Therapy, Ethics, and Society

Feng Yu/AdobeStok

SECOND THOUGHTS

After a working vacation in Brazil in August, I took time off from my column to restart the academic year and host 2 friends and family therapists from Mexico City here in Montreal.

I have several interviews lined up this fall, including Adalberto Barreto, MD, on integrative community therapy (ICT) in Brazil¹ and Javier Vicencio, MD, on his family therapy center in Mexico City, as well as Andrew McLuhan on the legacy of his grandfather, pioneering Canadian media scholar Marshall McLuhan, and Canadian historian Matthew Smith on the history of community psychiatry.²

Now, I want to set the stage for the questions that these encounters raise for social psychiatry specifically and for the psy disciplines generally.

Without Magic or Masters

During my visit to Mexico City in March of this year, I was inspired by a statue of Mohandas Gandhi in his famous loincloth. Gandhi’s homespun loincloth and the images of the spinning wheel and Gandhi in a loincloth became powerful symbols of Indian sovereignty. After my visit to Mexico, I wrote a message for my Mexican colleagues, published in their family therapy center’s monthly bulletin. Mexican therapists are at the stage of evolution where they need neither magic nor masters and should assert their sovereignty³:

To hope that what we do in our systemic and social practices is beneficial to those who seek our help is necessary to maintain our commitment to the care of others. Yet, to believe that this is enough in a world where there are limited resources and time for all of the population is magical thinking.

To listen to and to learn from the wisdom and practices of masters of systemic and social practices in other societies is valuable and fruitful. And yet, to import their approaches and models of practice wholesale into Mexico without careful and deliberate adaptations for your own needs both in your own systemic practices and for social practices in your society is to submit to the authority of masters.

Three Reflections

Here are my reflections on my encounters with systemic and social practices this year that will be the subjects of my columns this fall.

1. Brazil’s ICT addresses communities and takes us beyond the usual institutions. I have experienced ICT in workshops in Italy and Brazil; it is engaging and proven effective.¹ And yet, I am left wondering, is it psychiatry (or mental health)? Is it therapy? These basic questions provoke deeper reflections on what we mean by psychiatry (both academically and clinically) and what we mean by therapy.
2. My friend Javier Vicencio, MD, who directs CRISOL, the Postgraduate Center for Family Therapy in Mexico City, comes from Chile and left the country when his family was imprisoned and dispersed by the military coup against the government of Salvador Allende, MD, in 1973. When I asked him about politics today, his answer was very instructive. As a therapist, he is now more engaged with the ethics of our work than with a political vision.
3. Our friends and colleagues in the United States are caught up in an election that they consider consequential and critical to their vision of social life and its impact on the practice of therapy. Which leads to ask a question I have asked throughout my career: Does social psychiatry have a political agenda? Should it?⁴

A unifying thread through these second thoughts about therapy concerns ethics. I will revisit 2 papers I wrote on the ethics of therapy.

Saying It and Meaning It

In my study with David Roy, PhD, a pioneering bioethicist at the Clinical Research Institute of the University of Montreal, when I was chief resident in Psychiatry at McGill University, we studied the way therapists communicated in strategic and systemic family therapy.⁵ The key notion there was coherence. With the popular expression, “talking the talk and walking the walk,” people ask for politicians to be congruent in what they say and do. This applies to therapy as well. There is another layer here as well: saying what you mean. This requires integrity as well as coherence.

There should be coherence among 3 levels: What we think, what we say, and what we do. We should mean what we say and what we do should follow coherently from that. That is the operational definition of integrity. This line of thought was influence by a brilliant study by American philosopher and humanist Stanley Cavell called Must We Mean What We Say?⁶ And my analysis of why therapy fails has more to do with the incoherence among these levels than about training, models, or experience.

In our study, one of the first papers on the ethics of family therapy, we found that certain ways of communicating in family therapy were worrisome and I feel more strongly about it today, 40 years later.⁵ Inventing pretexts and examples to frame a clinical intervention, no matter how well intentioned, is unethical and unsustainable over the course of therapy. An example typical of strategic therapy at the time was to announce to a family that there are 10 people in the team behind the one-way mirror and that the team was divided: 5 people thought that the family should just continue doing the same thing while the other 5 believed that they should change direction. This was a way of prescribing ambivalence in order to provoke a family out of their homeostatic rut. To add to the complexity of this intervention, the actual composition and reflections of the supposed team were sometimes made up for strategic purposes. Maybe there were only 3 people behind the mirror rather than 10. Can we justify lying in order to help patients? This is a concrete example of the end justifying the means. Ethics long ago opined that it is very problematic.

