Ethics in psychotherapy

Allen

Should the century-old practice of

psychotherapy defer to science and
ignore its foundations in two
millennia of ethical thought?
Jon G. Allen, PhD

While agreeing with the mainstream view that psychotherapeutic

practice must be grounded in science, including research on the
effectiveness of psychotherapy, the author advocates giving more
weight to the venerable philosophical literature on ethics that
bears directly on what patients bring to therapists: problems in
living. These problems have been the domain of ethics since Socrates, wholike psychotherapistspromoted reflective dialogue.
This article reviews some contemporary thought regarding the
importance of reflection and the limits that patients and therapists
face in promoting it. Relying on attachment theory and the process of mentalizing, the author identifies a convergence of science
and ethics in the therapeutic aspiration to cultivate epistemic trust
and illustrates this convergence with a case example. (Bulletin of
the Menninger Clinic, 80[1], 129)

I could not practice psychotherapy competently without extensive scientific knowledge that shapes and buttresses my approach to the craft. Yet when I am talking to a psychotherapy
patient over the course of an hour, this scientific knowledge is
generally far from my mind. We are immersed in a conversation about daily troubles, seemingly impossible decisions, and
mostly problems in present and past close relationships. These
conversations are in the domain of ethicshow best to live
as rational and social beings in cultures of our own creation.

Correspondence may be sent to Jon G. Allen, PhD, at The Menninger Clinic, 12301
Main Street, Houston, TX 77035; e-mail: jallen@menninger.edu (Copyright 2016
The Menninger Foundation)

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Allen

About a dozen years ago, somewhat fortuitously, I discovered

that reading the philosophical literature on ethics seemed more
pertinent to this daily work than the mainstream psychotherapy
literatureand certainly more inspiring and troubling. I should
not have been surprised: Philosophers have been writing about
problems in living for two millennia, whereas psychotherapists
have been at it for a mere century. In that time, we have made a
profession out of talking to people about their problems. I wonder, seriously: Why do we need psychotherapists?
I have a simple answer to this question. In the past century, a
science of psychopathology has been developed, largely in relation to an episodically refined taxonomy of psychiatric disorders (American Psychiatric Association, 2013). In the past halfcentury, psychologists along with mental health professionals
from other disciplines have developed increasingly specialized
brands of psychotherapy to treat these psychiatric disorders and
related symptoms. The simple answer: We need psychotherapists to bring their scientific-technological knowledge to bear on
the treatment of psychiatric disorders.
This answer is simplistic. A few decades ago, Thomas Szasz
(1974) tendentiously titled his book The Myth of Mental Illness. We knew then, and we know far better now, that mental
illness is no myth; psychiatric patients are illphysically and
mentally. But Szasz rightly identified the fact that mental health
professionals work with their patients problems in living; his
trenchant criticism bears repeating: Psychologists and psychiatrists deal with moral problems which, I believe, they cannot
solve by medical methods (p. 9). As Szasz implied, aspiring to
be empirical scientists, mental health professionals neglected the
ancient context of their work, namely, the domains of ethics,
religion, and philosophy (p. 9). Science trumped humanities.
Szasz had plenty of astute company in his critique of scientism
in the field of psychotherapy (Allen, 2013b), including Karl
Menninger (1973) who, a few years previously, had written a
book on psychiatric practice provocatively entitled Whatever
Became of Sin?
In the wake of myriad distinguished predecessors, I break
no new ground in this essay but rather aim to revisit the now

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venerable critique of the ostensible amorality of psychotherapy.

This essay proceeds in five sections: (1) I start by summarizing
in capsule form the scientific status of psychotherapy and then
(2) offer a perspective on the neglected contribution of ethical
thinkingfrom ancient to contemporaryto the practice of
psychotherapy. Recognizing the audacity of aspiring to do justice to this vast domain of knowledge in a brief essay, I merely
illustrate my thesis with one main example, Bernard Williams
(with considerable help from Martha Nussbaum and a nod to
Christine Korsgaard). Williams was disposed to reflect on his
own discipline of philosophy, including its limited perspective
along with its unique contributions. As I hope to make evident,
much of his illuminating writing about ethics applies equally to
psychotherapy, not only to the conduct of sessions but also to
the broader value and challenges of psychotherapeutic work.
(3) Continuing to rely on Williams, I present a point of convergence between ethics and science, illustrated by my colleague
Peter Fonagys recent thinking about the role of epistemic
trust in early attachment relationships and in psychotherapy.
(4) I present a clinical example of striving to establish epistemic
trust in a therapy relationship and (5) conclude by advocating
the complementary use of ethical thought and scientific knowledge in psychotherapy.
Although my practice of psychotherapy is somewhat eclectic,
my primary background is in the psychodynamic tradition. As
Patrick Luyten and colleagues asserted, this tradition is characterized by two cultures that can be polarized but should be
complementary: The interpretive culture is the bridge to the
humanities, whereas the neopositivistic, empirical culture is the
bridge to the natural and social sciences (Luyten, Mayes, Blatt,
Target, & Fonagy, 2015, p. 5). I aspire to keep the balance by
giving the humanities due weight, developing further the theme
of science-informed humanism articulated previously (Allen,
2013b). Its surface complexity notwithstanding, this essay has
one fundamental aim: to broaden our perspective on the practice of psychotherapyswitching from a telescopic to a wideangle lens.

