Thoughts on Ethics, Psychotherapy and Postmodernism

THOUGHTS ON ETHICS, PSYCHOTHERAPY ANDPOSTMODERNISM

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] century…We 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 therapist’s 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 therapist’s

role of listening and responding to the client’s 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 one’s 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 McHale’s 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 therapist’s 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

client’s 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 White’s (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 people’s 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

client’s 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 client’s 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 client’s 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 one’s 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 one’s 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 therapist’s 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 ethicsEthical Code

Therapist “is the ethics”

Therapist Client Training Benefit to the client Problem/s Values Need for

Personal biases 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 one’s 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 one’s ethical obligation is to make a choice vis-à-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 one’s 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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