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Ethics and Values in Psychotherapy
  1. Jeremy Holmes
  1. North Devon District Hospital, Barnstaple, Devon

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    Alan C Tjelveit, London, Routledge, 1999, 336 pages, £17.99.

    Ever since Thomas Szasz announced that mental illness was a myth and that psychiatric disorders were in fact moral dilemmas hiding beneath the shirt-tails of medicalisation, psychiatric ethics has been hotly debated, a debate given poignancy in the 1970s by the revelations of the abuse of psychiatry in Soviet Russia. However, discussion of ethical aspects of psychotherapy has lagged behind its psychiatric cousin, and it is mainly the emergence in the past decade or so of psychotherapy as a profession in its own right—and with it the need to develop professional codes of ethics—that has stimulated practitioners and their critics to take psychotherapeutic ethics seriously.

    This book is one of the few devoted exclusively to the subject, and it covers a wide range of topics, including questions such as the following. Is psychotherapy a medical technique, or a secular religion masquerading as science? What is the nature of the therapist-patient relationship—friendship, moral guidance or service provider and consumer? Does the therapist have a primary duty to the individual patient, or must she also consider the needs of community and society? Do practitioners have an obligation to consider the efficacy of their treatments, and to know about alternative methods (including antidepressants) which may be more effective in helping their clients? Does the ethical backdrop within a given society change the nature of the therapeutic relationship—would a Muslim woman wanting counselling about an unwanted pregnancy expect a different response from her therapist compared with a Catholic or an atheist? What is the ethical duty of therapists to third party payers such as the National Health Service (NHS) or insurance companies? Do the personal beliefs and values of therapists matter or can they be ethically neutral when face to face with their clients?

    Those looking for easy solutions to these questions will be disappointed. Tjelveit's comprehensive and scholarly volume, much influenced by Taylor's “Ethicist Authenticity”, does not provide answers, but, in the true Socratic tradition, offers a thoroughgoing exposition of the different viewpoints and arguments that need to be considered. For example, in his section on therapist values systems and how they may influence therapy, he lists, (in alphabetical order) and gives a short account of, 14 different ethical viewpoints, ranging from casuistry, feminist ethics, through narrative ethics to rationalism, religious perspectives and romanticism. Similarly, in his discussion of ethical pluralism he gives four (he is fond of lists) possible responses, including ethical neutralism (which is what most NHS therapists would probably aspire to) at one end of the spectrum, and a declared ethical stance (for example saying to the client: “this is what I consider to be the characterists of a good life”) at the other.

    Despite, or perhaps because of its attempts at comprehensiveness, (and there are some strange omissions from the discussion, most notably the recovered memory debate) this is not an easy book for the practical clinician. There is very little case material, and what there is tends to be rather simplistic. The author is excellent at describing others' theories, but rather reticent when it comes to his own views—in this respect, if no other, like a good therapist. There are occasional lapses: surely Socrates's famous statement that the unexamined life is not worth living cannot simply be transposed into the positive that the examined life is worth living (page 284). Many a tortured obsessional would disagree—again the author reveals his clinical naiveté. In the end this is a book more for the philosopher than the psychotherapist, although those running courses on psychotherapeutic ethics may find it a useful sourcebook.

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