Therapy or Coercion

Does Psychoanalysis Differ from Brainwashing?

R.D. Hinshelwood

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429922916
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book focuses on the professional ethics of medicine and psychiatry, to know whether psychoanalysis differs from brainwashing. It addresses a divergence—a choice between repression and splitting, and examines how the findings concerning a divided mind relate to philosophical issues.

PART ONE

THE UNITY OF THE PERSON

CHAPTER ONE

Freedom or force

The way people interact is socially controlled by laws and customs. On the whole, these are established on an intuitive basis, but moral philosophy attempts to ground these laws and customs within a rigorous conceptual framework. One set of characteristics that applies to relations between people concerns the degree to which they allow each other to be individuals. Conversely, there is suspicion of relations in which one party attempts to control or impose its will on the other. This dimension of freedom and force has gained a higher priority as Western culture has developed a special emphasis on the individual, especially since the Enlightenment.

Clear frameworks for guiding conduct are especially necessary in professional relationships. These are particular social relationships in which a contract (usually involving money, another central pivot of Western culture) is established for rendering services. However, such are the complexities of these social arrangements that it has become increasingly difficult to distinguish good from bad practice. When the practice involves changing people—that is, changing them in themselves, as persons—there is particular suspicion. For the purposes of this book (which is by a psychoanalyst) the question has been phrased in the following form:

• How do we know that psychoanalysis is different from brainwashing?

However, the question is much more widely applicable—to the psychotherapies and therapy and, indeed, to psychiatry, medicine, and professional ethics in general.

Moral philosophy

In his search for principles that might address ethical questions in general (Raphael, 1981), Kant formulated his central moral principle in the form of an injunction:

Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end.

This formula aims to apply to all actions and is, therefore, an absolute principle. Another similarly absolute principle was that of Jeremy Bentham and the Utilitarians:

The action is right that produces the overall greatest amount of pleasure.

There are considerable problems in defending either of these approaches. Typically, the problem with Kant’s principle is the instance of lying to a murderer. If a murderer asks you where his intended victim has gone and you know, should you tell him? On intuitive grounds, the morally best judgement is to lie to him, but this contradicts Kant’s basic moral principle—by lying to him, you fail to treat him as an end in himself, to respect his autonomy and reason and so on. You treat him instrumentally as a means to an end of preventing a murder. Similarly, the test case for Utilitarianism is that of the gladiatorial contest. It would be morally right to put on contests in which gladiators hacked each other to pieces, if it provided enough pleasure for enough spectators to outweigh the disaster inflicted upon the gladiators. Again the principle seems to lead to a justification of something that, intuitively seems quite immoral. These arguments are not in any way comprehensive (Scheffler, 1988) but merely illustrative of the difficulties of finding and defending a single basic principle that can underlie all moral decisions.

To get out of the problems of searching for an absolute moral principle, another philosophical approach posits that there is no single absolute principle. Thus two or more principles have to be weighed against each other in any situation. Intuitive judgements are emphasized in practice. Various principles, such as honesty, benevolence, liberty, and so forth, have been proposed and argued over. Often these multiple principles are arranged in such a way that one principle takes precedence over another—for instance, one might argue: “Always be honest, but when honesty conflicts with the principle of benevolence (when, for instance, an honest remark would hurt someone), then observe the principle of benevolence.” In that special circumstance, benevolence takes precedence over honesty. These kinds of non-absolutist views tend to be adopted in professional ethics.

John Stuart Mill (1859) attempted a solution on this basis by bringing together the Kantian and Utilitarian positions. He included in the Utilitarian injunction the need to respect liberty, not just pleasure. Freedom has become an important “good”, but it takes its place at the head of a non-absolute set of ethical principles. Freedom—or its modern equivalent, autonomy (Lindley, 1986)—is central to current professional ethics. With the recent revelations of abuse within the setting of ordinary therapies, and even of the more sophisticated psychotherapies, and the increasingly litigious attitude towards professions in general, there have been many attempts to address the establishing of an ethical approach to psychotherapy—for instance, by London (1964), Lakin (1988), Austin, Moline, and Williams (1990), and Barker and Baldwin (1991). In contrast, more classical treatments (Szasz, 1965; the 1959-1960 seminars of Lacan, 1986) take a more metaphysical and less legalistic stance.

