic discourses (Anderson & Goolishian, 1988, p. 372). A therapy system is similarly one that is coalesced around some problem (Anderson & Goolishian, 1988, p. 372): it is a meaning system created by a problem (Hoffman, 1985), a problem-determined system. The therapist is an observer-participant and co-creator of such a therapy system. The implication of this for therapy is that there are no set facts about the individual or family that exist independently of the therapists observations. For postmodern therapists, this lack of objectivity and its concomitant uncertainty results in the increased importance of ethical choice. As observer-participants, therapists in a relationship with their client, are ethically obliged to acknowledge that their observations and interventions are as much personal edits as they are a function of the clients presenting problem. For example, a therapist may describe the aetiology of a presenting problem as either neonatal or anxiety based, depending on how he/she makes sense of the problem. This understanding will guide the therapist to ask certain questions, respond non-verbally

in particular ways and in so doing unwittingly and regularly identify specific problem descriptions. Furthermore, Polkinghorne (1992, p. 158) points out that successful therapy is carried out by practitioners who give allegiance to various theoretical systems treating them as models or metaphors. A lack of awareness of these therapeutic influences in steering the therapy has ethical implications in that therapists may make assumptions that result in a label being treated as the truth. For example, a child who presents with scholastic problems and sees an ADHD specialist may exit the therapy with a confirmed diagnosis of ADHD. Although the diagnosis of ADHD may well be valid within the framework within the DSM IV diagnostic categories, the fact that the fathers of four of his school colleagues were killed violently in the past year was not factored in constitutes an ethical transgression. The ethical implication is that a singular description presented as the truth will lead to a singular solution, which may be limiting. The client in this instance may not be afforded all the appropriate solutions that could maximise his/her improvement. Aside from the influence of being observer-participants, the ethical challenge is further complicated by the fact that therapists perceptions are underpinned by personal values regarding gender, sexual orientation, class and ethnicity, etc. According to Bateson (1951, p. 176), the network of value partially determined the network of perception. For example, therapists who value family over the individual may inadvertently focus on promoting the continuation of the marriage rather than the specific needs of the individual. Another example is Whites (1995) stance on accountability that is elucidated in his approach to working with men who abuse. He believes that as a male therapist he needs to, with his client, accept accountability for the abuse that men perpetrate against women. For

him ethical accountability means that the therapist makes it clear to the clients that he sees himself as being basically part of the same culture from which the abuse has taken place (White, 1995, p. 158). The implication is that therapists who are members of a dominant culture need to take responsibility for the power relations and subjugation, associated with that group, and for what these associated marginalized clients may experience, or may have previously experienced. In this regard Freedman and Combs (1996, p. 266) speak of a margin-in approach to ethics one which values the experience of people at the margins of any dominant culture [by] making space for such peoples voices to be heard, understood, and responded to.

Boundaries and ethics In a dualistic and hierarchical reality, clear distinctions are drawn between categories and classes, and the relationship between such categories is often defined by power. Psychotherapy was conceived in a world where clear power differences circumscribed the relationship between therapist and patient. Therefore, the inherent power differentiation in the therapeutic relationship was further confirmed and entrenched by the modern worldview. In practice, therapists maintained their therapeutic stance of interpersonal distance by endorsing these power differences. This made the therapist-patient boundary virtually impermeable. By contrast, in the interconnected postmodern world power relations have become contentious and with that the clearly circumscribed power differentiation between therapist and client. In the absence of a hierarchical external structure, on the one hand, and as learners who define themselves as part of the therapeutic system, on the other, postmodern therapists need to set boundaries more than ever before.

