K.R. Smith on Ethics and Psychotherapy
It was, if I recall correctly, Jason Blakely (whom I interviewed here) who put me in touch with Kevin R. Smith, author of two recent books: Therapeutic Ethics in Context and in Dialogue (Routledge, 2020, 108pp) and The Ethical Visions of Psychotherapy (Routledge, 2020), 112pp. I have read both of these books with great profit, and found them much more philosophically enriched and enriching than anything else I have to read currently in the area. I might even be bold enough to say here that clinicians who are only clinicians, that is who have never done any hard work in philosophy, have no business lecturing the rest of us on topics they scarcely understand themselves. Happily, Smith is not like that, coming at these books with a wide-ranging background that shows up in both books to great profit.
Following my usual practice, I e-mailed him some questions for an interview about these books, and with heroic patience (such a key virtue for clinicians!) he has waited
AD: Tell us a bit about your background:
KRS: My path is not the standard one for professional psychologists. I was not a psychology major as an undergraduate. While I had some good psychology classes at Berkeley in the early 1970’s, the program was influenced by positivist and behaviorist conceptions of psychology that missed the complexity and richness of human experience. As an alternative to a psychology major I took advantage of the option available at Berkeley to construct an interdisciplinary major that included classes in psychology, other social sciences, and the humanities.
After a master’s degree in religious studies at the University of California at Santa Barbara, I entered the doctoral program in clinical psychology at Duquesne University. I had been exposed to the work of Ricoeur and Heidegger at Berkeley and Santa Barbara, and was excited to be studying psychology from the perspective of existential phenomenology. This program deepened my appreciation for the implicit philosophical assumptions often present in psychological theories that purport to be based upon objective data alone.
But finding work where this alternative perspective on psychology was even known, let alone valued, was not easy. I worked in various settings (community mental health, a rehabilitation hospital, and a large psychiatric institution, and research center) where I gained further experience and training before starting my own practice. In retrospect, I’m glad I have had experience in these work settings, where mainstream ways of understanding and practicing therapy and conceptualizing psychopathology were dominant.
But the sense was always there that something was amiss with the standard approaches. I have been struggling ever since to articulate what seemed wrong, and what the alternative might be. I have had help along the way from fellow therapists who wanted to understand people and their psychological difficulties in depth. Pittsburgh provided me a continued connection to the human science approach to psychology at Duquesne, experience with psychotherapy research at Western Psychiatric Institute and Clinic, and a series of seminars organized by Bill Cornell that exposed me to a variety of perspectives on psychodynamic therapy.
AD: You had me hooked on the first page of The Ethical Visions of Psychotherapy when you wrote this: "Therapy is also a social practice that enacts some perspective on what constitutes a good life, human well-being, or flourishing." And yet you note later on (ch.5) that "therapists rarely allow themselves to use the language of ethics in a full sense. They are often more comfortable with the language of repair." Why does it seem that virtually every school of psychotherapy wants to run from this question of the good, of flourishing--even as it smuggles in such assumptions through the backdoor?
KRS: There are a number of reasons why therapists avoid explicitly acknowledging that they are promoting ideas about the good. One category of reasons has to do with the nature of the goods that therapy promotes. These are often some variant of personal freedom or authenticity that is frequently understood to have its source in the individual. Whether this is viewed as a personal choice of how to live one’s life, or as fidelity to some core, authentic self, it often leads therapists to assume that they ought not to interfere with the patient’s free choice, or that their task is simply to free up an authentic self that has been buried, blocked, or distorted by social constraints and internal defenses. These ideals can often be valuable guides for practice, but therapists are mistaken when they think that there is no vision of a good life on offer here. Autonomous self-direction and authenticity are ethical ideals.
Another category of reasons for reticence about the promotion of some picture of human flourishing in therapy is the history of therapeutic efforts to challenge or undo the damage done by the excesses of conscience. Many people seek out therapy because they feel they are failing at life in some important respect. For some of these people, there is a recognition in therapy that they have been suffering from excessive demands to meet standards for a good life.
Psychoanalytic ideas about relieving the relentless character of superego demands and rational-emotive therapy’s challenge to the oppressive “oughts” and “musts” under which people labor are both examples of the way that therapy seeks to undo the damage done by alienating expectations of doing well or being good. As a consequence, many therapists are wary about proposing another set of obligations for patients to live up to. Nevertheless, an ethical ideal is still present here, one that emphasizes the need for people to find their own way to live rather than take on what family, church, society, or their therapist have said their aims should be (even as the therapist is here promoting an ideal).
