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This book, edited by Anne Kearns, consists of nine articles -- three by Kearns herself, two by Kearns and others and the rest by other authors -- that look at the difficulties involved in psychotherapeutic relationships. It is written by psychotherapists trained in either object-relations theory or humanistic practice, or both. The book is mainly addressed at professional psychologists but potentially of great interest to lay readers who wish to understand the nature and ethical dimensions of the therapeutic relationship, particularly with respect to conflict mediation in the context of an increasingly legalistic turn taken by Anglo-American society. It is clearly written, free of unnecessary jargon and thus fairly accessible to a wide readership. The discussion of numerous case studies certainly helps the authors to make their case. However, having a good knowledge of psychotherapy and its discontents will be very useful for understanding some of the subtleties of the authors' arguments as well as, perhaps, the importance of its main point.
At the center of the book is an analysis of the relationship between therapists and their clients. In a nutshell, the argument is that many of the difficulties of the therapeutic relationship -- of which an increasing number end up as formal complaints filed by the dissatisfied clients -- are inherent in the nature of therapy. No doubt, some of the conflicts appear as the result of provable sheer neglect or abuse from the part of the psychotherapist, as in situations when the therapists uses his or her power over the client in ways that lead to fraud, or to sexual misconduct. But these do not represent the focus of the book, as they are the theoretically unproblematic cases, when it is relatively easy to decide the warranted course of action against the therapist. In many other conflicts, neglect or abuse are merely perceived by the client. The therapeutic relationship may go wrong in relatively minor ways, provoked by the lack of experience or insufficient self-analysis of the therapist combined with the client's own unconscious projections. These "ordinary human errors", as Kearns calls them, can nevertheless lead to serious harm and to the loss of client's trust and often lead to a premature termination of the therapy. In turn, such termination can be harmful for the client -- especially if she or he loses confidence in all therapy. And when conflicts lead to litigation, both the client and the therapist suffer from additional harm. The latter because of the immense strain put on him or her by legal accusations. The former because trials involve the disclosure of details that were meant to remain confidential between client and therapist and because often the conflict with the therapist was a re-enactment of older conflicts or conflictual patterns of the client rather than genuine conflict. Thus, a possible victory in court over a therapist whom the client perceived as indifferent or mischievous can turn into a therapeutic loss.
Underlying this argument is the belief that psychotherapy is itself an erotic relationship, infused with intense and mutual feelings of love and hate, and in which both the clients' and the therapists' psychic processes are involved. Because the relationship is structurally unequal, and at the same time highly intimate and confidential, therapists are placed in a particularly vulnerable position, more often than we would like to think.
The articles discuss both the psychological aspects of the relatively minor mishaps -- how easily they can happen, indeed how almost unavoidable they are given that good therapy usually involves strong processes transference and counter-transference from both sides, how trust is affected and how healing is thus prevented -- and also the consequences of taking a legalistic approach to these conflicts. (I.e. presupposing they can be at all sorted out in courts.) By exposing the inherent difficulty of establishing the parties' exact responsibilities for the harm, as well as the additional harm easily done to both therapists and clients when conflicts are brought to courts, Kearns makes a forceful case for her message that "injuries that happen in relationship need to be addressed in relationship." (xiii) In practice, she advocates procedures of mediation between client and therapist that take place outside courts, in settings organized by professional bodies of therapists who have the necessary understanding of what is involved in the therapeutic relationship and are thus better prepared to minimize the harm brought by conflict. Because the interests of client and therapist are so deeply intertwined, both parties involved in conflicts need the support of professional bodies of therapists who can ideally protect the relationship as well as the individuals involved in it.
For me as a moral philosopher, the understanding of the therapeutic relationships, as proposed by this book, raised challenging ethical questions related to autonomy, justice and care. For example, what is interesting for the autonomy question is the following quandary: on the one hand, we value autonomy very highly, and are committed to affirm and protect it, especially in relationships that are unequal in terms of power -- and therapy is such a case. On the other hand, in order for psychotherapy to be effective, the client and the therapist need to establish a relationship that is very much like the parent-child or lovers' relationships in terms of intensity and risks. This inevitably compromises autonomy. Another ethical conflict exposed by this book is that between on the one hand a commitment to restore justice when one party has harmed or abused the other and on the other hand the importance of protecting the therapeutic relationship from disturbing intrusions that compromise its effectiveness. Finally, the book reveals the sharp ethical dilemma of therapists who are convinced they have been unjustly accused and who have to take care of themselves by defending themselves as effectively as possible; by definition they are at the same time committed to their former patient's well-being and thus naturally reluctant to use, in their own defense, their intimate knowledge of the client. Kearns' book shows that, at least when a therapeutic relationship is at stake, these are not easy questions. Moreover, it is easy to see why the same types of difficulties of judgment and action can be extended to issues of autonomy, care and justice involved in the regular erotic relationships which serve as a model for understanding the therapeutic one.
© 2008 Anca Gheaus
Anca Gheaus is working in moral and political philosophy, with a focus on the ethics of care and theories of distributive justice. Currently she is a postdoctoral researcher at the Universite Catolique de Lille.
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