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Scientific aspirations
In the context of psychologys eager break from philosophy to
establish itself as an independent scientific discipline, Lightner
Witmer founded the first psychological clinic at the University
of Pennsylvania in 1896, and he was the first to use the term
clinical psychology to reflect the application of science to practice. Witmers clinic was devoted to the care of children showing
problems in school, and he capitalized on the budding scientific
field of psychological measurement (Korchin, 1976). Over the
course of the first half of the 20th century, substantially abetted by the development and ensuing hegemony of psychoanalysis, psychotherapy became a mainstay of psychiatric treatment.
Despite Freuds scientific background and aspirations, psychoanalytic practice was not directly tied to science and was continually criticized on that basis. Alfred Tauber (2010) argued
that Freud grounded his work in a humanistic philosophy of
human freedom coupled to a vision of moral self-responsibility
and that psychoanalysis was directed toward an ultimate ethical mission (p. xvi). More specifically, The analytic process
relies on the skill, imagination, and creativity of the analyst and
analysand in crafting a narration, which captures a reinterpreted life. This is not science (p. 197). Hence, in Taubers view,
Freuds main contribution, despite himself, was not to science
but to the humanities. In my view, therein lies its enduring value
for psychotherapists, notwithstanding the scientific evidence
that supports it belatedly (Luyten, Mayes, Fonagy, Target, &
Blatt, 2015).
In the middle of the 20th century, scientific skepticism about
the effectiveness of psychotherapy came to the fore, with Hans
Eysenck (1952) being one of the more vocal critics. Psychologists rose to the challenge in two broad ways. First, they began
developing treatments directly linked to experimental psychological research. Second, they used scientific methods to demonstrate convincingly that psychotherapy yielded outcomes superior to no treatment. But the triumph of this scientific study of
psychotherapy was marred by an ironic result: Psychotherapy
was deemed effective, but no single treatment approach was

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Ethics in psychotherapy

consistently more effective than any other. Lester Luborsky (Luborsky, Singer, & Luborsky, 1975) memorialized this irony in
his paper on the Dodo Bird effect: Everyone has won and
all must have prizes. A half-century of research on psychotherapy still leaves us struggling to go beyond the relatively futile
horse-race comparisons of over 150 different well-researched
brands of psychotherapy (Malik, Beutler, Alimohamed, Gallagher-Thompson, & Thompson, 2003) to answer the most pressing clinical question: What works for whom? (Roth & Fonagy,
2005).
Science largely has carried the day in the recent demand for
evidence-based therapies, that is, therapies conducted with
adherence to theory-based treatment manuals that have demonstrated efficacy in randomized controlled trials. Increasingly,
reimbursement for psychotherapy is contingent on the employment of these evidence-based treatments, which have demonstrated positive outcomes in the treatment of specific psychiatric disorders. The proliferation of such evidence-based therapy
brands, identified by a spate of acronyms (e.g., PE, CBT, DBT,
DIT, ERP, SIT, MBT, TFP, MBCBT, and the like), has created
problems for the would-be psychotherapist. Peter Fonagy
counted up 1,246 different brands of psychotherapy and considered this number to be an underestimate (personal communication, August 5, 2015). No one could learn to practice all
these treatments. Compounding that problem is the fact that
patients typically present with multiple disorders, which might
call for a multiplicity of therapies. Furthermore, the ostensible
distinctiveness of the different psychiatric disorders implied by
the taxonomy obscures their extensive overlap (Caspi et al.,
2014). And we continue to be dogged by the difficulty of demonstrating the general superiority of any one brand of therapy
over any other.
Around mid-century, Jerome Frank (1961) presciently asserted, Much, if not all, of the effectiveness of different forms
of psychotherapy may be due to those features that all have
in common rather than to those that distinguish them from
one another (p. 104). By the time Frank wrote, Carl Rogers
(1951, 1957) had launched research on the patient-therapist re-

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lationship and made a compelling case that the quality of this

relationship (i.e., the therapists empathy, positive regard, and
genuineness)rather than any particular treatment method
accounted for the beneficial outcome. The subsequent halfcentury has borne out Rogerss conviction: Decades of research
has shown consistently that the relationship makes a substantial
contribution to the outcome, whereas the particular treatment
approach makes a relatively minimal contribution (Norcross &
Lambert, 2014).
All these considerations, coupled with my aversion to therapy
brands, manuals, and acronyms, led me in protest to declare
myself a practitioner of plain old therapy (Allen, 2013c). Yet
I am not dismissive of psychotherapy research. The systematic
evidence for the effectiveness of psychotherapy is essential to
justify the profession, and the scientific findings offer a crucial
response to the question, why do we need psychotherapists?
Psychotherapists deliver effective treatments. Moreover, there is
room for different brands of therapy tailored to different kinds
of psychiatric disorder, notwithstanding the extensive overlap
among disorders and brands. As in general medicine, we need
specialists as well as generalists. We have made some progress
on the what-works-for-whom problem (Roth & Fonagy, 2005).
Plain old therapy, with its emphasis on cultivating understanding
in the context of a therapeutic relationship, is not optimal for all
patients (e.g., exposure therapy is essential in the treatment of
some anxiety disorders). Moreover, we are making some progress on the problem Frank identified, namely, searching for the
mechanisms of changeto use contemporary technological
languagethat are common to the various therapies (Kazdin,
2007). This essay refers to one such aspect of psychotherapy
promoting epistemic trustthat overlaps with the literature on
ethics. I would not refer to the promotion of trust, however, as
a mechanism.
As the foregoing implies, the scientific aspirations of the field
of psychotherapy risk colliding with its humanistic foundations. The collision is evident in recurrent antagonism between
academics and clinicians. What do the patients have to say?
In a study of more than 5,000 patients treated in the National