However, these boundaries should be based on functional role differences and not on power. For example, such differences may entail using expert knowledge to facilitate the process of therapy while at the same time being a learner in terms of the clients story. In a world woven together by networks and connections, boundaries are permeable and the possibilities of crossing such boundaries in interpersonal interaction abound. Blurred boundaries can distort the professional nature of the therapeutic relationship and impair therapists judgement. This can lead to a potentially exploitative situation and in turn bring ethical issues into play. For example, the ethical management of a properly bound therapeutic relationship would preclude socialising with a client or consulting with acquaintances or relatives. The question is how is this different from the position of the modern therapist? Where the boundary was previously predetermined by the definition of the power relationship between therapist and client (which served as a static professional standard), postmodern therapists have the onerous responsibility of employing their discretion regarding professional boundaries. Hence, ethical decisions become a dynamic part of the professional conduct of therapists in every therapeutic engagement. For example, modern therapists would seldom self-disclose. However, self-disclosure for postmodern therapists could serve to help to normalise the clients perception of his or her problem. The ethical decision in choosing to self-disclose would be at the discretion of the therapist and would rest on what he or she felt was in the clients best interest. In multi-client therapy, the ethical dilemma of managing boundaries becomes an issue. For example, in couples therapy, the decision to see the individuals, parallel to the ongoing couples therapy, requires an understanding of changing boundaries on the part of the

therapist. The potential exists for the boundary that forms around the couple to be diluted by the intervening boundary that occurs around the therapist and the individual in the parallel therapy. Hence, there should not be an assumption that any of the therapies are immune from bias, alliances and collusion. The result of this understanding compels therapists to be even more aware of their own position in order to maintain an ethical stance.

The client and ethics The individual and his or her psychological well-being has been the nucleus of traditional psychotherapy. Freudian psychoanalysis, which was conceptualised at the height of Western individualism, focuses on individual personality dynamics. The primacy of the individual was further endorsed by the pervading acceptance of Kantian ethics, emphasising the needs and rights of the individual. The question arises whether in therapy, by prioritising the individual over his/her relationships and family, the welfare of these relationships is not subjugated and thereby negated. And more specifically, for the purposes of this article, what the ethical implications of the modern/individual approach are. Since the 1950s, clinicians and theorists, looking beyond the individual in their endeavour to understand behaviour, have found that behaviour can be better understood when seen in context (Bateson, 1978). The advent of systems and relational perspectives has brought about a contextual view of the client. This is a movement away from seeing an isolated individual to seeing the individual in context, couples, families and organisational teams (Hoffman, 1985).

This raises certain critical ethical questions, for example: Who is the client and whose interest must the therapist serve in multiple-client therapies? Does the therapist have an ethical responsibility to those partners or members not partaking in the therapy? Ethics of relationality may serve to address some of these emerging issues. In a survey conducted on the issue of individual versus relational morality, Wall, Needham, Browing and James (1999) found that although the dignity, worth, needs and autonomy of the individual were recognised by the majority of the marital and family therapists interviewed, a preference, for what the researchers call relational ethics, was evident. In the research, the therapists less frequently endorsed an ethic of being true to the unfolding potential of ones inner self than they did an ethic of creating and fostering loving and caring relations (Wall et al., 1999, p. 144). These results imply a morality that not only commits individuals to self-actualisation but also to their attachment to others. Given the above developments, it is helpful to compliment the Kantian individual ethic with an ethic of relationality. This means that one would prioritise and value relationships, act towards others as you would like them to act towards you, maintain responsibility not only to oneself but also to others and understand the interpersonal consequences of ones behaviour and in so doing foster caring relationships. These considerations could help inform ethical decisions regarding the relationships inherent in multi-client therapies.

Ethics as a dynamic process Ethics is about confidentiality, the right to privacy, informed consent and clients rights. However, it is also inherent in the dynamic relationship between therapist and client.

Because therapists are aware of their ethical responsibility the onus must rest on them, in this relationship, to ensure that this process be ethically managed on an ongoing basis. In the diagrammatic representation below (Figure 1), the client enters the therapeutic relationship with a problem and the need for an intervention. The therapist, in turn, engages his or her client informed by his or her training, values and personal bias. If, in this meeting, the therapists responses, behaviour and interventions are calibrated by individual and relational ethics based on a professional code of ethics, the client will in turn trust him or her and commit to the therapeutic process. Such a dynamic relationship will provide an optimal context for psychotherapy. In this context, where the therapist is the ethics, the ethical principle of benefit to the client will be fulfilled.

