Autonomy as a Goal of Psychotherapy
The Oxford Handbook of Psychotherapy Ethics
Edited by Manuel Trachsel, Şerife Tekin, Nikola Biller-Andorno, Jens Gaab, and John Z. Sadler
Personal autonomy describes the exercise of self-determination through informed and rational decisions that reflect an agent’s authentic values. The nexus between autonomy and psychotherapy is broad, with both respect for client autonomy through informed consent, and promotion of client autonomy through therapy itself representing key instances of the significance of autonomy in the consulting room. While inadequate disclosure of information poses a major threat to personal autonomy, so too do unjustified paternalism, coercion, and the injudicious use of therapeutic privilege. The capacity of psychotherapy to promote client autonomy, evidenced by more effective decision-making during periods where the risk of recurrent illness is high, is argued to be a key advantage of psychotherapy over treatment with medication alone. Ultimately, enhanced autonomy is a goal of treatment grounded in a more defensible conception of well-being for people with psychological disorder and, it is concluded, should be sought specifically through psychotherapy.
Keywords: autonomy, paternalism, informed consent, prudential value, cognitive behavioral therapy
After what might seem like an eternity in the shadows, the world has definitely turned for the ethical principle of autonomy. The change has been most notable in medical practice where, for years, the paternalistic dogma of “doctor knows best” provided tacit justification for physicians to direct the nature of treatment, provide minimal information and, mostly, fail to solicit the views of patients on what they thought best.
This approach of “beneficent authoritarianism” (Pellegrino and Thomasma 1988: 5) was grounded in the idea that good decisions about medical treatment hinged on a scientific understanding of what worked, a realm of knowledge to which the doctor, justifiably, claimed superior access.
Such an approach ignored, however, the notion that facts about a treatment’s efficacy are always interpreted in light of a patient’s particular values, values that not only vary in a pluralistic society, but also impact decisively on what treatment an individual might prefer (Buchanan and Brock 1990: 29–30).
In the medical domain, cancer chemotherapy provides a case in point. The possible life extension offered by chemotherapy might be identical for two patients, but whether that is considered a worthwhile gain—and reason to undergo treatment—when weighed against side effects such as intractable nausea, is ultimately determined by the individual’s particular values.
Against this backdrop, respect for personal autonomy has emerged as a key driver of informed patient choices which, in turn, permit assessments of a patient’s best interests to accommodate their idiosyncratic circumstances, goals, and values. Scholars Faden, Beauchamp, and King (1986) encapsulate this in the notion of informed consent as an “autonomous authorization” of treatment, where treatment choice is an expression of self-determination by a competent agent. Indeed, backed by intense efforts to enmesh ethics training into medical curricula, respect for autonomy as part of informed consent is now routine in most healthcare settings.
For a number of reasons, however, acknowledgment of the importance of autonomy in psychological therapy has been later to arrive (Trachsel et al. 2015). Insight-oriented psychotherapies such as psychoanalysis, for example, center on the acquisition of self-knowledge, an open-ended process that can be uncertain about how, when, and to what degree distressing thoughts and feelings will be relieved. Informed consent in this type of therapy is more problematic than for outcome-oriented, symptom-focused treatments such as Cognitive Behavioral Therapy (CBT), whose procedures, goals, and time frames can be stated with greater certainty (Trachsel et al. 2015).
At least part of the shift that now sees informed consent enshrined in the psychotherapy guidelines of countries including the United States (American Psychological Association 2017), the United Kingdom (British Association for Counselling and Psychotherapy 2016), and Australia (Australian Psychological Society 2007) can be traced to the case of Osheroff v. Chestnut Lodge (Klerman 1990). In this case the patient was hospitalized with severe depression, at significant expense, for seven months, yet offered only psychotherapy which was ultimately unsuccessful. The man, who was eventually successfully treated elsewhere with medication, launched legal action which was ultimately settled.
The case highlighted the importance of information disclosure, in particular, about psychological diagnosis and the availability of alternative effective treatments, as key to respecting autonomy through informed consent. In tandem with recognition of the critical nature of information provision to autonomous consent, there has been an upsurge in research aimed at establishing an evidence base for psychotherapy, utilizing the same hierarchy of evidence adopted in physical medicine, with the randomized controlled trial as a gold standard (American Psychological Association 2013). In trying to discern the role of autonomy in psychotherapy there is, however, another key consideration that muddies the waters.
Autonomy is increasingly argued to be not just a capacity that must be respected through informed consent, but a trait that ought to be promoted, in and of itself, as an outcome of psychotherapy (Biegler 2011; Ryan et al. 2011). Such arguments typically appeal to dual notions about the value of autonomy, both as an instrument to the agent achieving their own conception of the good, and as a trait with intrinsic worth, irrespective of the outcomes that its exercise might bring about.
Those arguments give rise to intense controversy about what the true goals of psychotherapy ought to be, because the goal of autonomy promotion can diverge from the more established aim of symptom reduction, including, in particular, enhanced positive affect. That debate can only be furthered if the discussants are properly informed about the notion of autonomy itself.
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