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Health Service in the United Kingdom, Pat Bracken and colleagues (2012) found no differential effects of the specific treatment method and noted that many service users did not value
the technical expertise of the professionals but rather were
more concerned with the human aspects of their encounters
such as being listened to, taken seriously, and treated with dignity, kindness and respect (p. 432). The long-known risk of
losing the humanistic aspects of medical care (W. W. Menninger,
1975) is now potentially exacerbated in psychiatry with the advent of biological interventions stemming from advances in neuroscience. Without denying the enormous actual and potential
benefits of these advances, I have raised concern about biomania (Allen, 2014), that is, excessive enthusiasm for reductionistic approaches that are liable to sideline the humanistic aspects
of psychological care that Bracken and colleagues highlighted.
It would not be a bad thing, for example, for the prescription of
specific drugs to be guided by the results of genetic testing and
functional brain imaging. But it would indeed be detrimental to
our patients if psychiatry as a whole were to become nothing
more than biological psychiatry.
One manifestation of biomania is reframing psychiatric conditions as brain disorders, an effort inspired partly by the
humanistic agenda of reducing the stigma associated with psychiatric diagnoses (which, ideally, should be no more stigmatizing than general medical conditions). Although this reframing
has had the intended effect of alleviating blame, it has had unintended side effects: Not only does it fail to reduce stigma (i.e.,
social distancing) but it also engenders greater pessimism about
prognosis and might increase perceptions of dangerousness
(Kvaale, Haslam, & Gottdiener, 2013; Pescosolido et al., 2010).
Moreover, owing in no small part to pharmaceutical companies
successful advertising, reliance on psychotherapy is decreasing,
and this decrease may well be associated with negative attitudes
toward seeking nonbiological treatments (McKenzie, Erickson,
Deane, & Wright, 2014). Accordingly, reframing psychiatric
conditions as brain disorders must be done with more than a
sound bite. To rehabilitate Szaszs (1974) point without myth
making, these brain disorders do not emerge de novo on the

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basis of genetic makeup; ratherin conjunction with genetic

riskthe brain disorders develop in the context of problems
in living, prominently including stressful personal relationships
andmost problematicallytraumatic attachment relationships in early life, often repeated across generations and into
adulthood (Allen, 2013a).
Our scientific aspirations, bolstered by the advent of neuroscience and biological treatments, must continue unabated to
drive progress in the treatment of mental illness. Science has
fostered substantial progress in elucidating the basis of the effectiveness of psychotherapy, including plain old therapy; moreover, notwithstanding the Dodo Bird effect, science has spurred
diversity in psychotherapies that hold promise for tailoring the
therapeutic approach to individual patients problems and disorders. More broadly, I would founder in doing psychotherapy
without understanding psychopathology, a field to which science has made far-reaching contributions. Furthermore, working in a hospital setting with a focus on serious mental illness,
I cannot imagine trying to conduct psychotherapy with profoundly impaired patients without the aid of biological treatments. Without such biological interventionscoupled with the
safety and support of a hospitalpsychotherapy often would
be impossible at worst or of limited effectiveness at best. Contra Szasz, medical methods do help our patients psychological
functioning such that they are in a better position to address
moral (i.e., ethical) problems in living.
Crystal ball gazing, I believe that science will continue to refine the practice of psychotherapylikely guided by developments in neurosciencebut that psychotherapy will not undergo dramatic or fundamental change. To put it simply, healing human relationships will remain grounded in the human
capacities for attachment and understanding; these are not new
inventions. In contrast, I believe that dramatic improvements in
the treatment of psychiatric disorders are likely to come from
neuroscience and neuropsychiatry. But we psychotherapists are
practicing in an age-old ethical tradition of talking to people
about their problems in living, and we might make better use of
that tradition.

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What might psychotherapists learn from philosophers?

Bernard Williams (1985) began his book Ethics and the Limits
of Philosophy by addressing Socrates Question as follows:
It is not a trivial question, Socrates said: what we are talking about
is how one should live. Or so Plato reports him, in one of the first
books written about this subject [i.e., The Republic]. Plato thought
that philosophy could answer the question. Like Socrates, he hoped
that one could direct ones life, if necessary redirect it, through an
understanding that was distinctively philosophicalthat is to say,
general and abstract, rationally reflective, and concerned with what
can be known through different kinds of inquiry. (p. 1)

Our patients do not come to us asking Socrates question. In one

form or another, for example, we encounter a presenting complaint: I am depressed. Or Im so anxious I cant sleep or
keep my mind on my job. Alcohol has made everything worse,
and now my wife is threatening to leave me. Helpfully, such
complaints present us with psychiatric disorders for which we
have our evidence-based treatments. But once we start exploring the basis of patients illnessesthe depression, anxiety, and
alcohol abuse, for examplewe are back to problems in living,
with their attendant questions: Should I divorce? Should I look
for another job? Why do I keep falling for men who ultimately
betray me? My life is pointless and painfulwhy shouldnt I just
kill myself? These urgent questions call for practical reasoning,
the domain of ethics since Aristotle (Bartlett & Collins, 2011).
Yet the personal variant of Socrates questionHow should I
live?lurks in the background in such instances because the answers to these questions hinge on priorities and values as well as
conflicts among them. Pressed far enough, the question relates
to what Paul Tillich (1957) called our ultimate concerns. Then
we are entering the territory of Socrates question.
In her psychologically astute book, The Therapy of Desire,
Martha Nussbaum (1994) amassed compelling evidence that
the successors of Socrates, Plato, and Aristotle in Greece and
Rome were actively engaged in what we now call psychotherapeutic practice:

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The idea of a practical and compassionate philosophya philosophy that exists for the sake of human beings, in order to address
their deepest needs, confront their most urgent perplexities, and
bring them from misery to some greater measure of flourishing
this idea makes the study of Hellenistic ethics riveting for a philosopher who wonders what philosophy has to do with the world. it
seems possible that philosophy itself, while remaining itself, can perform social and political functions, making a difference in the world
by using its own distinctive methods and skills. The Hellenistic
philosophical schools in Greece and Rome all conceived of philosophy as a way of addressing the most painful problems of human
life. They saw the philosopher as a compassionate physician whose
arts could heal many pervasive types of human suffering. (p. 3)