Figure 1: Ethics as a dynamic process

Individual & relational ethics Ethical Code Therapist is the ethics

Therapist Training Problem/s Values Personal biases Benefit to the client

Client Need for intervention

Trust Commitment to the process

Diverse influences and ethics In conclusion, the circumscribed theory, method and therapeutic practice of the modern therapist has been moderated by an external ethical standard. This standard, if conformed to, ensured that the therapist was practising in an ethical way. These rule were prescribed and enforced in a top-down way (Freedman & Combs, 1996, p 265). Because of the movement away from a Eurocentric and calibrated psychotherapeutic practice, ethical standards and practice now include a far greater internal emphasis. This shift in emphasis is a result of the rejection of an objective truth, the linguistically co-evolved descriptions of problems, the observer-participant status of the therapist, and the changing definition of the client. This is concurrently reflected in various theories, methods and therapeutic practices. In order to discharge ones ethical duty as a therapist, working in a diverse context such as South Africa, aside from conforming to an external code of conduct, there is the added responsibility of continuous self-monitoring by questioning and checking the ethical implications of each therapeutic encounter, intervention and decision. A helpful guide in this regard is what Karl Tomm (Freedman & Combs, 1996) describes as ethical postures. He suggests that one becomes aware of how one is positioned in a therapeutic relationship and that ones ethical obligation is to make a choice vis--vis this posture. He describes the range of postures as extending from manipulation through confrontation to empowerment and finally succorance. Psychotherapy, in his opinion, includes all four postures with the proviso that an ethical stance will ultimately lead to the empowerment of the client.

Secondly, ethics in practice means that aside from choosing an ethical stance, one takes responsibility for the effect of ones actions. This translates into a feedback relationship where the calibration of an ethical action is the implication of that action for the client. For example, a manipulative intervention such as prescribing the symptom may leave the client unheard and therefore have an undesirable effect on the client. Thirdly, the postmodern notion that everything exists as relationship subsumes openness. This means that to hide or non-disclose infers an element of disengagement or negation of that relationship. Transparency therefore must be the ethical choice. A way of monitoring this choice would be to question if a conversation about a client with a supervisor could be conducted in the presence of that client.

Recommendations In light of the above it is essential that the South African therapist take cognisance of the movement away from a Eurocentric top-down view of ethics. In order to be ethically accountable ethics must be seen as integral to the therapeutic encounter. The therapist therefore needs to take responsibility for all therapeutic choices and interventions made in the therapy and the inadvertent messages these may hold for the client. In view this the following recommendations are suggested: 1. In order to be the ethics the therapists should self-monitor. This means that cognisance of the content and process of each therapeutic encounter and the ethical implications of every intervention should be considered. This ethical awareness needs to be inculcated through discussion and training. This could be implemented by expanding post-therapy notes to include questions such as whether the therapist

performed from an expert position; whether the therapist took cognisance of dominant and marginalized power relations; whether the therapist acknowledged the effects of his/her interventions; and whether the relationship was open and transparent. 2. In the training and supervision of psychologists, ethics should be integrated into all modules offered rather than presented as a free-standing component. Beyond the inclusion of ethics in curricula and discussions the application of ethical accountability needs to be modelled by trainers and supervisors so that the trainee and supervisee are experientially exposed to an ethical stance and behaviour. 3. In continuing training, the above principle should also be adhered to. All courses offered to psychologists should take cognisance of the ethical implications of the material presented. Furthermore, because of a previously held assumption that meaning and truth are the same for all people, discussions in continuing professional education need to further awareness around differences in meaning so that South African diversity can be ethically accounted for.

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