This paper addresses the three questions posed which are: What are the ethical dilemmas faced by the psychotherapist and patient? What are the ethical conditions for employing techniques of psychological influence with individuals and groups? Is there is a role for religion in mental health and psychotherapy? It does this by reviewing the ethical codes of practice of the American Psychological association and Association of Family Therapy to provide an outline of how ethics are thought about in contemporary psychotherapy. However, the therapeutic encounter is a highly subjective one that involves client and therapist factors in the therapeutic relationship, which is a vital mediating factor in how change is created and experienced. Knowledge and techniques are argued to be rooted in a Western epistemological and theoretical worldview. This is not to suggest that these are not of value for working with clients form non-Western cultures, but rather that care needs to be taken to not colonize and impose views on clients. This encounter with the ‘other’ can pose challenging ethical dilemmas for the therapist that can test their knowledge and ability to connect across differences and so an alternative approach to ethics is presented, which takes a more relational approach to ‘ethics in practice’ and involves a deeper emotional engagement with the ‘other’.
The final question, whether there is a role for religion in mental health and psychotherapy is approached in terms of the urgent needs of Muslim clients for a safe exploratory space to work through and reconcile their contemporary challenges with their religious beliefs. It is argued that religion may have a role to play in returning us to ontological questions about the nature of the self and relationship to the Divine to help us re-consider the meaning of ethics in a way that can inform the psychotherapeutic relationship. By considering the Islamic notion of Akhlaq and its etymological root Khalq, it is argued that a meaningful Islamic Ethics could be a foundational framework that develops awareness of our innate human qualities and honors the human being, upholding his/her right of free choice and holds him/her responsible for these choices, helping to return us to truthfulness, to justice, to beauty and to goodness.
1. What are the main ethical dilemmas faced by the Psychotherapist and patient
Psychotherapy is a broad umbrella term that incorporates a number of different theoretical approaches. In general it involves a treatment contracted between a trained professional and a client (this could include an individual, family, couple or group) in which the client hopes to understand and change their psychological condition, including exploring their own feelings, thoughts, behaviors, as well as relationships in order to respond to challenging situations in a more insightful or healthier way.
Psychotherapy is a complex process, which involves a deep and intimate exploration into the very nature of self and delicate areas of human experience, including unconscious conflicts and inevitable dilemmas involving self/other relations.
Kartchovil (1978) points out that the goals of Psychotherapy tend to be formulated in two significantly different ways:
- Removal of difficulties – the goal is achieved when symptoms are removed e.g. the goal to improve a marital relationship
- The goal is to transform the client’s personality in the direction of maturation and realization of the life purpose. Symptom removal would be a secondary consequence.
Vyskocilova & Prasko (2013) argue that both approaches pose ethical dilemmas as clients do not always explicitly know the goals and means from the beginning and it is hard to anticipate what may unfold and what issues may arise. Even if one was to take a more superficial symptom-oriented approach, it is questionable whether it can be done without changing the underlying personality or relationship and if the underlying cause is not dealt with then new symptoms may develop.
However, a change in the personality or relationship has repercussions for self/other relations. For example, dilemmas may arise about whether a client should break out of a limiting relationship or adapt to it. The best outcome for the client, family, community, or society is not often clear until sometime into the therapy process and may present a conflict between these different entities. In fact, the therapist and client may come to see the best option for change differently and dilemmas may even arise for the therapist about dual loyalty to the client or societal beliefs. Vyskovilova and Prasko (2013) thus point out that ethics is integral to the very endeavor of Psychotherapy, as the psychopathology and symptoms the clients present with often reflect their moral problems and implicate interpersonal issues such as the relationship between an individual and society, personal autonomy and freedom of moral choice.
The key objective of psychotherapy, which is better coping and autonomy of an individual to achieve their potential in a particular social context, means that it is vital for the therapist to explore his/her motivations and not to colonize or impose their personal or cultural views on the client. Yet there is no doubt that the therapist has a lot of influence over the client and how they come to understand themselves and their situation. The therapeutic relationship may aim to be egalitarian, but it is often an asymmetrical one. As Vyskovilova and Prasko (2013) put it.
‘the therapist acts as the fixed point that makes a change in the client’s experiencing of self and the world possible… in any intervention, interpretation, attitude taken, even question or non-verbal expression, an ethical aspect may be found’ p 165.
Thus, given the complex, intimate nature of the therapeutic relationship and those clients often approach psychotherapists in highly distressed and vulnerable states, numerous ethical dilemmas may arise. To ensure that harm is not done, and that the therapist acts ethically, psychotherapeutic bodies have issued guidelines to regulate their conduct, which have also now become pre-requisites for training, qualification and supervision.
However, before considering these guidelines it is important to understand the philosophical and cultural roots out of which the contemporary approach to psychotherapy arises.
Approaches to Ethics
Simply put, ‘normative ethics’ addresses how we should make decisions governing our and others’ behavior and what would be right or wrong conduct in moral disputes. Ethics are often taken to be universal truths but Rowson (2001) questions whether they are truths, facts or opinions. He points out that we tend to regard our ethical judgments as moral facts but often they are our opinions and the conventional attitudes of the culture to which we belong. Cotaes (2001) makes a distinction between ethics and morality. She argues, ethics is the value system and thinking that underpins moral behavior. She points out that the word morality stems from the Latin ‘mores’, meaning ‘customs’ and so has a social or consensual dimension reflecting how the vast majority of people are interpreting the ethical thinking of the time. Ethics is therefore, to an extent culturally relative.