Working with individuals and groups, these philosophers engaged their students and interlocutors in exploratory, collaborative discourse. They addressed venerable therapeutic concerns, including virtue, ambition, power, need, compassion,
attachment, dependency, love, sex, loss, grief, jealousy, envy,
resentment, anger, aggression, fear of death, and suicidejust
as therapists do now. They keenly appreciated the role of family relationships in these concerns. Anticipating Freud by two
thousand years, they recognized unconscious defenses and resistances to change. For centuries after its classical beginnings
in Greek and Roman philosophy, much of the ethical work of
healing came under the purview of religion. With the Enlightenment, secular philosophy came back into ascendance. In the
past century, professional psychotherapists have stepped into
this ethical territory, now equipped with scientific methods.
How far can philosophy take us? Regarding Socrates question, Williams (1985) continued, It would be a serious thing if
philosophy could answer the question (p. 1). But he seriously
entertained the idea that it is not true that philosophy, itself,
can reasonably hope to answer it, and he doubted that there
could be a philosophical subject (e.g., as might be taught in a
philosophy course) that could answer the basic questions of life.
For Socrates, he said, there was no such subject but rather,
he just talked with his friends in a plain way (p. 2, emphasis
added). Socrates invented plain old therapy.
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If we take seriously Williamss answer to Socrates questionthere is no answer from philosophythen we are left
with Socrates method: questioning. Williamss remarks about
philosophy also seem apt for psychotherapy: The traditions
of philosophy demand that we reflect on the presuppositions of
what we think and feel (Williams, 2006, p. 211); furthermore,
philosophy might play an important part in making people
think about what they are doing (Williams, 2006, p. 198). Yet,
to reiterate, philosophical considerations may help us to understand our feelings on these questions, rather than telling us
how to answer them (Williams, 1995, p. 233).
Williamss point that philosophy does not have answers to
Socrates question needs qualification. In philosophical writing from ancient to contemporary there is ample substantive
thoughtif not consensusabout how to live and what really
matters (or should matter). But the Hellenistic philosophers
well recognized what psychodynamic practice makes so plain:
General principles yield answers only when grounded in thoroughgoing knowledge of the individual, acquired by the patient
and therapist in a painstaking collaborative exploration. As
Nussbaum (1994) illuminated it, the philosophers explicitly employed a medical model in this enterprise, although the best of
them emphasized the symmetry of the relationship rather than
the authority of the expert doctor. Like Williams, Nussbaum
acknowledged our desire for answers: A comprehensive philosophical appraisal would require nothing less than answering
the fundamental questions of human life, but she pointed instead to the elucidation of problems: Much of the distinction
of Hellenistic ethics lies in the complexity of its description of
these problems, and in the fertility of the questions it thus continues to provoke (p. 484). Yet her conclusion should guide
psychotherapists as well as philosophers:
I am not sure that it is philosophically good to believe that one has
an exhaustive once-and-for-all solution to these problems. If one
can lucidly describe their difficulty and ones own perplexity before
them, criticizing inadequate accounts and making a little progress
beyond what was said in the more adequate, this may stand,
perhaps, as a Socratic substitute for arrogant certainty. And that
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sort of philosophical work should be a good preparation for the
complex particular confrontations of life. (pp. 484485)

In my view, reading philosophy can help psychotherapists by

cultivating the process of reflection about these age-old problems in living as they apply to individuals. This study can raise
our awareness of the limited extent to which we have answers,
and it can help us to engage our patients in the process of reflectioninspiring reflection as Socrates did with his friends
and interlocutors. At our best, we help our patients think with
others and think for themselves about problems in living that
are emotionally charged and fraught with feelings, motives,
and conflicts and about which they are unaware or muddled
to varying degrees. Also following the model of Socrates and
his successors, we encourage clarity and awareness through dialogue. Ideally, if we can put aside all our theories and jargon,
we can accomplish this by talking in a plain wayno small
achievement for those of us imbued with scientific aspirations
and elaborate theories.
What does reflection on ethical considerations entail, and
how much benefit can we expect from doing it? As Williams
(1985) noted, Socrates question can be put to anyone inasmuch
as it seems to ask for the reasons we all share for living in one
way rather than another. It seems to ask for the conditions of
the good lifethe right life, perhaps, for human beings as such
(p. 20, emphasis in original). He added that Socrates thought
that reflection was inescapable for a good life, but he thought
Socrates went too far, referring to the terrible Socratic oversimplificationor, to put it more plainly, falsehoodthat the
unexamined life is not worth living (p. 28). No doubt, many
persons live a reasonably good life without any philosophical
(or even much psychological) reflection. But patients seeking
psychotherapy perforce must engage in some level of reflective
examination inasmuch as something has gone seriously wrong
in their lives. Rarely do patients merely want to be told what
to do about their problems in living. If they do want to be told
what to do, that calls for reflection.
We psychotherapists are in the same general business as our
philosopher colleagues, although we do not have the luxury of
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detached philosophical reflection in the manner of Socrates; we

have more in common with Socrates Hellenistic successors as
we become immersed in patients painful struggles that reflect
the intertwining of psychiatric symptoms and problems in living. I find that reading philosophy helps me reflect with patients
on a daily basis, but it also does more than that: It helps me
reflect on the general practice of psychotherapy (and this essay
is a progress report). Unless it is thoroughly governed by implementing technical procedureswhich some of it can bepracticing psychotherapy confronts therapists with their humanity
and its limitations. As I have contended elsewhere, our effectiveness as psychotherapists comes down to our skill in being
human (Allen, 2013c, p. 214). If we are at all reflective, we
are never too far from our existential (or ultimate) concerns. If
nothing else suffices, grappling with suicide will bring these concerns to the fore; many of our patients want to die, and some
kill themselves. If this challenge does not move us to reflection
about our work, nothing will.
Williams (1985) concludes his book on the limits of philosophy with a vision that applies equally to us psychotherapists; he
expressed his
optimistic belief in the continuing possibility of a meaningful individual life, one that does not reject society, and indeed shares
its perceptions with other people to a considerable depth, but is
enough unlike others, in its opacities and disorder as well as in its
reasoned intentions, to make it somebodys. Philosophy can help to
make a society possible in which most people would live such lives,
even if it still needs to learn how best to do so. Some people might
even get help from philosophy in living such a life. (pp. 201-202,
emphasis added)

