Psychotherapy and the Ethics of Attention

Abstract

Many psychological difficulties for which patients seek psychotherapy can be seen as requiring some kind of development in the ethical life of the patient. Existing forms of therapy, whether implicitly or explicitly, provide contexts for such development. The aspect we intend to explore is the special role of attentional dynamics: how our capacity to attend underlies our ethical abilities. By investigating attentional dynamics, we do not seek to advocate a particular set of values or a particular brand of moral practice (for example, consequentialist, deontological, virtue-based). Instead, the capacity to attend can be exercised in the service of all the major theories of ethics as they currently exist. Our concern is the psychotherapy of ethics, rather than the ethics of psychotherapy, which represents something of a departure from the norm. To date, discussions of ethics and psychotherapy have shared with other medical ethical inquiry a nearly exclusive focus on ethical constraints on the practitioner, with far less emphasis on ethical processes within the patient. To some degree, this situation derives from the history of normative ethics in philosophy, which has tended to announce a principle or discuss a practice but not to investigate the intrapsychic and interpersonal conditions under which persons affect one another's moral development for the good. When medical ethics today concerns itself with the meeting point between health care provider decisions and patients' moral sensitivities, it tends to focus on questions regarding choice of treatment as mediated by patients' beliefs taken as fact, rather than on how techniques of treatment interact with patients' ethical development. The perceived authenticity of a Jehovah's Witness's beliefs, for example, may affect the decision to honor or to supervene the patient's refusal of blood transfusions. Yet it will not, at least officially, affect the technical details of how blood is transfused, how other treatments are applied, or how patient and physician might converse and modify their views. Nor does the evolution of patient beliefs or the phenomenology of moral decisionmaking on the part of the patient form a subject in standard bioethical theory. In psychotherapy, however, which concerns itself with the patient as a self-aware and, changing psyche, considerations of the patient's ethical stances and their development might be expected often to assume a central role and significantly to affect the details of the course of psychotherapy. This is all the more to be expected when we consider that certain recognized standards of mental health are prima facie ethical in nature. Thus, when the Diagnostic and Statistical Manual IV defines Antisocial Personality Disorder, it includes not only lying, stealing, and cruelty among the diagnostic criteria, but also lack of remorse.[1] Similarly, the exclusive focus on one's own body, self, and self-states reflected in the diagnostic criteria for Narcissistic Personality Disorder--and the inclusion of lacks empathy among the diagnostic criteria--implies that the corresponding healthy adaptation involves responsive relatedness to other human beings (p. 661). Even the DSM IV, then, seems at times to invoke, as one criterion of health or pathology, the behavioral and experiential correlatives to commonsense and philosophical conceptions of ethics. If mental health practitioners advocate high ethical standards for themselves, and if diagnostic categories are founded in part on a moral dimension to psychological health, then it seems appropriate for psychotherapists explicitly to engage ethical issues in the lives of those they treat. Indeed, one of the American Psychological Association's remedies for ethical lapses in psychologists' practice is to mandate psychotherapy for the offender, demonstrating that ethical development can be fostered by psychotherapy. There is no reason for this morally regenerative capacity of psychotherapy to operate exclusively for patients who happen also to be psychotherapists. …