Both these reasons to steer away from open discussion of human flourishing receive support from yet another quarter. This has to do with the effort to give therapy scientific credentials. Often this effort is built upon a conception of science as only giving us information about what is the case, not about how things should be (the “fact-value dichotomy”). To the extent that therapists think of themselves as intervening in disorders or patterns of behavior based upon a scientific understanding of their causes, they can claim that they are simply agents who help to change circumscribed problems, not proponents of a particular set of ideas for how to live well.
This view of therapy as technical intervention can hide from view the ways that therapy also functions as a social practice that instantiates various ideas about living well. Consider the different ways that psychological disorders are defined. If one compares the Diagnostic and Statistical Manual of Mental Disorders with the Psychodynamic Diagnostic Manual, for example, it is clear that there are different conceptions of the difficulties in living that people bring to therapy, conceptions that imply different ideas about what is important for human well-being. The DSM model implies that disorders are impediments to people getting on with their lives as they have decided to live them--the ideal is some form of autonomous self-direction. The PDM proposes a thicker set of ideals regarding a complex set of capacities for self-reflection, affective attunement, and interpersonal engagement, with autonomous self-direction as only one of many valued characteristics of psychological health.
AD: You write early on that "the central thread that runs through this book is the philosophy of Charles Taylor." I've been reading Taylor for years, and drew on him in my recent book about the Catholic sex abuse crisis. Tell him why he's important for your work, and what ideas of his you find especially useful.
KRS: Taylor’s philosophical anthropology makes a great deal of sense to me, and helps to highlight many of the dead ends of current conceptions of therapy. A central theme of Taylor’s work on human science is his critique of claims to naturalistic objectivity and ethical neutrality. Insofar as persons are “self-interpreting animals” in Taylor’s sense, it is not possible to understand their actions as the result of objective influences alone.
People do much of what they do because of how they understand themselves and the dilemmas and difficulties that arise in the effort to live a form of life they aspire to. To aspire to a form of life is to assess what one does and how one lives against a set of standards that one feels called to answer to, it is to be what Taylor calls a “strong evaluator.”
An enormous range of questions can arise in this context that go far beyond removing obstacles to pursuing a life one has chosen. One can question whether the way one has been living one’s life is basically misguided. Do I hold myself to an impossible standard of perfection? Have I misunderstood what I am aiming for? Why do others keep responding to me as though I were someone different from whom I understand myself to be? Is the life I’ve been trying to live possible for me, truly my own, or an alienating imposition from family or culture? Questions like these are often an essential context for understanding particular psychological problems like panic disorder or depression. The level of discourse in which such questions are framed and addressed cannot be derived from a set of findings about which technical interventions bring about changes in particular symptoms.
Further, it is not just the difficulties that patients struggle with that point to deeply held evaluative assumptions. In the effort to assist people with their difficulties each therapy also promotes a particular take on what is essential to a life well-lived. The role of ethics in therapy is not always acknowledged. Sometimes the failure to acknowledge an implicit ethic is based upon therapists’ assumptions that their ideas about well-being are so basic or universal that there is no need to justify or reflect upon them.
It is here that Taylor’s work on the modern identity in Sources of the Self, The Ethics of Authenticity, and A Secular Age is enormously helpful. In identifying the particular socio-cultural context for many of the modern ideas about human flourishing that are evident in the psychotherapies Taylor provides a platform from which to begin see that ideals like authenticity, interpersonal intimacy, rational self-mastery, or liberation from social constraints are not universally desired components of a good life.
AD: You note the importance of examining "ethics" in the eyes of psychology and psychotherapy and all the assumptions therein--as well as what is missing. You note that every form of therapy has some implicit ethical or moral notions: CBT people implicitly value what they call rationality (to which I'm always wanting to retort with MacIntyre's famous question: Whose Justice? Which Rationality?); psychoanalysts place great store on freedom; and of course everybody, including mainstream medicine, stresses "patient autonomy." Why is it important to call these out and examine them? What happens, in other words, if we continue to leave these notions of rationality and freedom unexamined?
KRS: To see that various assumptions about living well only make sense in socio-cultural context makes it possible to begin to question those assumptions. This is important, even if at the end of this questioning a decision is made to re-affirm those views, now not as unquestioned assumptions but as having some situated rationale. For example, it is not difficult to locate different therapies in relation to Taylor’s exploration of two distinct versions of the modern “inward turn.”
There are traces in contemporary therapy of both the stance of rational, disengaged reflection descending from Descartes and Locke and the more immersive self-exploration running from Montaigne through Rousseau and the Romantics. As Taylor spells out the history of these two forms of modern inwardness he also points to the ethical rationales that have been given in support of them. In Taylor’s view, neither of these has definitively won the day nor proven the other to be simply mistaken. The differences between them are not such that there is likely to be a resounding defeat of one by the other, even if mutual critique is illuminating.