Some people potentially includes us therapists and, through

our best-informed efforts, our patients.
To put my agenda somewhat differently, we psychotherapists
might look to philosophers not only for some guidance about
the conduct of our work but also for some inspiration about the
value of our workto ourselves as well as our patients. In this
vein, Christine Korsgaard (2009) penned one of the most inspir-

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ing passages I have read, applicable to us and our patients alike,

beautiful as it is brilliant:
Your life fits into the general human story, and is a part of the
general human activity of the creation and pursuit of value. It
matters to you both that it is a partyour own partand that it
is part of the larger human story. What you want is not merely to
be me-in-particular nor of course is it just to be a generic human
beingwhat you want is to be a someone, a particular instance of
humanity. So its like this: in being the author of your own actions,
you are also a co-author of the human story, our collective, public,
story. As a person, who has to make himself into a particular person, you get to write one of the parts in the general human story,
to create the role of one of the people you think it would be good
to have in that story. And thenat least if you manage to maintain
your integrityyou get to play the part. (p. 212)

A point of convergence: Epistemic trust

George Gergely and colleagues (Gergely, Egyed, & Kirly, 2007)
have developed and researched a theory of human pedagogy to
account for the rapid acquisition of cultural knowledge, beginning early in life. This learning is based on the primarily epistemic function of actively seeking out and cooperatively providing reliable, new and relevant information by knowledgeable
adults to ignorant infants about universally shared cultural
knowledge (p. 140). Building on Gergelys work, Peter Fonagy
has made a significant contribution to our understanding of
the value of psychotherapy that pertains especially to our most
challenging patients: those who have been traumatizedat the
extreme, by neglect and abusein early attachment relationships and who have developed pervasive distrust as a result.
More specifically, psychotherapy has the potential to cultivate
or rekindle epistemic trust, defined as trust in the authenticity
and personal relevance of interpersonally transmitted information (Fonagy & Allison, 2014, p. 372) and an individuals
willingness to consider new knowledge from another person as
trustworthy, generalizable, and relevant to the self (p. 373).

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As Gergely and colleagues (2007) put it, epistemic trust develops early in life as a default assumption about communicative agents as sources of universally shared cultural knowledge
and is predicated on the assumption of good will, entailing a
built-in assumption of basic epistemic trust in the other as a
benevolent, cooperative, and reliable source of cultural information (p. 145). This built-in assumption rests on moral trust,
that is, trust in goodwill (Origgi, 2004) and in the moral character (Daukas, 2006) of the other.
Fonagys insight about the role of epistemic trust in psychotherapy is grounded in a half-century of scientific research
on attachment theory (Ainsworth, 1963; Ainsworth, Blehar,
Waters, & Wall, 1978; Bowlby, 1958, 1982). In overview, attachment evolved in mammals to keep offspring close to their
mother for the sake of protection from predators. Attachment
in humans develops over the course of the first year of life not
only to provide protection but also to provide a feeling of safety
and security in the face of diverse threats; thus the safe haven
of attachment is a foundation of emotion regulation (Coan &
Maresh, 2013; Sroufe & Waters, 1977). Attachment security
also provides a secure base for exploration, including exploration of the social world and thus the development of social competence (Sroufe, Egeland, Carlson, & Collins, 2005). Hence the
family is the wellspring of social learning and the development
of social cognition. A cornerstone of social cognition is mentalizing (Fonagy, 1989; Fonagy, Gergely, Jurist, & Target, 2002),
that is, the capacity to understand the actions of others and the
self in relation to intentional mental states such as desires, feelings, and beliefs.
Extensive research reveals a fundamental developmental
principle: Mentalizing begets mentalizing (Allen, Fonagy, &
Bateman, 2008). Children learn to mentalizeto understand
themselves and othersby being mentalized (e.g., when their
caregivers are attuned to their feelings and talk to them about
feelings and the reasons for them). Conversely, profoundly insecure attachmentand distrustis associated with maltreatment and the associated failures in mentalizing, which can be
traumatic in leaving the infant or child psychologically alone

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and feeling invisible in the midst of unbearable emotional states

(Allen, 2013a). At worst, children can become terrified of apprehending the caregivers indifferent or hateful state of mindas
well as their own state of mindand thus develop an aversion
to mentalizing; this aversion closes off the main avenue for social learning (Fonagy & Allison, 2014; Fonagy & Target, 1997).
The relation between attachment security and epistemic trust
in the attachment figure warrants systematic research (Koenig
& Harris, 2005), and the methods to do so are available. Our
working assumption is that the expectable mentalizing that occurs in the context of secure attachment promotes epistemic
trust, that is, the confidence that caregivers are a reliable resource for accurate information and, in particular, the acquisition of cultural knowledge. This cultural knowledge includes
self-understanding and understanding of others and relationshipsthe territory of ethics. As Fonagy understands it, the
most pernicious traumatic outcome of extreme adversity in
early attachment relationships is closing off the mind to social
influence and learning, which undermines the foundation of social, emotional, and cognitive development (Fonagy & Allison,
2014). Yet, even under the best of conditions, the child must
learn to discriminate:
A further developmental task is to acquire the specific conditions
under which the generalized epistemic trust in communicating
others, needs to be suspended or inhibited. Young children have to
learn the hard way (that is, through accumulating experience) to
differentiate trustworthy, benevolent, and reliable communicative
sources of information from communicators who are unreliable,
uninformed, or downright bad-intentioned providers of useless or
deceiving information. (Gergely et al., 2007, p. 145)