Schools of ethics in Western philosophy can be divided, roughly, into three sorts:
Virtue ethics attributed largely to the work of Aristotle emphasised virtues or moral character. It holds that virtues are dispositions to act in ways that benefit both the person possessing them and that person’s society. This persisted as the dominant approach in Western moral philosophy until at least the Enlightenment.
Deontology attributed largely to the work of Kant, emphasised duties or obligations. It made the concept of duty central to morality: for example, humans are bound, from a knowledge of their duty as rational beings, to obey the categorical imperative to respect other rational beings.
Consequentialism emphasised the consequences of actions. Bentham in his approach, known as Utilitarianism, asserts that the guiding principle should be that which ‘produced the greatest happiness or benefit for the greatest number.’
Contemporary approaches to psychotherapy having modeled themselves on enlightenment ideals of science and reason tend to take a consequentialist or deontological rules-based approach to ethics.
This can be seen in the approach taken by the American Psychological Association (APA) code of ethics, which was compiled by systematically gathering data from 1,000 psychologists concerning ethical dilemmas that they had experienced in the course of their work and distilling topical areas on which specific rules which informed the ethical choices for psychologists could be developed. Hence ‘operating rules’ evolved to avoid harmful consequences to clients based on the Utilitarian principle of outcome being for the ‘greatest good’.
I will return to this issue of Philosophical approaches to ethics and the consequences it has for Psychotherapy later, but for now I would like to focus on some of the ethical principles ‘rules’ that Psychotherapy regulating bodies have delineated in order to deal with the main ethical dilemmas that psychotherapists face.
Psychotherapeutic Codes of Ethics and Practice
In particular, I will consider the guidelines offered by the American Psychological Association (APA) and Association of Family Therapists (AFT), in order to consider a range of more individually orientated (APA) and more relationally orientated (AFT) therapeutic approaches.
Professionals are required to have ‘knowledge’ in the form of a nationally recognized qualification in order to be members of a regulatory body. They are required to maintain their ability to perform competently through continuing personal and professional development and supervision. Where a professional may feel a client’s problem is beyond their limits of competence they should seek supervision and if necessary cease to practice and seek alternative provisions for the client.
b. Promote well-being and not cause harm
All approaches stress the fundamental aim to promote greater well-being and understanding and not cause harm. ‘Professionals should seek to safeguard the welfare and rights of those with whom they interact directly but also other affected persons’. This applies in particular to children and dependents, and where an adult may be feared to be a risk to children, emotionally, physically or sexually. Professionals have a duty to report the risk to statutory organizations in order to comply with legal child protection legislation. Professionals are advised to adopt the course of action that ‘maximizes the good and does the least harm’, attaching particular weight to the rights of the vulnerable and those with least power’ Psychologists are also alerted to take accountability and not misuse their power, as their actions may affect the lives of others, they should be alert to and guard against personal, financial, social, organizational or political factors that may lead to the misuse of their influence.
c. Relationships with clients
Professionals should establish relationships of trust with those, whom they work, they should be aware of their responsibilities to clients, society and communities. They should uphold professional standards of conduct clarify their roles and seek to manage conflicts of interest. They should maintain appropriate boundaries with clients and should take care not to engage in multiple roles or exploit clients emotionally, financially or use relationships with clients to further personal, religious, political or other non-professional interests. In particular, violence and sexual intimacy is prohibited. The use of reasonable force is only justified if there is a threat to the safety of any person present. Should any feelings of sexual attraction arise they should be discussed with a supervisor and alternative therapy arrangements should be made. Therapy should only be continued so long as it is beneficial to the client and not for the therapist’s advantage.
d. Respect for People's Rights and Dignity
Professionals should respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination.
Professionals should clearly explain the confidential nature of their work to clients at the outset of therapy and the exceptions, such as sharing information with supervisors or to other professionals within the organisation who may be able to offer consultation but are also bound by rules of confidentiality. In certain circumstances professionals may need to break confidentiality due to their public duty, e.g. if there is risk of self-harm to the client or others. Any disclosure of information should be based on the client’s consent if possible (AFT).
Professionals should respect clients’ privacy and should seek written permission and consent if recording or sharing information about the client. They should anticipate the consequences of breeches in privacy and any harmful effects for clients and discuss these openly with them.
Therapists should not impose their views on clients or preclude their right to self-determination. They should be aware that special safeguards might be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision-making. They should be aware of and respect cultural, individual and role differences, including those based on age, gender, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language and socioeconomic status and consider these factors when working with members of such groups. They should try to eliminate the effect on their work of biases based on those factors, and they should not knowingly participate in or condone activities of others based upon such prejudices (APA). They should try to do what they can to make therapy accessible to those constrained by disability, poverty or language barriers.
Therapists should recognize that all people are entitled access to and benefit from their services and to equal quality in the processes, procedures and services. Professionals should exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence and the limitations of their expertise do not lead to or condone unjust practices (APA).