The situation is similar with regard to the therapeutic orientations that derive from them. Failing to consider the fundamental ethical differences between different therapies leads to the mistaken idea that one type of therapy can be vindicated by simple empirical evidence regarding a narrowly defined efficacy at symptom reduction. But it also leads to avoidance of the richer ethical language necessary to grapple with what is at stake between the therapies. Moreover, any particular view of what it means to live well can have an enormous range of variations, even within one therapeutic orientation (consider the variations between the different schools of psychoanalysis). Autonomy, authenticity, liberation, and rationality can all come in many forms that deserve careful examination.
AD: You note at one point something that has long bugged me: The very idea of finding more "efficient" means of therapy contains within it a conception of the good life. And then Ch.5 opens with: "If one type of therapy works better than another, why should we care about its underlying view of flourishing?" Tell us a bit more about your thinking here about issues of efficiency and efficacy, and why it is important to analyze such seemingly unobjectionable ideas while also taking account of human flourishing?
KRS: The emphasis upon efficacy and efficiency in many discussions of therapy can introduce one notion of living well that deserves consideration, but it cannot simply be assumed to be definitive. There are nested domains in which this language appears. The most common one is the call for efficient and effective therapy, that is, for therapy whose value is measured in terms of how well, how quickly, or sometimes, how lastingly, it reduces concrete measures of disorder, like symptoms, self-report measures of distress, or associated measures of functioning, life satisfaction, etc. At a “meta-level” are arguments to develop methods to effectively disseminate these effective therapies, that is, to effectively and efficiently train therapists to do these therapies.
Fundamental to all of this is a sort of utilitarian ethic that attempts to develop a sort of calculus of suffering and scientifically founded methods to reduce that suffering. There clearly can be value in this project. It has motivated the development of therapies that have benefited many people. Reducing the fear about and frequency of panic attacks or decreasing suicidal ideation are not trivial improvements in people’s lives.
But to think about the benefits of therapy only in these terms is to ignore other ways of thinking about how therapy helps people to live well. It is simply not a forgone conclusion that therapy is the removal of impediments to living whatever life people want to live. For many, their psychological problems point to something amiss in their reigning assumptions about a good life, assumptions that are now open for re-examination. One risk of a focus on effective removal of symptoms is that it can imply: “Get rid of your symptoms, then exercise your free agency to choose whatever form of life you like. After all, there can be no real answer as to what makes for a good life. It’s simply a matter of personal preference.” What is suggested here is that what really matters is an unencumbered freedom to choose. That is the ultimate good. But that leaves no reason for one’s choice, for there is no good outside of my preferences that I answer to, or that can give some confidence or grounding to my choice.
AD: If I was cheering earlier, I was on my feet for a standing ovation when you recognized that "the evidence to warrant the designation 'empirically supported therapy' is far weaker than is routinely claimed, especially for the short-term manualized therapies." Apart from Jonathan Shedler's invaluable work, yours is one of the only other voices I've come across recently calling out the dangers of excessive deference to that talismanic phrase "evidence-based," which tendentiously smuggles in all sorts of ideological assumptions hidden under philosophical naiveté. Tell us a bit more about the problems and assumptions built into claims to be "evidence-based."
KRS: It is certainly reasonable to ask if a therapy does any good. But the usual criteria for a treatment to be considered evidence-based are a truncated form of this question. The appeal of this way of assessing therapy is that it lends itself to empirical evaluation. The results are not always impressive. Shedler and other researchers have noted that the measurable symptomatic improvements of the short term therapies are often small and temporary.
Further, different types of therapy can achieve similar results according to standard measures of symptom reduction. The question then arises as to whether different therapies might offer different benefits beyond symptom change. One danger of the evidence-based practice movement is that it implies the irrelevance of questions about the relative value of a broad range of goods or benefits that may be on offer in therapy.
To use a simple example, if both Dialectical Behavior Therapy and mentalization-based psychodynamic treatment have some success in measurable outcomes in the treatment of borderline personality disorder, how do we assess the relative value of the dialectic of self-acceptance and change that is part of DBT against gains in mentalization? There is something internal to these distinct therapies, something that is part of their particular views about what matters most for living well that deserves consideration on its own merits, not just in terms of symptomatic improvement. As an analogy, suppose one were to decide whether to be a Presbyterian, an Episcopalian, a secular humanist, or a Marxist based upon research showing that the members of one of these groups had statistically higher measures of self-reported happiness, or higher levels of functioning. To choose one form of life over another upon such bases is to ignore the distinct views of the good internal to each.
Therapies designed and tested against the criteria to be evidence-based may well provide significant benefits. But the talisman of “evidence-based” can obscure a number of other important considerations about the value of therapy.