Research on the developmental trajectory of epistemic trust

(Gergely et al., 2007; Koenig & Harris, 2005) marvelously exemplifies the potential contribution of science to a fundamental
practice of collaborative discourse that comprises the foundation of psychotherapy.
Here is the crux of the ideal developmental and psychotherapeutic process: The very experience of having our subjectivity
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understoodof being mentalizedis a necessary trigger for us

to be able to receive and learn from the social knowledge that
has the potential to change our perception of ourselves and our
social world (Fonagy & Allison, 2014, p. 372). Accordingly,
perhaps the greatest gift of a mentalizing process in psychotherapy is opening up or restoring the patients openness to broader
social influence, which is a precondition for social learning and
healthy development at any age (Allen & Fonagy, 2014; Fonagy & Allison, 2014). Effective psychotherapy relationships, be
they in individual or group therapy, might be pivotal in catalyzing this development, but the greatest benefit will come from
generalizing epistemic trust beyond therapy such that the patient can continue to learn and grow from other relationships.
Socrates was promoting such development by speaking with his
friends in a plain wayas we therapists do at our best, promoting reflection on the best ways to live with ourselves and others.
As Socrates made clear, such trust must be founded on ethical
virtues.
The ethical literature converges with the psychotherapeutic
concept of the mentalizing stance (Bateman & Fonagy, 2006),
which we have characterized as entailing nonjudgmental inquisitiveness, curiosity, open-mindedness, uncertainty, not-knowing,
and interest in understanding better (Allen et al., 2008, p. 183).
Benevolence, acceptance, respect, and compassion are implicit
in the mentalizing stance, which is fundamentally an ethical
stance (Allen, 2013a; Allen et al., 2008). Moreover, fostering
epistemic trust entails transparency on the part of the therapist. As Anthony Bateman and Peter Fonagy expressed (2006)
it, The patient has to find himself in the mind of the therapist
and, equally, the therapist has to understand himself in the mind
of the patient if the two together are to develop a mentalizing
process. Both have to experience a mind being changed by a
mind (p. 93).
I find a remarkable convergence between this construal of a
mentalizing psychotherapy process and Williamss (1985) advocacy of shared deliberation in ethical decision making, defined
as a deliberation about what A is to do in which B takes part,
typically by seeing the situation so far as possible from the point

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of view of As S (p. 115), where S stands for As existing set of

desires, references, evaluations, and other psychological states
in virtue of which he can be motivated to act (p. 109). In short,
to assist A, B must mentalize. As a counterpart to psychotherapy and a helpful guide to its conduct, Williams articulated the
role of a deliberative assistant engaged in assisting the agent
to discover what he had reason to do, as opposed to giving the
agent new reasons or persuading him to do something he originally had no reason to do (p. 115). Williams spelled out two
necessary conditions for such assistance to be helpful, which
include truthfulness and transparency:
(i) The assistant will be truthful, in the sense both of telling the
truth and of helping the agent to discover the truth. An application
of this is that the assistant will be truthful about his own procedures and motives, with the result that these can be transparent to the
agent; the assistant has no hidden agenda in his dealings with the
agent.
(ii) The assistant will try to make the best sense of the agents S,
and, in particular, if there is a conflict between the assistants and
the agents interpretations of the agents S, the assistant will have
some suitable explanation of the agents misinterpretation. (pp.
115116, emphasis added)

Regarding the second point, we should add that the agent also
might have an explanation for the assistants misinterpretations.
With that caveat, these recommendations are a sound basis for
psychotherapy, which entails practical reasoning about ethical
matterswith mutual help (i.e., therapists help patients mentalize and vice versa).
If mentalizing is the means by which to catalyze epistemic
trust, truthfulness also should be regarded as essential to the
ethical basis of the mentalizing stance. Williams (2002) characterized the virtues of truth as the qualities of people that are
displayed in wanting to know the truth, in finding it out, and
in telling it to other people (p. 7, emphasis added). He identified two basic virtues of truth: Accuracy and Sincerity: you do
the best you can to acquire true beliefs, and what you say re-

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Ethics in psychotherapy

veals what you believe (p. 11). He elaborated, someone who

is conscientiously acting in circumstances of trust will not only
say what he believes, but will take trouble to do the best he can
to make sure that what he believes is true (p. 80). These virtues
of truth and truthfulness are important to almost every human
purpose (p. 57), certainly including psychotherapy.
If we therapists are to establish epistemic trust in psychotherapytrust in the therapist as a reliable source of social learning
and knowledge, including knowledge about the selfwe must
model accuracy and sincerity. Williams (2002) mirrors Gergely
in his belief about primitive trust, namely, it is no accident
that it begins in the family (p. 49). Conversely, gross failures
of primitive trust occur in early traumatic attachment relationships, which revolve around parental neglect of the childs state
of mind or distorted interpretations of the childs and others
states of mind, such that the child does not develop primitive
(epistemic) trust in the social world.
Truth is not easily acquired. Williams credited science with
the most straightforward and systematic methods of finding the
truth. Finding truth in the humanities, by contrast, is notoriously problematic. The same might be said of psychotherapy,
whichby standards of epistemic trustmust aim toward accurate understanding of individual persons and relationships.
Achieving accuracy in this endeavor is no mean feat. Accuracy
requires investigative effort in the face of innumerable obstacles, which is equally true of scientific and psychotherapeutic
investigation. To quote Williams (2002), owing to the inevitable
difficulties, our investigations do not typically yield certainty,
and we leave various avenues unexplored, often not knowing
exactly what avenues have been left unexplored. Moreover,
it may be hard to decide when one has invested enough effort
(p. 134). As Williams asserted, one obvious obstacle to accuracy
is laziness, but more interesting are the desires and wishes that
are prone to subvert the acquisition of true belief (p. 134). We
are all prone to self-deception and to a disinclination to know
and feel the impact of the truth. Nowhere is this aversion truer than in the treatment of horrific traumatic experience and
the self-destructiveand potentially fatalconsequences of