Therapists should promote honesty and truthfulness in order to promote their objectives of greater honesty and openness in clients. They should strive to keep their promises and avoid unclear, unwise commitments. In situations where they may need to for example break confidentiality and where it is ethically justifiable to prevent harm to others e.g. in cases of physical, emotional or sexual abuse, they need to consider the possible consequences and their responsibility to correct the ensuing mistrust or harmful effects (APA).
In addition, ethics guidelines also offer principles for research and publication, working with the media and complaints and disciplinary procedures. Nagy (2011) stresses that ethics codes are dynamic documents constantly evolving and reflecting continual changes in psychological work. Such as, ‘concerning technology (e.g., computers, videoconferencing), the emergence of new human problems, (e.g., compulsive behavior involving the Internet), new areas of specialization (e.g., lesbian and gay lifestyles), legal requirements (e.g., new laws), and changes in the culture (e.g., increase in racial/ethnic diversity, changing religious orientation and lifestyles).
These principles can no doubt serve as helpful guidance and a standard of practice to try to ensure the delivery of ethical services. It is beneficial for these principles to have been debated within the profession and a commitment to be made to upholding certain standards of ‘good practice’. Importantly they serve to ‘professionalize’ disciplines and to hold them in repute. Nagy (2011) summarizes that the guidelines attempt to strike a balance between being overly general - being too vague and lacking in operational definitions, and overly explicit – having too narrow a focus and providing only individual solutions. He stresses that the ethics code is a dynamic document and needs to evolve and change in relation to changes in the nature of the work.
According to Vyskocilova and Prasko, (2013), however, ethics in practice are invariably lived and are not only a matter of applying some previously given norms and principles, but often call for personal bravery on the part of the therapist to make decisions in situations where there are no clear rules and where they have to take responsibility for their assessments and decisions. They favour a more engaged relational approach to ethics in which ethics are embedded in the whole psychotherapeutic process intertwining psychological, social, and economic aspects. Holmes (2001) points out that a reductive approach to ethics based on guidelines alone misses out many of the key aspects of psychotherapy, ‘not least its confusions, uncertainties and mysteries’. Considering the ethical conditions for employing techniques of psychological influence with clients or groups begins to introduce the more complex, relational and highly subjective aspects of the endeavor of psychotherapy.
2. What are the ethical conditions for employing techniques of Psychological influence on individuals and groups?
Vyskocilova & Prasko (2013) point out that therapy involves a rather strange paradox; with clients often asking for advise and direction on what to do, and therapists responding by encouraging the client to learn to help themselves. On the one hand, therapists try to uphold the ethic of self-determination, and on the other, there is no doubt that they hold a lot of influence over the client. Thus, the ethical conditions for employing techniques of psychological influence on individuals and groups becomes vital if psychology is not to be used as an instrument for imposing our values and colonizing the other.
a. Client factors
Because of the high value placed on the ethic of self-determination, one of the key conditions for employing techniques of Psychological influence are the willingness and choice of the client. However, as pointed out above, this is not a straightforward matter as clients usually come to see a therapist in a highly distressed state and seeking their expertise or guidance without often being aware of what is on offer or the process involved. Depending on what is on offer, clients may have some choice in what particular psychotherapeutic approach they choose to seek or finding a compatibility with a particular psychotherapist or group. In fact, psychotherapy should be a two-way collaborative process with both the client and therapist seeing if they make a ‘good enough fit’ and are able to work through the issues the client brings. A good collaborative relationship that involves a negotiation of appropriate goals is likely to lead to a better outcome.
b. Therapeutic Relationship
Although, the different approaches to Psychotherapy bring a different array of techniques and interventions for the healing of clients, for any technique to be effective, there first needs to be a good understanding, engagement, and establishment of therapeutic boundaries to enable a trusting therapeutic relationship that can facilitate change. Understanding and engaging with the client are key aspects and do not just involve reflecting on the client’s history and current difficulties, it requires empathy, as well as active awareness by the therapist and attention to how the mutual therapeutic relationship develops. The therapeutic relationship often reflects other relationship patterns in the client’s life, their feelings, beliefs, expectations and ways of behaving and so in order to create change and if used reflectively, the therapeutic relationship, can become the vehicle for change. It is vital the therapist attends to ethical issues of their own power and influence in the therapeutic process. Vyskocilova and Prasko (2013) describe the complexity of the subjective dimensions of the relationship and how the client may project all sorts of wishes of rescuing and fantasies of omnipotence on the therapist. The role of the therapist is to meet this need in the client until they develop insights and greater autonomy over their own lives, but the fine balance is to do this without a loss of self-esteem for the client and without exploiting it to fulfill the therapist’s own need for dependence or wish to control or influence others, albeit with good intention. Holmes (2001) describes it as, ‘the therapist has to open themselves to the patient counter-transference – becoming aware of positive and negative feelings (including prejudice and sexual feelings) that may arise as a result of the intimacy of the therapeutic relationship.’ At the same time, they must cultivate an attitude of detached yet passionate curiosity about such feelings. The therapist must be able to accept the patient’s destructive and self-defeating actions as aspects of necessary defense mechanisms, while at the same time not condoning them.
