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This short book takes on the complicated task of explaining the various grey areas betwixt and between accepted codes of ethics within psychoanalysis. As such, it is aimed primarily at psychoanalysts, although it is also useful for psychiatrists and those in other branches of therapy: ethical issues are not confined to psychoanalysis. Editors Dewald and Clark have put the piece together with the aid of associate editors from the Subcommittee on Ethics Division, although it is not clear from the text precisely who is responsible for which sections of the book.
It does so through a series of vignettes, some of which are left to the reader to ponder, while others are given a clear explanation of the A.P.A. subcommittee’s opinion as to what is the correct course of action to follow. This combination is designed to allow for individual and group discussion of what is ethical in these scenarios, as well as to enable practitioners within psychoanalysis and outside the field to appreciate the thorny situations that may arise in practice. It also does an interestingly subtle job of highlighting the absence of moral absolutes in there situations: one analyst’s obvious response might be ethical anathema to another.
These vignettes are laid out in the book according to the issues to which they relate, with a convenience cross-reference index at the back. Also included are the current principles and standards of ethics of the APsA and provisions and guidelines for their implementation.
The various vignettes are a combination of disguised real cases and invented ones, with no clue to explain which is which. They cover a large range of potential problems, ranging from administrative issues that may arise when supervising students to whether or not it is appropriate to barter with a patient. In this case, and in some others, caution is advised: barter may be a habitual form of payment in some rural areas, and placing a blanket ban on it, as seems to be implied by the apparently unethical scenario depicted in the book (pp.54-55), seems to be inappropriate. Care must be taken that ethical standards reflect and respect social mores without swinging too far into cultural relativism, and issues such as these highlight the potential pitfalls into which the unwitting analyst might fall.
The main problem this book has is that it is very short. The issues that are discussed are covered interestingly and with care, but they represent only a fraction of the possibilities such a case book might offer. Little attention is given to the possibility that a patient might be better served by a therapist in an alternative therapeutic discipline, and how such a transfer might be effected in an ethical fashion. In addition, the possibility of a psychoanalyst employing other therapeutic methods is not discussed, although in practice few psychoanalysts are so strict as to entirely eschew all other therapies.
What is desperately lacking in this book is a study of the ethical implications of false allegations of misconduct or ethical malpractice against an analyst. This absence implies that all such allegations are to be taken seriously, and such an implication is dangerous for the individual analyst as much as for psychoanalysis as a whole. We might be forgiven for wondering if this apparent over-credulity is related to a fear on the part of psychoanalysts to repeat the gross boundary violations perpetrated by some of their most famous historical ancestors. The desire to avoid ethical quagmires is laudable, but what this book highlights is a potential for psychoanalysis to go to the other extreme, and sacrifice the necessary quality of confidentiality in favor of analytic transparency. There are repeated urgings to seek advice from others when an ethical dilemma arises. This is wise, but what is missing is the suggestion of what happens when the advice is unpalatable or bad: should a psychoanalyst ask further advice from someone else? What happens if those consulted disagree? In one rather alarming vignette (pp.48-51), a patient informs an analyst that his colleague is attempting to engage her in a romantic relationship, but she requests that this information remain confidential. One of the suggested responses rests on a technicality: the analyst seeks advice without naming any names, thus keeping to the letter, if perhaps not the spirit, of the requested confidentiality. It is in this vignette that there is an apparent disagreement within the ranks of the subcommittee: others among the group suggest that he attempt to persuade the patient to make a formal complaint, or that he himself make a general complaint of misconduct without publicly going into the details of the misconduct, thereby hoping that the requested confidentiality can be done away with altogether. While such a desire to avoid the difficulties of the past is noble, it seems that the pendulum is swinging too far in the other direction, and some caution might be appropriate on the part of the psychoanalysts using the book for advice on ethical dilemmas.
Cautionary tales aside, this is a nicely written and clearly presented book that should prove useful to psychoanalysts, analysts in training and those who are considering becoming psychoanalysts themselves or who practice some other form of therapy. Open discussion about ethical dilemmas that may arise is essential for all branches of therapy, and this book offers ample opportunity for discussion and debate.
© 2008 Lorna Lees
Lorna Lees is a post-doctoral researcher at the Department of Psychosomatic Medicine of the Technische Universität, Munich. She is a fellow of the DISCOS project and is working on the theoretical and ethical integration of therapy from a philosophical perspective. Her research interests are the philosophy of psychiatry and psychology, particularly when oriented to the self. She is also fascinated by the phenomenon of auditory hallucinations. Email: L.Lees@lrz.tu-muenchen.de