Provocative and strategic interventions are from an ethical point of view, unwise and hard to justify. They are condescending and authoritarian and militate against an open and transparent dialogue in the service of constructing a partnership with patient and families. Furthermore, framing the same sorts of interventions as hypotheticals or “future questions” is just as powerful without demeaning people or trying to get around their conscious choices. There is a subtle but critical difference between provoking people or putting them into “positive binds” and suggesting different ways of thinking and doing. Some of the approaches and tools that arose to replace such interventions come from the narrative and dialogical therapies.⁷ I am a fan of the “reflecting team,” in which a team offers a variety of perspectives on a family’s predicament to open space for healthier, more adaptative solutions.⁸

Three Social Psychology Experiments

The question of deception in experimental design grounded the standard approach to social psychology in the 1970s and 1980s, notably in American social psychologists Stanley Milgram’s obedience to authority studies at Yale⁹ and Philip Zimbardo’s Stanford Prison Experiment.¹⁰ Both experiments generated distress and complaints among their experimental subjects and critical reviews of their findings.

I would add American psychologist David Rosenhan’s study, “On being sane in insane places.”¹¹ For starters, I reject this language as pejorative and judgmental in the extreme towards our patients and our profession. I have worked in Rosenhan’s language in “insane places” since 1974—fully 50 years. No one I know calls our patients “insane” and psychiatrists do not declare themselves as “sane.” Sane and insane are legal terms in some jurisdictions that were long ago discarded by academic psychiatry—well before this study.

The nature of Rosenhan’s study was based on deception. Subjects—“confederates” in the jargon of social psychology experiments—presented their own life stories but falsely reported that they were hearing voices. Since the subjects were admitted to psychiatric wards based on their avowed symptoms, Rosenhan questioned the validity of psychiatric diagnosis. This is a spurious conclusion of an unethical premise. And psychiatry does not need social scientists to question the critical gaps in psychiatric classification since psychiatrists themselves have been among the most critical of the epistemological incoherence of our field.¹²

Coherence, Unfolding, Dignity

In a more recent essay, I outlined 3 principles for ethical work with children and families.¹³ They are: coherence, unfolding, and dignity. Coherence is described in this column and is related to integrity. Unfolding is my alternative term for development, as described in my last column. Dignity requires coherence, integrity, and respect for the unfolding of other people’s life journeys. It is perhaps more complex but also closer to the core of what therapy and any interpersonal encounter is all about.

French Jewish philosopher Emmanuel Levinas asserted that “ethics is first philosophy.”¹⁴ In other words, before theory, before any science of being (ontology) or knowing (epistemology), there is an ethical obligation to the other as a practical matter. Levinas grounded this in a very concrete way on the “face to face encounter” with other people, even in the face of violence. In this, he is deeper, more human, and more practical than Martin Buber’s notion of the “I-Thou” relationship as an encounter between 2 equals who speak in the intimate language of “Ich und Du” in German, “moi et toi” in French, and “I-Thou” in the archaic singular of you in English.

A Place to Stand

Is there an alternative to polarizing politics? Politics after all is intimately engaged with a vision for how to live in society. As a social psychiatrist, I cannot be indifferent to that. My answer is to be deeply informed but also cautious about partisan political engagement. It is not a form of quietism. My social philosophy is founded on my manifesto for slow thought calling for calm reflection before action,¹⁵ outlined in my column, “Slow Thought in a Fast City.”

German psychologist-psychoanalyst Erich Fromm, who was part of the Neo-Freudians in the US along with Harry Stack Sullivan and Karen Horney, wrote about the sane society.¹⁶ Is it possible?

For now, my only conclusion or rather my commitment is to see these 3 questions deeply linked:

• What is therapy?
• What is the sane society?
• And what is an ethical way to live in society and to conduct therapy?