In order to enable the client to be himself or herself and to be honest, the therapist has to take a non-judgmental position, so that the client feels safe enough to explore their own views and hidden thoughts, desires and secrets. They also need to respect the client with all their peculiarities and with whatever may come up, retaining confidence in their self-recovery potential, being willing to learn from them and not cover up their own mistakes without falling into contempt of the client.
In the postmodern context the therapist is seen as much a part of the therapeutic system and process of change as the client, and not an objective authority figure outside of the system. Hence, the ‘awareness of self’ on personal, social and political levels has gained greater attention as an ethical condition for effective therapy.
c. Self of the therapist
Vyskocilova and Prasko, (2013) propose that the ‘therapist’s personality is the main tool of psychotherapy’ p171. The therapist requires a high degree of self -awareness and to be able to take responsibility for his or her own personality, abilities and limitations. This is why, most Psychotherapeutic approaches require therapists in training to undergo their own self-exploration through personal therapy. Holmes (2001) asserts that Psychotherapists are no less flawed than anyone else is, as he puts it ‘they do not have to have the ethics of a saint nor the wisdom of a sage’ (xvi). In fact, they have often been through their own mistakes and challenges, which have often led them to the healing profession. However, he stresses that they need to have three interrelated qualities that go some way towards ensuring ethical practice.
- Capacity for self-reflection
- Ability to put these feelings, thoughts and action into words and not enact them
- Ability to attend to boundaries – e.g. personal and political; private and public.
Holmes (2001) further suggests, that when the therapeutic process does not go as anticipated, despite our best efforts we may not be able to protect a client form harm, it is important for the therapist to acknowledge their own limitations and to be able to think about and reflect on failures; reminding us that there is value in humility and in accepting one’s relative powerlessness.
In addition to self-knowledge and the ability to build a good therapeutic relationship, the therapist is required to have ‘knowledge’ that can be of benefit to clients in dealing with their Psychological challenges. Numerous approaches to therapy and training programs abound and each professional body defines in their curriculum what constitutes knowledge. Therapists are required to demonstrate this knowledge and their competence in theory and practice in order to qualify. Whilst in effect establishing a certain standard to ensure ethical conditions for practice, questions arise as to which knowledge or techniques are given precedence and which may be precluded. For example, most modern psychotherapy schools would distance themselves from techniques such as ‘spirit exorcism’.
More recently, with the setting up of National bodies, such as NICE in the UK- National Institute for Health and Care Excellence there has been further specification and guidance on what constitutes ‘knowledge’ and what are the ‘best’ evidence-based treatments for particular conditions. Some types of therapy may be more effective in certain problems and some more effective in others, or even contra-indicated. For example, if the only approach proven effective with severe obsessive-compulsive disorder (OCD) is Cognitive Behavior therapy, CBT, should clients be offered anything else?
Evidencing effective outcomes in psychotherapy is, however, complex, debatable, and not amenable to objective measures such as blood tests. For example, what constitutes a good outcome? A reduction in symptoms, although taken as indicative of a good outcome, may not relieve the underlying cause. Moreover, measuring outcome is highly subjective and relies on self-reports of clients and professionals. A one size standardized approach may not fit all clients. NICE, mitigates against this by recommending that professional assessment along with patient choice should guide treatments and techniques employed, but in effect it constructs a dominant discourse based on a medical model view of mental health and large scale studies that have managed to secure funding, and do not for example employ culturally diverse samples. This in fact may limit professional opinion and clients’ choice, as more and more public services available in the NHS or commissioned by insurance companies are based on ‘evidence-based practice’, and preclude other approaches to mental health, such as those drawing on different methods or cultural and religious beliefs which have not yet been ‘proven’ to be effective through research. Then again, this begs the ethical question of whether clients should be treated by methods the effectiveness of which has not been empirically evidenced.
e. Techniques and Interventions
Different Psychotherapeutic approaches have developed different techniques for intervention to help the client gain insights into their own condition, establish dialogue, experience change and improve their condition. Psychotherapists should be careful to introduce these to clients in a way that they have choice in partaking in them and are able to decline if they do not find the approach helpful without the therapist taking offence. It is hard to distinguish at times when a technique fails, whether this is due to client factors, the technique, or the way it was administered itself. The therapist’s assessment of which technique may benefit which client and discernment about the appropriateness of a technique for a client often depends on their clinical judgment and previous experience.
In order to ensure the ethical use of skills and techniques, as well as to personally develop the therapist and hold them accountable to their practice supervision is an ongoing mandatory requirement for registration. It ensures transparency and enables on-going learning as well as a space where the therapist’s own values and ethical dilemmas can be explored.
Critique of contemporary dominant approaches to ethics and practice
This approach to ethics in contemporary Psychotherapy in the form of ‘universal codes of practice’ and the ‘conditions for applying psychological techniques’, is no doubt useful and instructive to some extent in understanding what is already a highly complex encounter between patient and therapist. However, I would propose that this approach is limited and betrays the Western cultural assumptions and philosophical roots that it is based on. Furthermore, it does not acknowledge the challenges involved in cross-cultural encounters with the ‘other’ that may belie the seemingly Universalist ethical stance that contemporary psychotherapy presumes.