The significance of psychoanalysis for moral issues has attracted interest mostly amongst psychoanalysts. Freud introduced the concept of the superego as the moral principle in human beings (Freud, 1923b), with the implication that, prior to the development of the superego at around 3-5 years, children are amoral beings. Interestingly, he had already encountered apparently amoral adults—criminals who were, he understood, not fixated at a pre-moral stage but, instead, in thrall to an unusually strong unconscious morality (unconscious guilt) that was so severe that it actually crippled a moral sense altogether (Freud, 1916d). In contrast, Klein regarded the human being as born into a moral universe of conflicting and competing objects which, from the beginning, it evaluates as good or bad (Klein, 1932); amoral behaviour and criminality are, then, forms of acting out an internal state of persecution (1934). Money-Kyrle (1944,1952) employed Klein’s theory of the depressive position as a system of ethics. This psychoanalysis of morality in human beings has been a dominant trend for a long time: (e.g. Brierley, 1947; Feuer, 1955; Flugel, 1945; Hartmann, 1960). Following the major wars, there have been many attempts to enlist a psychoanalytic view, specifically regarding the destructive sadism of human beings, to explain war—Glover (1933), Strachey (1957), and Fornari (1966), among others.

This debate concerns the alternative roots of morality in human beings: either an inherent morality (not yet with specific morals) or purely socialization. There has been relatively less interest in the development of actual ethical principles concerning psychoanalysis. However, psychoanalysis and psychotherapy seem to create their own value system, which may be offered to, taught to, or imposed upon patients (Reid, 1955; Seaborn-Jones, 1968; Szasz, 1965). Recently, Holmes and Lindley (1989) have discussed what they call the “values” of psychotherapy. In this they delineate the values implicit in the work of psychotherapists, which they subtly expect their patients to converge towards. As a result, there is a potential concern about the morality of psychoanalysis (Lifton, 1976). In the aftermath of the Vietnam war, a symposium organized as a joint meeting of the American Psycho-Analytical Association and the American Association for the Advancement of Science (Ekstein, 1976; Erikson, 1976; Lifton, 1976; Michels, 1976; Serota, 1976; Wallerstein, 1976) addressed issues of the conduct of the professional in a war.

Because the notions of psychoanalysis are now inserted deep within Western culture—in terms of the concept of the individuality of the person, of the working of hidden motives for which the individual cannot be consciously responsible, and of the consequent emphasis on issues of personal freedom and autonomy—the values according to which the activities of psychoanalysts and psychotherapists are judged to be ethical derive in part from a psychoanalytic framework of thinking. Thus the emphasis on those principles that underlie the ethics of psychoanalysis is in part determined by psychoanalytic ideas and practice.

We discuss this circularity in the course of this book. But from the start we must note that the ethical conduct of professionals, including psychoanalysts, is publicly regulated by professional bodies that generally adopt standard medical ethics as their paradigm. The shortcomings of this model are addressed first. In the process, we will see that much of the impact of psychoanalysis on social and professional values derives from theories that developed at the beginning of psychoanalysis itself. Contemporary psychoanalysis has moved on and is itself a new vantage point for a critique of these values.

CHAPTER TWO

Medical ethics

At times in our work we sense that we must proceed in spite of the patient, and that this does not bring us—doctor, nurse, or psychoanalyst—into the category of torturer or brainwasher. Intuitively, we would agree that there are some conditions in which it is beneficial to go against the patient; but how can this be decided? To examine these situations carefully, we will turn to the paradigm of medical ethics, and then to the question of whether medical ethics can, in fact, apply to psychoanalytic work.

A priority of values

The resolution of ethical problems revolves around knowing when to apply which ethical principle. In medicine the principles governing treatment are non-absolutist, are clearly arranged, even though the discriminating criterion may be difficult to measure at times.

Roughly speaking, standard medical ethics is based on the following principles (Gillon, 1986):

1. AUTONOMY: Medical practice concerns doing good for the patient. It is the patient’s right to expect this from his doctor. The doctor should respect the patient as the final arbiter of the choice of treatment. The patient has a right to receive good medical advice and to be put, by his doctor, in a position to be able to choose the best line of treatment. The patient has autonomy. He must be allowed to assert his right of informed consent.

The principle of autonomy is clearly open to transgression by doctors who do not properly inform patients or who bring undue influence on them for various unprincipled reasons—such as financial considerations, sexual exploitation, and so on. However, most doctors, being of reasonably good character, do respect the patient’s autonomous rights over his own body and his own decisions about health and about offers of treatment—an “informed consent”—and they will avoid clear exploitation and severe violation of the patient’s autonomy.

