The Patient as an Ethical Subject: Technical Implications of the Patient’s Irreducible Responsibility

Abstract

As part of what has been called “the ethical turn” in psychoanalysis, analytic theorists have begun to recognize patients as ethical subjects in their own right, in possession of a full range of moral responsibilities and obligations, including to analysts themselves. While this ethical conception has made its way into our theories of mind and therapeutic action, less attention has been paid to the topic of technique. This paper attempts to tackle the question: how do we integrate an exploratory analytic method with a therapeutic stance aimed at cultivating patients’ ethical responsiveness toward Self and Other? The author reviews the literature on ethical intersubjectivity, in which therapeutic action is constituted by the mutual ethical development of both analyst and patient. Utilizing a clinical example from the treatment of a young male patient engaged in a paranoid and erotic transference, these techniques are illustrated at the level of moment-to-moment therapeutic process.

Keywords:

• ethics
• intersubjectivity
• mentalization
• relational turn
• technique

Notes

1 I have modified demographic and identifying information about this patient in order to disguise his identity. The patient has reviewed this paper and granted permission for it to be published in its present form.

2 How are we to understand this lack of discussion of patient-centered ethical technique? Perhaps ironically, I attribute it to concerns about ethics, namely the longstanding psychoanalytic assumption that we should not be imposing our personal values onto patients. This old concern has taken a new shape in relational/interpersonal theory, which tends to discourage us from having a “roadmap” about how the treatment is supposed to proceed, instead recommending we tailor our interventions to the unique needs and experiences of the particular patient with whom we are engaged (Mitchell, 1993; Tublin, 2011).

3 While I utilized a wide range of more “traditional” analytic techniques in this treatment (e.g., involving exploration of early developmental experiences, sexuality, defensive operations, dreams, transferential processes unrelated to ethics), given this paper’s focus on ethical experience, I will primarily highlight my ethically-oriented interventions with this patient.

4 In his case example of the patient who intrusively visited him at his home when he was recovering from heart surgery, Irwin Hoffman (2000) offers one of the most fully elaborated illustrations of ethical transference work, involving exploration of the patient’s own ethical conflicts, consideration of the patient’s “power to hurt” the analyst (p. 831), and self-disclosure of the analyst’s emotional response to the patient’s ethical transgressions against the analyst.

5 While I think that the patient being able to “use the clinician” is an important part of all effective analytic work (Winnicott, 1971), there are also ways in which the patient can only use the clinician without developing a full regard for the clinician as an independent person. Such processes often imply ethical vulnerabilities having a broader relevance for the patient’s relational matrix outside of sessions.

6 In any treatment, there are certain times when I am more focused on helping patients elaborate the more “Self”-oriented aspects of their experience, and other times when “Other”-oriented explorations attain greater prominence. In future discussions of these matters, there could be value in considering the question of when we direct greater attention to Self versus Other in ethically-oriented psychoanalytic work, and how to even go about determining such a thing.

7 In advocating for the importance of ethical technique, I am not claiming that we should ever seek to impose our moral values onto patients, or to “convert” them to our ethical worldviews. There is a mammoth difference between declaring, “The way that you are treating your wife is wrong,” and disclosing, “When you talk about your interactions with your wife, I sometimes find myself starting to judge you, and worrying about whether she is feeling heard and seen in your relationship.” In the former case, I am speaking from a position of non-reflective objectivity, as if I have access to “the truth” about right and wrong behavior. This sets me up as problematically having authority over the patient, naturally placing the patient in an inferior role. The patient is forced either to resist or comply, which prematurely shuts down exploration of the matters in question. In the latter case, I am simply sharing my subjective states in response to the patient’s relational patterns, which thus become analytic data that can serve as the object of collaborative inquiry in the dyad.

Additional information

Notes on contributors

Robert P. Drozek

Robert P. Drozek, LICSW, is a staff psychotherapist in the Personality Disorders Service at McLean Hospital. He serves as a teaching associate in the Department of Psychiatry at Harvard Medical School, and as a supervisor of Mentalization-based Treatment through the Anna Freud Centre in London. He is author of the book Psychoanalysis as an Ethical Process, and coauthor of the forthcoming Mentalization-based Treatment for Pathological Narcissism: A Handbook. He is in private practice in Belmont, Massachusetts.