Whilst it advocates self-determination as a key ethic, it is in danger of imposing its own values on clients form other cultural and religious traditions by not being transparent about its ethnocentric roots. This is not to say that psychotherapy codes of ethics are of no value and that a therapeutic relationship cannot be formed across cultures, rather it is to argue for a more relational approach that in trying to find some common ground deeply respects the ‘other’ and their world view and does not try and appropriate them to our own pre-conceptions and world view.
A number of writers have critiqued the contemporary approach taken to ethics by psychotherapy even within the Western tradition as being reductionist, and for separating the personal and professional. Haidt (2006) in his book the ‘Happiness Hypothesis’ points out that the Western approach to ethics, like that of most other cultures, started off as rooted in ancient wisdoms - the Old and New Testaments and the works of Homer and Aesop. He argues that these more grounded approaches used maxims and role models to teach ethics but were replaced by the post Enlightenment scientific approach deploying proofs and logic. Fowers (2005) traces how Psychology, in order to cast itself as a science started to distance itself from history, culture and religion. It did this by shifting the focus from Character, which was seen as resulting from normative social ethics, to the amoral term ‘Personality’. According to Haid, the turn to rationality and the search for universal laws, as is found in the work of Kant and Benthem, reduced ethics to a set of guidelines focused on actions- what ‘we aught to do’ rather than ‘what kind of person we should aim to become’. He refers to this as a turn from character ethics to quandary ethics and a shift from teaching moral education as virtues to moral reasoning. For Fowers (2005) this objectification of knowledge obscured the subjective dimension of ethics, which she regards as being vital for embodying ethics.
Haidt (2006) regards the turn from character to quandary ethics as a profound mistake as it weakened and limited the scope of morality. Instead of being seen at work in everything a person did, as was the case in a virtue-based approach, it got relegated to specific situations and a trade-off between self-interest and the interests of others.
Loewenthal and Snell (2001) go further in commenting on ethics and the dominant notion of autonomy in modern Psychotherapy. They argue that western culture has become dominated by the Greek notion of autonomy which places the individual first and that the Hebraic notion of heteronomy, which places the ‘other’ first has become subjugated. Drawing on the work of Jewish Philosopher Levinas on heteronomy they posit that truth is not outside of experience, and so it is always beyond us (i.e. the individual). They argue, ‘experience is, that which gets us in touch with that which is other than what we are’ p25 and so it inevitably requires the ‘other’ and stepping outside of ourselves. Hence they propose that the focus of ethical psychotherapeutic practice should not be on reductionist codes of conduct that only serve to replicate our own autonomy and the values of our culture which we are unconsciously subject to, but rather on what we regard as essentially human and that which incorporates and accepts the ‘other’. They conclude that ethical codes and their subsequent complaints procedures, although they appear to be about the ‘other’, can obscure the relationship and get us caught up in a ‘type of knowing’ that stops us from thinking of and accepting the ‘other’. They claim that ‘ethics as practice’, necessitates that we can only be ethical if we take responsibility and see the ‘other’ as someone we can serve and learn from.
Frosh (2009), also argues that we underestimate the degree of alienness that otherness entails and he cautions against appropriating or colonizing the other, following the work of the feminist psychoanalyst Benjamin, he proposes that we should contest our omnipotence by taking a stance of, what Benjamin calls, ‘recognition’ that allows for and presumes separateness rather than absorbing the self into the other or by colonizing the other. He points out that the recent debates about the limits of multiculturalism highlight ‘the small space between the liberal urge to understand the other and the wish to remove the other’s ‘otherness’’ p 189.
Similarly, Dalal (2011) in his book ‘Thought Paralysis’ describes this paradox of liberalism, and how in effect is has guarded against truly engaging with the other by adopting a stance of ‘leave and let alone’. It has done this by over-emphasizing policies and procedures as objective and under-emphasizing that human beings are intrinsically biased and are the implementers of procedures, which can thus always be appropriated and put to other ends. He argues that as professionals we are constantly discriminating but need to be clear about whether our discrimination when working across cultures is an ethical one or a racist one. The only way to test the ethic, he says, is by dialogue and engagement, which in turn is terrifying as it involves an exchange in intimacy and ideological fluids that may shift my identity and allow the others world view into mine, so that I may become ‘other’ to myself. Haidt argues that this kind of deep engagement with ethics is only possible by engaging with the particulars of a situation (as opposed to relying on general rules) and engaging emotionally and not just at a rational level in a way that is transformative of the person and their character.
Psychotherapy and the intimate relationship that this entails offers the opportunity and necessitates an active engagement with the other and the human dilemmas that they bring if it is to be transformative for the client and therapist. For Larner (2009) the aim of the therapy is to be such an ‘ethical container’, it requires the therapist to adopt a position of ‘not knowing’ to be able to receive the thinking and emotional experience of the other, and as Levinas suggests, to truly put the other first. Similarly, Weiner (2001) argues that if the therapist is to struggle with ethics then the therapist has to be able to hold a state of mind, a kind of liminal space, in which the discomfort of opposing tensions can be tolerated and thinking becomes possible. In fact, Solomon argues that ethics, in contrast to morality, implies an attitude achieved through judgment, discernment and conscious struggle, often between conflicting rights and duties.