AD: At one point after comparing DBT and psychodynamic approaches to treating borderline personality disorder, you note that "common factors are operative across technique and problem. They do not subsume and dissolve all specifics into one common therapy for all disorders." This leads me to a worry I have about those calling for psychotherapy integration, not unlike appeals for "Americans to come together" after the election: what notions--potentially problematic and objectionable notions--of the good life are being smuggled in behind these appeals to unity and integration?
KRS: Efforts to bridge the differences between the therapies by integrating different components of practice or theory are not necessarily misguided. It can be part of a laudable effort to develop therapy in new directions, and can lower the temperature of debates between competing schools.
But there are dangers. Under the guise of integration, one perspective can be subsumed within another, with the loss of what is distinctive about what has been subsumed. The aim should not be to move the many schools and sub-schools of therapy to a unified theory and practice, but to engage in a more vigorous debate about the competing aims of the therapies. There is value in respectful engagement with the diversity of approaches. Dialogue here includes debate and critique—agreement may not be the outcome. But at least with regard to the debates between different schools of therapy there should be some protection of the right for all to be part of the debate. This is far more valuable than unity.
AD: At the end of ch. 5 I felt very much called to account when you write that "adherence to favored therapeutic orientations is influenced by the appeal of the particular picture of flourishing, of how to live life well and fully." This very much undergirds my continuing allegiance (but not uncritical, or unappreciative of other approaches) to psychoanalysis and its picture of flourishing as freedom which disrupts various forms of repression--individual and social alike (as we see in a recent book A People’s History of Psychoanalysis: From Freud to Liberation Psychology by Daniel José Gaztambide, whom I interviewed here). Is part of your argument that therapists need to be more open about their adherence, and more willing to subject it to searching examination to analyze underlying moral claims?
KRS: Absolutely! Adherence to a particular approach to therapy often has complicated sources: experience with being a patient or therapist in a particular therapy, or the way that a particular therapy matches one’s intellectual or cultural assumptions and style. And there’s nothing wrong with therapists finding a home in one school rather than another, even if that means they are limited in what they have to offer patients. None of us can be all things to all people. But it is problematic to let the justifications for a favored approach lead to definitive conclusions or institutionally enforced policies regarding which therapies are legitimate. Therapists’ reflection upon and debate with others about their underlying moral claims can not only protect against hubris--it may also help them to amend or even fortify their ethical assumptions.
AD: If that's the case, then I'm wondering whether training programs do not need a whole lot more serious philosophy courses built into them, so that "ethics" is no longer a single course telling prospective therapists what their professional association's code forbids and requires, but instead gives them a level of facility and insight so that philosophical debates about human flourishing can be much richer than they are now?
KRS: I would love to see greater discussion of these issues within training programs. Unfortunately, ethics is often presented in training programs simply in terms of how not to avoid missteps in one’s professional duties. As valuable as those considerations are, they overlook important questions. For example, the American Psychological Association’s code of ethics promotes fundamental principles of beneficence and nonmaleficence, principles which enjoin therapists to offer something of benefit and to avoid doing harm. But if the benefits are understood only in terms of standard ideas about effective treatment a wide range of fundamental ethical questions are overlooked, or worse, they are assumed to already be definitively answered.
AD: Sum up your hopes for the books and who especially would benefit from reading them.
KRS: I hope that these questions get a wider hearing, and certainly there are others who are raising them, like Philip Cushman, Frank Richardson, Blaine Fowers, Brent Slife, Donnel Stern, Donna Orange, Robert Stolorow and others.
But the culture of therapy, which is shaped by the larger culture of modernity, has certain built-in impediments to recognizing the salience of these questions, so I think the effort to gain recognition for them will be an uphill battle for some time to come.
My hope is that the books would have a readership beyond those who are already interested in philosophical questions about therapy. I think any therapist, regardless of theoretical orientation or stage of career, can have questions from time to time about more fundamental issues about therapy, about what it is, what its fundamental aims are, what good it might do, what therapeutic aims are most worth pursuing, and why. I hope that these books provide some specificity to and justification for asking such questions. I have tried to be respectful to therapeutic orientations other than my own because I do respect them, but also because I want to encourage therapists across the spectrum of different schools to consider these more fundamental questions.
AD: Having finished both books, what projects are you at work on now?
KRS: I’m currently working on a paper for a special issue of International Journal of Philosophical Studies dedicated to Taylor’s legacy and possible future impact. I am also working with a group of analytically oriented psychotherapists in Pittsburgh to develop a new program for education in psychoanalytic psychotherapy, the Western Pennsylvania Community for Psychoanalytic Studies.