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that experience. Although therapists and patients have distinct

roles in the process, these barriers to accuracyfrom laziness
to disinclination and self-deceptionapply equally to both. We
also face a systemic barrier to adequate investigative effort that
warrants mention, namely, constraints on the intensiveness and
duration of psychotherapy and the ever-increasing pressure for
brief therapy, constraints that are associated with the economics of health care. Of course, we therapists are also subject to
the internal constraints that apply to our patients, including defenses, implicit assumptions, and prejudices.
Like accuracy, sincerity is not easily achievable in psychotherapy, and the challenge applies equally to patients and therapists.
On the patients side, Sheldon Korchin (1976) long ago made
the straightforward point that the fundamental commitment
of psychotherapy is a willingness to look at oneself fully and
honestly (p. 302). This commitment requires sincerity within
oneself as well as with the therapist, which is no small achievement given the defenses and shame that patients bring to treatment. And therapists must also be willing to look at themselves
fully and honestly. We contend with a catch-22 here: The patients epistemic trust depends on the therapists accuracy and
sincerity, but the therapists grasp of the truth is dependent on
the patients accuracy and sincerity. As in all relationships, there
must be a ratcheting-up process such that mutual trust developsevolving accuracy and sincerity on both parts.
On the therapists side, we might credit Rogers (1951) with
the early emphasis on sincerity in his pointing to the therapists
genuineness and authenticity as crucial to therapeutic relationships (Kolden, Klein, Wang, & Austin, 2011). Here the emphasis on transparency in Williamss writing and in the mentalizing approach is highly pertinent; for epistemic trust to develop,
therapists must share their mind with their patients, freely and
respectfully letting their patients know what they are thinking.
As Williams (2002) identified, one manifestation of sincerity is
spontaneity: Sincerity at the most basic level is simply openness, a lack of inhibition (p. 75). Therapists are not experts on
their patients mind, nor are they in a position to make declarative statements about their patients mind with any sense of cer-

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tainty; rather, if sincere, they offer their thoughts and sometimes

their feelings forthrightly for their patients consideration, such
that patients can affirm them ormore helpfullycorrect and
refine them.
Williams (2002) recognized fully the pragmatic importance
of truth and truthfulnessaccuracy and sincerityin cultural
development, that is, as a solution to a social co-ordination
problem (p. 95). The same is true of psychotherapy: Patients
cannot benefit from the process if they are not trusting and
therapists are not trustworthy. But Williams believed that such
instrumental reasons do not take us far enough; we might be
wary of relying on those who tell the truth because it is expedient or adaptive (e.g., to maintain a reputation for honesty).
We want something more fundamental. Williams believed that
the virtues of truth must come to have intrinsic value; accuracy
and sincerity each must be seen and felt to be a good thing in
itself (p. 95). For patients who come to therapy lacking epistemic trust, manifesting the virtues of truth should not be seen
as a precondition for therapy but perhaps as an ideal outcome
of psychotherapy. If the process is to get off the ground, however, the therapist must exemplify these virtues to some reasonable degree from the outset, which will be contingent on the
therapists reflective capacity. As Williams wrote, we are dealing
with an ethical state of mind (p. 108) here, and I have deliberately put ethical considerations on the ground floor of psychotherapythese considerations make psychotherapy possible (or
impossible). As the following example illustrates, developing
epistemic trust can take considerable work on the part of the
patient and the therapist.
Clinical example
Andrea sought hospital treatment in her mid-30s in the wake
of a suicidal crisis precipitated by having to take leave from her
position as an accountant in a prestigious firm. She felt profoundly ashamed as her escalating depression and substance
abuseboth exacerbated by a flare-up of an old back injury
had eroded her functioning to the point that she had sequestered

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herself in her apartment, only leaving her cocoon periodically

to buy whiskey and food. She had become completely isolated
socially, and she reached out to her mother only in utter desperation when she was on the brink of overdosing with a large
stash of prescribed pain medication.
Andrea attributed her social isolation to long-standing problems in developing relationships. She was an only child and stated flatly that she did not trust either of her parents, whom she
described as merely wanting to control her and extract the best
performance out of her for the sake of their own egos. For
this purpose, they colluded with each other and showed no
genuine interest in her needs or feelings. Accordingly, she said
she could not trust anything they said about her, about others,
or about relationships. She found a position in a profession in
which she could work mostly by herself, and for a number of
years she was sufficiently successful that others left her alone.
She had never dated seriously, nor had she developed confiding relationships with friends; her minimal social life consisted
largely of hanging out in bars.
Andrea did not begin psychotherapy easily. She complained
to her hospital treatment team that she could not relate to her
therapist because he did not give her enough direction in the
process, and he was an older man who reminded her of a grandfather whom she detested. Yet she was desperate for help, and
she was not inclined to quit treatment. Notwithstanding her distrust, she had conveyed a substantial amount of her history and
problems to her therapist. When she brought up the reasons for
her aversion to working with an older man, her therapist took
seriously the possibility of finding another person with whom
she might feel more comfortable and emphasized the cardinal
importance of her feeling of safety and security in the process.
Yet the two of them recognized the logistical problem of making
a switch and starting over again in what would be a time-limited hospitalization. The therapist also acknowledged the substantial effort that Andrea, despite her aversion, had made to
confide about her problems. In response to Andreas feeling that
she was not getting enough direction, the therapist constructed
a written formulation that carefully delineated his understand-