Thus, along with these critics Haidt (2006), Fowers (2005), Lowenthal and Snell (2001), Frosh and Larner, I prefer a more engaged relational approach to ethics in which ethics are embedded in the whole psychotherapeutic process intertwining psychological, social, cultural, economic and political aspects. This becomes even more necessary when working with clients from diverse backgrounds to one’s own, be it cultural or religious, and where we may not be able to reach an easy ethical reconciliation. This venturing into ‘unknown’ territory as Holmes (2001) points out is avoided by a reductive approach to ethics based on guidelines alone, and misses out many of the key aspects of psychotherapy, ‘not least its confusions, uncertainties and mysteries’
3. Is there a role for religion in Mental Health and Psychotherapy?
Western Psychotherapy has historically separated itself form religion, and is largely based on a liberal secularist world-view. It is rooted in Western historical and cultural contexts marked by the Enlightenment, which has led to the separation of man from the universe. Fowers (2006) argues, ‘Separating "objective" and "subjective" domains was a powerful move toward opening up scientific observation of the world, but part of the allure of this separation has been that it makes personal feelings and preferences subjective affairs, unconstrained by either traditional dogma or scientific fact. The separation of truth (to be determined scientifically) from the good (to be defined in terms of personal preferences) was designed to liberate individuals to pursue their own freely chosen ends. In this developing worldview, we in the West have come to increasingly see the world as neutral matter for individuals to shape according to their own purposes.’
Whilst this outlook provided certain benefits, Fowers argues it has also led to considerable loss of meaning and connectedness.
‘This outlook provided the considerable advantage of being able to attain a greater and greater ability to predict and control the physical world by tracing the contingent correlations among and causal influences on phenomena. At the same time, this separation of the observer from a meaning-laden cosmos in which one had an intelligible and significant role was a dramatic loss, which opened the possibility for a profound sense of alienation and meaninglessness to us moderns’.
The scientific world view of humanity has led to a highly compartmentalized view of the human being that not only separates the self from the universe, but also separates mind from body (along the lines of Descartian dualism) and dismisses the spirit altogether. This is at odds with more holistically orientated non-Western cultures, in which the worldview is still of a moral universe, in which ethics are integral to the sense of self and notions of health and illness. I do not wish to idealize this in any way, as religion too can easily be distorted and used for unethical ends. Religion may therefore have a two-fold role to play in mental health:
- 1. To effectively treat clients from these cultural backgrounds and I will address specifically the case of Muslims, it is important to engage and work with their beliefs. This is the kind of encounter with the ‘other’, described above, where psychological theories and the therapist’s and client’s personal beliefs on ethics, such as; authority, gender relations, sexuality etc. may be in conflict and challenged.
- 2. To construct an alternative Psychological framework based on a more holistic notion of self that is integrated with indigenous cultural religious and spiritual beliefs and wisdom that promote well-being. This does not mean completely discarding what contemporary Psychotherapy has to offer (for example, the approach to ethics outlined thus far), but to question some of the central assumptions and to offer alternative concepts and techniques that can contribute to our understanding of the human self.
Either way, an engagement with religious beliefs is urgently required to meet the mental health needs of Muslims, who find themselves split between their faith tradition and their contemporary world and with limited avenues in which to seek help for the contemporary problems they face. That is, faced with difficulties, do they seek help from religious scholars who have little understanding of mental health and may lack the required therapeutic skills to help them explore and mature? Can the client find a safe space that allows the honest questioning of beliefs and an open exploration of oneself in order to bring about change from within that can be rooted in one’s religious framework? Or do they seek help from Western trained psychotherapists whose theory and approach may be colonizing and lacks understanding of the client’s religious and spiritual beliefs or may not be able to help them integrate this aspect of themselves in the changes that they need to make.
In my work with Muslim clients over the last twenty years I have been trying to integrate religious and spiritual beliefs in my approach, and like other practitioners I have tried to do the best I can in terms of finding creative ways to engage with impasses that clients come to, drawing on and re-working deeper understandings of religious and spiritual concepts that may facilitate well-being. But a more rigorous approach is required that engages with the interface between Islam and psychotherapy, and that can operationalize concepts that may be of psychological benefit to human well-being.
For the purposes of this paper, I will focus on ethics in particular and begin a tentative exploration of what an Islamic perspective on ethics may have to offer psychotherapists. This also alludes to a different underlying notion of self. Thereby giving an example of how this interface may be approached.
The notion of Ethics in Islam is referred to as Akhlaq in the Arabic language, the root of which is ‘Kh-L-Q’, which is the same root as for creation. This etymological relationship suggests that Khalq, creation, and Akhlaq, ethics, are intrinsically related and integral to one another.
Some verses that refer to this relationship in the Quran are:
Taha-50: He said, “Our Rabb is the one who gives everything its nature (Khalq) and then guides it.”
Jaathiyya-22: Allah created (Khalaq) the heavens and earth by Truth (Haqq) that every soul (Nafs) may reap the consequence of what it earns and they are not oppressed.
