The limits of client autonomy in psychotherapy

In the movie, Analyze This, a psychiatrist has to deal with treating a criminal whose anxiety interferes with his ability to do his job, which includes killing people. The movie is a preposterous and rather horrifying scenario, but it doesn’t challenge accepted ethical guidelines on client autonomy—clients do not have a right to request treatment to enable them to harm others. Such demands are well outside of the scope of client autonomy.

While no one (all right, so I can’t promise there is not some sick exception out there) thinks clients should have unlimited autonomy, maximizing autonomy has been particular focus of bioethics since its inception in the 1970s. This, combined with movements in psychotherapy and feminism to empower both clients generally and women in particular, gives way to some perplexing situations. This is particularly true, to my mind, in cases of so-called “internalized oppression.”

In the 1980s, feminist philosopher Dale Spender rejected the idea of singular truths as being too oppressive, claiming instead, “Only within a multidimensional framework is it possible for the analysis and explanation of everyone to avoid the pitfalls of being rejected, of being classified as wrong.” Spender was specifically advocating a multidimensional view of reality as a way of empowering women.

Similarly, collaborative therapy intends to empower clients by rejecting preconceived notions of truth and meaning, or even of therapeutic goals. In her 1997 book, Conversation, Language, and Abilities, Harlene Anderson writes, “A therapist is not a detective who discovers the truth, or what is true or truer, false or falser.” She goes on to say, “A therapist does not control the conversation, for instance, by setting its agenda or moving it in a particular direction of content or outcome. The goal is not to take charge or intervene.”

So, what is to be done with a client who embraces and fails to question a system that is oppressive, hierarchical, and one-dimensional? If a client has embraced a system that devalues the worth of the client, it would seem honorable and right for the therapist to guide the client to question a system that is degrading and demoralizing, rather than helping the client explore ways to function more effectively within that system. Of course, a therapist may simply open a conversation and hope the client with find liberation on his or her own, but this is a disingenuous respect for multiple truths.

Commenting on the goals of multidimensional feminism, Jean Grismshaw said, “The fact that one group has power over and exploits another, cannot be reduced to anyone’s belief that this is so; nor does the fact that someone does not understand their own experience in terms of oppression or exploitation necessarily mean that they are not oppressed or exploited.”

A belief in moral progress entails a conviction that some truths are better than others. We must believe that changing what we believe can make the world better. In Plato’s allegory of the cave, the philosopher who has become enlightened will not want to return to improve the affairs of men, but it is a duty to do so. If those who are in chains do not realize they are in chains, those who are free must help them.

William James, who I believe is one of the greatest psychological theorists of all time, also rejected the certainty of truth, but he noted that when we give up certainty, we “do not thereby give up the quest for truth itself. We still pin our faith on its existence, and still believe that we gain an ever better position towards it by systematically continuing to roll up our experiences and think.” James also believed in progress—epistemic progress and social progress. A commitment to truth does not demand that we discount the knowledge or experience of others, but it does demand that we constantly seek what is better in our lives.

While we may not pass judgment on someone who does not share our values, the values we hold most deeply must remain important to us. If our own values mean nothing to us, our lives have no meaning. The postmodern therapist has values and wants others to share them; otherwise there is no point in seeking healing. If we don’t seek more valuable lives, there is no point in living.

How free can we be?

I’m a little behind the curve on this, but a Jan. 2 article by Dennis Overbye in The New York Times deals with free will and the latest developments in cognitive science regarding free will. Overbye cites the work of Benjamin Libet who demonstrated (to his satisfaction, anyway) in the 1970s that people act before becoming consciously aware of their choices. Consciousness and apparent free choices seems to follow the mechanism we call our body rather than direct it. It is compared to a monkey riding the back of a tiger and making up a story about how the monkey directed the tiger’s actions.

The no free-will bus campaign
The no free-will bus campaign (Photo credit: morgantj)

To some extent, I guess we all believe that actions are caused by physical laws and past events. Whenever someone commits a horrible crime, we ask, “What would cause someone to do such a thing?” We believe there is an answer, and scientists seek the answers. People who argue most strenuously for free will will generally back off when confronted with their own shyness, depression, impatience, or other trait they’ve tried for years to modify.

A simple test for free will involves the compulsion to crunch on ice. For reasons I don’t understand, people with an iron deficiency will crunch ice compulsively, annoying co-workers, family members, and passers-by. Give them iron, and suddenly they “choose” to stop crunching ice all the time.

English: Daniel Dennett at the 17. Göttinger L...
English: Daniel Dennett at the 17. Göttinger Literaturherbst, October 19th, 2008, in Göttingen, Germany. (Photo credit: Wikipedia)

So, is this cause for despair or optimism? Understanding the causes of our actions gives us more tools to help control them (giving iron supplements, for example). At the same time, knowing our actions are caused makes us doubt the free will of the soul (or mind, if you prefer). We feel a loss of dignity, for some reason. Daniel Dennett argues consistently and persistently that recognizing and understanding causal relationships gives us more freedom, not less. When he says “more” freedom, though, he really means more than none, which isn’t comforting to the hard-core indeterminists in the world.

One problem is that punishment becomes meaningless if people are not free, or so it is claimed. Baruch Spinoza answered this by saying that you would control the actions of a rabid dog in the same manner regardless of whether the dog chose to be rabid. The same, he claimed, should apply to humans. Punishment is no longer retribution, though, it is now simply a necessary condition of life.

William James
William James (Photo credit: Wikipedia)

On the other hand, William James claimed that we are forced to believe in free will because we are forced to make choices every day. If we do not believe in free will, we cannot make any choices, so we are paralyzed. From a practical standpoint, we feel we are free and must act as if we are free.

This may be as good as it gets.