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Ethics in psychotherapy

ing of the core problems that they would need to work on. Andrea read through the formulation and considered it accurate
and helpful. She and the therapist decided to continue working
together, and Andrea settled into the therapy. Over the course
of 20 sessions, she became relatively comfortable in the process
and, with her collaboration, the therapist revised the formulation twice before her discharge. She said she felt understood.
Importantly, this psychotherapy did not take place in a vacuum. The hospital treatment placed a premium on relationships
with peers, and Andrea had considerable difficulty with these
relationships. She said she had always felt like an outcast,
and this was true in the hospital as well. She said her peers had
typecast her as a lonera familiar social role. She was able
to address this role in group psychotherapy and to offer to her
peers some understanding of the reasons for her isolation. In
turn, a few of her peers warmed up to her, and she reciprocated. She said she had never before confided in others to this
degree, and she was pleasantly surprised by the level of empathy she received. She discovered that she could enjoy socializing, at least occasionally, without alcohol. Whereas initially she
dismissed the educational groups as psychobabble, she subsequently believed that she had learned something valuable
from them about herself and her relationships. Furthermore,
with the aid of family work, she was able to articulate some of
her distress to her parents (e.g., in relation to their high expectations without any apparent regard for her anxiety or limitations), and she felt somewhat heard by them, albeit by her
father more than her mother. She was understood well enough
that her parents agreed to support further treatment financially.
Finally, she was able to talk forthrightly with the director of
human resources at her firm and to negotiate the terms of additional leave such that she could have intensive follow-up treatment before returning to work. When asked by her therapist in
the last session to summarize what she had gained from treatment, she responded cautiously, I have a little ability to trust
other people.

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Aligning science, philosophy, psychotherapy, and attachment

There was only one technique in the psychotherapy with Andrea, and it is not derived from science but rather exemplifies an
ethical state of mind: co-operative and trustful conversation,
to borrow Williamss (2002, p. 111) phrase. As noted earlier,
the therapeutic potential of the ethical-mentalizing stance lies
in a developmental principle: Mentalizing begets mentalizing.
Genuine therapy occurs when patients come to share this stance
with their therapist and then extend it to other relationships, as
Andrea had begun to do. This guiding developmental principle
is grounded in scientific research (Allen, 2013a). We might extend this principle to the realm of ethics: One persons ethical
state of mind might beget a parallel state of mind in another;
trust begets trust. Moreover, to apply Williamss point, ethical
states of mindor their absencehave their origins in the family. This point applies to therapists as it does to patients, although one hopes that therapists have the additional benefits
of professional education and supervision that reinforce ethical
states of mind.
There is no inherent incompatibility between the scientific
and ethical perspectives on psychotherapy; the challenge is to
get the balance right. Mainstream practice privileges science:
Psychotherapists employ science-based techniques while adhering to their professional ethical principles. I turn this balance
around: Psychotherapists must bring science to bear on what
is fundamentally ethical work, that is, employing science-informed humanism (Allen, 2013b). Perhaps many psychotherapists and patients would agree with Williamss (1995) point
that a correct understanding of human evolution suggests that
human beings are to some degree a mess (p. 109). Could we
expect any one academic or scientific discipline to understand
this mess? As he pointed out, to think about ethical issues entails thinking about a lot more than philosophy: It is to try to
think seriously about a decent life in the modern world, and it is
a platitude to say that it needs more than philosophy to do that.
It is equally a platitude to say that philosophy should at any
rate help one to do that (p. 148). Williams made ample room

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Ethics in psychotherapy

for psychology in this endeavor but pressed the point that it is

not true that the individuals psychology is entirely explained
by psychology and that There are human sciences other than
psychology, and there is not the slightest reason to suppose that
one can understand humanity without them (p. 86). Indeed, all
the humanities are pertinent to the endeavor of understanding
the mess of humanity and some of the messes our patients bring
to psychotherapy.
From the perspective of plain old therapy, I aim to converse in
a way that enriches understanding of the patients problems and
their development, including their psychiatric disorders. Specializing in psychological trauma created in attachment relationships, much of my work entails the construction of a coherent
narrative, which is a long-standing quest of ethical discourse
(Nussbaum, 1994), a foundation of attachment security (Main,
Hesse, & Goldwyn, 2008), and an outcome of effective trauma
treatment (Foa, Huppert, & Cahill, 2006). But coherence is not
enough; the stories we construct must have the ring of truth. It
would be the height of insincerity merely to find a story that the
patient finds satisfying regardless of its truthfulness. We should
not take this therapeutic aspiration for the truththe basis of
epistemic trustlightly. On the contrary, a careful reading of
Williams (2002) account of the challenges to accurately making sense of the past and talking about it sincerely are enough to
make a reflective therapist shudder. And we are in the business
of creating stories about the present as well as the past. As Williams rightly stated, It is the merest truism that there is nothing
special about the past as suchit is simply what used to be the
present (p. 247). In psychotherapy we construct stories of the
past to make sense ofand revisestories of the present. Recognizing that the absolute truth is an ideal that we never attain,
patients and therapists alike nonetheless must keep their aim
pointed in that direction, trusting each others commitment to
accuracy and sincerity while accepting profound limitations in
those aspirations. Science, philosophy, and psychotherapy align
in this endeavor, and they align with attachment security insofar
as it develops in synergy with epistemic trust.

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