Sajdah-7: He is the One who made beautiful and good (Ahsana) everything He has created (Khalaq). And He began the creation (Khalq) of the human being from clay.
Infitaar-7: He is the one who created you (Khalaq), balanced you and made you upright.
In these verses, Creation “Khalq” and noble character “Khuluq” are intimately related. The first verse suggests that the Divine act of Creation has embedded within it the imprint of human character qualities. The human being is created with an innate sense of ethics, an intuitive cognition of what is truthful, and a natural inclination towards what is beautiful and good. These are the elements of divine guidance that are intrinsic to Allah’s creative power and they give the human being the capacity to evolve and develop his/her character to reach the ultimate level of humanness, which is Ihsan.
The second verse suggests that the universe is created, i.e. it is brought into existence, through Truth. The very structure of existence is based on Truth. Moreover, every soul is given the freedom to choose what it will earn, and it reaps the consequences of its own choices without compulsion, without coercion, and without injustice.
The third verse suggests that everything in existence has been created with the innate potential of utmost beauty and goodness. Creation is an evolutionary process that advances towards the realization of this beauty and goodness. The human being begins from the lowest of substances, clay, and evolves to realize his innate beauty and goodness.
The fourth verse suggests that Allah created the human being with a natural sense of balance, uprightness and justice.
Together and in terms of their implications for psychotherapy, these verses suggest that the human being suffers psychologically when he/she is not in harmony with his/her innate nature (often referred to as Fitra) that is when he is separated from truthfulness, when he is engulfed in ugliness, when he is subjected to or inflicts injustice, when he/she is repressed, or oppressed, or prevented from making his/her choices freely and to be deprived of responsibility for his/her own actions.
I am not suggesting a moralizing stance here, but rather I am suggesting that a meaningful Islamic Ethics could be a foundational framework that develops awareness of our innate human qualities that helps to return us to truthfulness, to justice, to beauty and goodness. Islamic Ethics would honor the human being, uphold his /her right of free choice, and hold him/her responsible for these choices. The result of this would be a psychologically healthy balanced human being.
Ethics can be thought of laws and limits to try to ensure human dignity and self-determination, and this may be the task for Sharia scholars, but it can also be thought of as a dynamic approach that helps us come to realize ethics in practice - truthfulness, justice, beauty and goodness, through self-exploration, which is the task of psychotherapy.
To illustrate this, I will share a case vignette, which highlights this struggle.
I have changed features and details of this case in order to protect the privacy and respect the confidentiality of the clients.
Mr. Rida contacted me for urgent help with his son. The family was of Iraqi origin and their sons and daughters had grown up in the UK. I asked Mr. Rida if he would like to come and see me together with his son, or whether he preferred to come alone. Mr. Rida, spoke to his son and they decided his son Ahmed would initially come and see me by himself. Ahmed was 22 years old and he explained to me how his relationship with his father had always been difficult and distant, as his father was pretty much absent throughout his childhood. Things had got much worse recently. He seemed uncomfortable and as if, he was uncertain about what to share with me. I asked why and encouraged Ahmed to share what he was troubled by. Ahmed decided to take a risk and told me that the problem was that he was homosexual. He had known this from the age of 15 years old but had always concealed it. The consequence of repressing this was that he felt like a liar and hypocrite and had started to harm himself by cutting himself to relieve the emotional pain he felt. A few months ago, he decided to pluck up the courage to tell some friends at university. Most of his friends had seemed accepting, but then one of them had told his father behind his back. When his father confronted him, Ahmed admitted to being homosexual. His father was devastated, and told him that he could repent and that Allah forgives sins. As his father, he offered to keep this a secret and that he would support his son if he repented and would forget this ever happened. Initially Ahmed, on seeing his father’s distress, agreed but then some weeks later had started loathing himself again for not being truthful and continued to self-harm. Ahmed felt he had no choice in his sexuality, he said he would never have chosen to go through this. He believed in Islam and considered himself a Muslim but knew this was considered morally wrong. Ahmed could no longer stand the situation at home and feared if his brothers found out they may physically harm him. He started looking for a job abroad and told his parents that he would be leaving home. As the time approached, Ahmed noticed that his passport had gone missing. When he approached his father, he admitted to taking it and said he would not let Ahmed leave. Ahmed was now in a difficult situation where he had to leave to start his new job in the next few days. He did not think his father would back down and resolved that if his father did not return his passport he would run away from home or kill himself.
I was in a dilemma; I was worried about the safety of this young man and aware that this situation was escalating and coming to a head. At the same time, I knew how difficult this must be for his father, keeping this to himself and to risk letting go of his son, to what he regarded as life of sin. I offered to meet with his father to see if I could be of any help, although I was apprehensive, as I at first imagined him as an authoritarian Muslim father who would be unlikely to change his view on this matter.
Mr. Rida agreed to see me. He was distraught and stressed, as Ahmed was due to leave the next day. He told me the situation from his perspective and how he had tried to be a good father and to guide his son to repentance and offering to support him if he changed his way. He had also offered to keep this a secret between them. This approach had not worked, as he knew that Ahmed was lying to him and the trust between them had been broken. He was afraid that if his son moved abroad and had greater freedom he would go further down this path. He had researched homosexuality on the Internet and knew the different perspectives.