2. PATERNALISM: The situation, however, is not always so simple. Not all patients are capable of making good decisions. “Autonomy” takes precedence unless exceptional situations occur. When a patient cannot contribute to the decision, the doctor has to override the patient’s right to autonomy. Dyer (1988), for instance, stresses the fact that suffering may not be relieved for patients by too slavish a regard for autonomy. This is particularly common in psychiatry. The psychiatrist must, at times, adopt a position of knowing best what is good for the patient. This is an attitude of paternalism.

3. RATIONALITY: The principles of autonomy of the patient and paternalism towards him would conflict unless they are managed by ordering the principles according to strict criteria. Thus the patient must always be given his autonomy, unless the patient is not capable of making good decisions about himself and his treatment; then the doctor is entitled to “know best” for the patient and make paternalistic decisions on the patient’s behalf about the treatment.

The tricky point is to know when exactly the doctor should relinquish his respect for the patient’s autonomy and take it into his own hands to decide what is best—to become paternalistic. That is to say: how does the doctor decide that the patient cannot make good decisions? The issue turns on one criterion—the patient’s degree of rationality (Gillon, 1986). If he is sufficiently rational, he should be allowed to make his own decisions (autonomy); but if he is irrational, in some relevant way and to a particular degree, then the doctor must decide for him (paternalism). This is straightforward enough, but it does depend on the doctor making an assessment of the rationality of the patient and of the degree of rationality that is sufficient in any specific case.¹ These exceptional instances occur particularly in psychiatry, when the patient is considered not to be of sound mind.

4. PSYCHIATRIC PATERNALISM: Influencing people’s minds for their own good is the activity of psychiatrists. This is a particular issue when patients are under compulsory orders for detention or treatment (Bloch & Chodoff, 1981; Dyer, 1988; Edwards, 1982), and the psychiatrist’s responsibility may require him to go directly against the patient’s deeply held convictions or fears. A severely paranoid patient may believe that his nurses are conspiring against his life; a severely depressed patient may be just too ill to be able to make a decision about having ECT. The psychiatrist has to take over the decision-making function of the patient; though some would dispute this (Laing, 1959; Szasz, 1961).

5. PSYCHOANALYTIC CONSENT: We will examine in much greater detail the exact conditions that operate in a psychoanalysis; here we can recognize that psychoanalytic patients do not always cooperate with treatment. In fact, we know that something else happens: resistance, symptoms, the transference, acting-out, and so on. One important factor is the—often unconscious—intention to thwart or circumvent the “work” of the psychoanalyst.² One instance of this can be seen in Freud’s case of Dora (Freud, 1905e [1901]), whose consent turned out to hinge on being able to use Freud to enact a successful revenge. At least, she seemed to have consented to treatment on the basis that this would be a part of her treatment. In addition, her leaving treatment as a form of acting-out suggested that her consent had been given on the basis that she was the one who knew which course of action was best for her difficulties, and she did not heed Freud’s instruction at the time that she “should not take any important decisions affecting [her] life during the time of [her] treatment” (Freud, 1914g, p. 153).

The changes we expect in a patient’s personality, and, indeed, in his unconscious, are, therefore, often very remote from the process that he wants, and to which he believes, unconsciously, he is submitting himself (and engaging the analyst to provide him with). Simply, the patient, unconsciously, comes in search of a mother-figure, say, despite meeting a professional advisor. With this inevitable conflict between what the patient, in some sense, consents to and what the psychoanalyst consents to, we are confronted with an unexpectedly complex ethical situation. It is comparable to the case of the doctor in a casualty department who wishes to give a blood transfusion to a road-traffic accident victim but finds that the patient is a Jehovah’s witness and has a conscientious objection to transfusions. If there are, indeed, similar ethical problems, then, on the face of it, standard medical ethics would appear to be a good model for how to proceed with this conflict between psychoanalyst and patient. And in practice psychoanalytic ethics has until now taken medical ethics as just such a suitable model.

However, we need a detailed examination of how the conditions in medical ethics—in cases where the patient does not cooperate with treatment—might correspond to the psychoanalyst proceeding despite...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• PREFACE
• Introduction
• PART ONE THE UNITY OF THE PERSON
• PART TWO THE PROBLEMS OF AUTONOMY
• PART THREE THE ETHICS OF INFLUENCING
• PART FOUR PERSONS AND SOCIETY
• REFERENCES
• INDEX