I am yoking these questions about therapy and society to ethics because I am convinced that the conduct of therapy is linked to how we see society and that it must address ethics. In other words, to paraphrase Emmanuel Levinas, “ethics as first therapy.”

We must stop seeing therapy as separate from the rest of society even when we see therapy as a response to the problems of society. That model no longer works for me. All too often, the therapies on offer are themselves a reflection of the limitations and blind spots of the society that creates them and deploys them.

I am reminded of the ironic lament of Viennese social critic Karl Kraus in the time of Freud who defined psychoanalysis as that disease that considers itself its own cure. There is more truth to this than I like to admit as a psychotherapist.

The Greek mathematician and inventor Archimedes famously declared that given a place to stand, he could move the Earth. While that may be theoretically possible in physics, it is impossible in social life. There is no place to stand outside of society in order to change society. It is an inside job and in social science, social psychiatry, and social philosophy we are trying to change the very conditions which shape both our problems and our attempted solutions.

Resources

For an introduction to the 2 key thinkers in this column, start here:

• Emmanuel Levinas. Wikipedia. Accessed September 1, 2024. https://en.wikipedia.org/wiki/Emmanuel_Levinas
• Erich Fromm. Wikipedia. Accessed September 1, 2024. https://en.wikipedia.org/wiki/Erich_Fromm

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addiction medicine at the University of Montreal and President of the World Association of Social Psychiatry (WASP). He has been recognized with numerous national and international awards, honorary professorships, and fellowships, and was recently elected a Fellow of the Canadian Academy of Health Sciences and given the Distinguished Service Award of the American Psychiatric Association. Dr Di Nicola’s work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s writing includes: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of a prize from the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021); and, in the arts, his “Slow Thought Manifesto” (Aeon Magazine, 2018) and Two Kinds of People: Poems from Mile End (Delere Press, 2023, nominated for The Pushcart Prize).

References

1. Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative community therapy in the time of the new coronavirus pandemic in Brazil and Latin America. World Soc Psychiatry. 2020;2(2):103-105.
2. Smith M. The First Resort: The History of Social Psychiatry in the United States. Columbia University Press; 2023.
3. Di Nicola V. Sin Magia ni Maestros: Para las prácticas sistémicas y sociales mexicanas [Without magic or masters: For Mexican systemic and social practices].Boletín CRISOL (Centro Posgrado de Terapia Familiar, Mexico). 2024;1:4-6.
4. Di Nicola V. “Do Social and Transcultural Psychiatry Have a Political Agenda? Should They?” Culture & Mental Health Research Unit Meeting, Division of Social & Transcultural Psychiatry. McGill University, Montreal, QC. February 20, 2020.
5. Di Nicola VF. Saying it and meaning it: forging an ethic for family therapy. Journal of Strategic and Systemic Therapies. 1988;7(4):1‑7.
6. Cavell S. Must We Mean What We Say? Cambridge University Press; 1969.
7. White M, Epston D. Narrative Means to Therapeutic Ends. W.W. Norton & Co; 1990.
8. Andersen T. The Reflecting Team: Dialogues and Dialogues About the Dialogues. W.W. Norton & Co; 1991.
9. Milgram S. Obedience to Authority: An Experimental View. Tavistock Publications; 1974.
10. Zimbardo P. The Lucifer Effect: Understanding How Good People Turn Evil. Random House; 2007.
11. Rosenhan DL. On being sane in insane places. Science. 1972;179(70):250-258.
12. Di Nicola V, Stoyanov DS. Psychiatry in Crisis: At the Crossroads of Social Science, the Humanities, and Neuroscience. Springer Nature; 2021.
13. Di Nicola V. Coherence, unfolding, dignity: three principles for ethical work with children and families. In: Letters to a Young Therapist. Atropos Press; 2011:131-147.
14. Levinas E. Entre Nous: Thinking-of-the-Other. Smith MB, Harshav B, trans. Columbia University Press; 1998.
15. Di Nicola V. Take your time: seven pillars of a slow thought manifesto. Aeon. February 27, 2018. Accessed September 1, 2024. https://aeon.co/essays/take-your-time-the-seven-pillars-of-a-slow-thought-manifesto
16. Fromm E. The Sane Society. Rinehart; 1955.