He told me he knew he had two options, either to stop his son forcefully, but he knew this was illegal in this country (the UK) or to accept his son’s sexuality, but he could not do that as a Muslim.
Some of the ethical dilemmas that crossed my mind were: does this young man have a right to self-determination even if it goes against his father’s wishes? What was his father’s responsibility and what was Ahmed’s responsibility? What would be the consequences if this young man seriously harmed himself or committed suicide? What would be the consequences if his brothers found out and harmed him? What would happen if this came out in the community and to what extent was shame a factor in Mr Rida’s reaction?
The situation reminded me of an episode in my own family that had led to a painful separation due to insurmountable differences, which had felt tumultuous and like then end of the world at that time. I empathized with Mr. Rida and told him I knew this was the most difficult situation for him. I urged him to try to be merciful and wise in how he handled this situation as a father and told him my real concerns for Ahmed’s safety in terms of familial violence or self-harm and wondered how Mr. Rida would live with these consequences if they transpired. I told him that I did not think you could force or change someone against his or her will and did not know if Ahmed’s sexuality was a matter of choice and that this may be something Ahmed had to struggle with. I also told him that I thought the situation was intolerable for both of them to keep living together and that it would keep leading to conflict.
Mr. Rida said he had thought I would say this, and at first, I wondered whether he was just dismissing what I was saying. He expressed concern about his son’s self-harm and knew he had threatened to kill himself. He told me that he knew that he had no choice but to let his son go. We both sat in silence for a few moments, in which all I could do was to try to connect with his pain and anguish as he agonized about what to do. He hung his head down in resignation, and said he had two further options. Either he could let him go and tell him he was no longer his son, or he could let his son go and keep the ties as a father. I waited in anticipation for another few moments and then Mr. Rida said, “I am a father, and I know I have to keep the ties.”
My heart went out to Mr. Rida as I knew he had made the harder choice and that for him as a father to let his son go, into something he did not agree with, but to keep the family ties, was heartbreaking. Somewhat surprisingly to me, the ethics of familial ties and his responsibility as a father had become a higher context marker than his son’s sexuality in how to do deal with this ethical dilemma. This highlighted for me the fine balance, competing considerations and conflicting feelings that have to be taken into account in each specific situation to reach what may be the best outcome in a particular situation. For me this process was akin to the ethical container that Larner describes, in which the ‘other’ is put first and the therapist and client come to know together, through the therapist connecting with the suffering of the client, rather than their own pre-conceived ideas. Meyer et al (19) in their description of the ninety-nine names point out that The word Haqq– Truth, in Arabic as a verb becomes haqqaqa – meaning ‘to journey into the heart of the night and at the same time to exert oneself to the outmost degree’. For me the psychotherapeutic process is often about such a struggle. It is only by engaging with the pain and ‘unknowing’ of what to do when faced with difficult relationships with those we are closest to, and with genuine human dilemmas that we are called into the struggle of ethics in practice. If we are able to respond to such situations in a truthful and balanced way, then we have the opportunity to do good and act with beauty – Ihsan.
Shah-Kazemi, R (2014) points out that the supreme source or condition for ethics is Rahma – Compassion and Jamal – Beauty. God is said to love Beauty. In addition, it is the love of divine Beauty that inspires us to do good in this world and that leads to Ihsan, i.e. beauty and goodness. Furthermore, the creational relationship is defined by, ‘God loving everything that He Created’.
The psychotherapeutic space can be seen as a co-creational space in which clients are coming to know themselves, to facilitate this delicate process and help people to come to their inner guidance. Moreover, in order to realize what is beautiful and good there needs to be space for Rahma - deep love and acceptance of the human being that allows learning and growth.
The therapist should be the embodiment of virtue and needs to journey with the client, sincerely struggling with the ethical dilemmas that come up through the relationship. This is as much a learning process for the therapist as it is for the client and cannot be reduced to some rule-based code of ethics. The Psychotherapeutic context may be an instructive one to consider the kind of ethical dilemmas that Muslims are facing and to facilitate a process of connection to our Rabb, through a compassionate relationship that allows us to access His guidance to His Khalq in a living way that in turn helps people connect to their intuitive cognition of what is truthful.
Clarifying the Islamic foundational framework for ethics may help Muslim clients orient themselves in how to deal with the ethical dilemmas they face and not feel torn between their Religious beliefs and modern approaches to dealing with socio-cultural and psychological challenges such as Psychotherapy. Furthermore, it may help them bridge different worldviews and integrate their identities, creating a sense of inner and outer coherence and better relationships and stronger communities.
* Dr. Rabia Malik is a Consultant Systemic Psychotherapist based at the Tavistock Centre in London. She presented this paper in the “Islamic Ethics and Psychology” seminar, which was held in Doha on 22-24 November 2014.
 This could include Psychology, Psychiatry, Psychoanalysis, Counseling, Systemic therapy, Transpersonal Therapy, Hypnotherapy, Movement therapy, Art Therapy and more.
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 In Arabic, the root of words is formed by tri-literal verb structures.
 Sharia is the Arabic word for the science of Islamic jurisprudence.
 The Arabic word Rahma – translated as compassion, comes from the etymological root-meaning womb.