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Articles    H3'ed 3/13/11

Rescue: When is it Unethical?

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This essay arose from two sources -- a class I am teaching at the Union Institute & University and a discussion I had with Michael Ortiz Hill, the author of a marvelous new book on medical compassion called The Craft of Compassion.   My class is called "Professionalization Seminar" or ProSem, for short.   I teach the Vermont section (we also have a Cincinnati session) in which four first year graduate students in clinical psychology join me one Saturday per month for a full day of interaction.   We continue our discussions online during the remaining month between meetings.   These are not ordinary graduate students.   Each of my students has a Master's degree in a psychology related field and all have been actively working for more than 10 years.   They are experienced.

Our discussions this past month wandered into the ethics of rescue.   When do we try too hard to help clients?   When do we give our clients the feeling that they have to do better to please us, to satisfy our own needs?   And is that fair, right, just, or good?   At the same time, Michael was discussing radical empathy with me as a solution to what he calls "professional narcissism", which is when we need to feel powerful, superior, or more capable than our clients and we use them and their predicaments to help us feel that way.   In Michael's book, he writes about this process on the psychiatry inpatient unit in which nurses critique patients in demeaning and humiliating ways while interacting inside the locked "nurses station".   I have heard this on every psychiatric unit I have ever visited and know exactly what Michael means.   In medicine, and especially in psychiatry, we have a tendency to magnify the differences between us and our clients.   We want to feel that they are qualitatively different from us, that we could never be in their shoes.   Often we use the genetic argument to support this conclusion that they are somehow genetically flawed and we are not.   If only they would just be good patients and take their medicines, all would be fine".I tend to take the opposite position -- that our clients are much like us, but perhaps further along on the continuum or less socially privileged or having had worse luck.   There but for the grace of God could we be.   This is more similar to the classical Greek position of Ethos, in which our we are perpetually being formed and could fall short or stray at any moment, that the fallen are not so different from those who have risen.   Small twists of fate separate the two.   

Michael's discussion and my class led me in a more subtle direction.   When a client consults a therapist or a physician, how much of the time does the practitioner need the client to improve for the practitioner's own gratification.   I see this frequently among alternative medicine practitioners who take pride in "curing" people whom conventional medicine could not help or actually harmed.   These practitioners need a continued stream of successes to stoke the fires of their feeling effective.

On the other hand, as practitioners, we need to feel effective.   We need to feel like we have something to offer.   I find this so much truer in private practice where the client hands me a check and I name a fee.   It's easier in an institutional setting in which we never see or know the fees charged for our services.   So, how do we balance our need to feel competent and effective with the wish not to put excess burden upon the client to improve for our benefit?

Here is where Michael's concept of radical empathy emerges -- the idea of becoming so absorbed in an Other's stories that we stop paying attention to our own.   The French psychoanalyst Jacques Lacan called this the greatest gift a practitioner could give a client -- to listen fully and completely without judgment or interpretation.   The elders we met in Australia shared this idea, which they translated into English as "the deep listening".   American psychologist William James' concept of volition and attention play a role here.   In practicing the deep listening, we will ourselves to focus completely on our client so much that we lose awareness for almost all other aspects of experience.   This is a possible definition of trance and of what has been called absorption.   We will ourselves to direct our full attention to another person and his or her stories.   Practicing meditation and/or mindful awareness help us to do better, of course.

When we enter into this state of radical empathy or deep listening, we become capable of participating in a dialogue in which change can happen.   But this is a more mindless state.   In this state, my stories recede into the background except, of course, for my story about why deep listening matters and that I can do it.

Recently I found myself wanting too much for a client to change.   I found myself disappointed that nothing had improved after our first session.   I questioned my magical powers to help and to "cure them in one session".   On the surface, after all, anxiety and panic seem so easy.   I thought I would have to redouble my efforts to produce a change.   Suddenly awareness hit.   I was caring too much about my success.   My stories about being a magical and powerful wizard (or at least the world's best psychotherapist!) were interfering.

Explanations for this emerged when I reflected upon what was happening for me.   The client had come from a facility which I had only recently left.   Apparently I still had something to prove to "them" about my amazing and awesome skills that they had refused to let me use.   Also, even though this client was paying a reduced fee that she agreed was reasonable, I knew that money was tight for her, so I wanted to be powerfully effective to save her money.   And, sigh, there was my version of what Michael Ortiz Hill calls professional narcissism.   Do we all enter this profession because we couldn't be a superhero (I would have been Green Lantern; he was the coolest).

I took a deep breath and relaxed.   What if she were the fish that got away, the person I couldn't help?   Was it ok for her not to improve?   As I slowly visualized that possible future, I found myself starting to enjoy our session more.   I was finding her more interesting and amusing.   My compassion level rose.   I recognized that many forces were working upon her besides me and that I would give her what I could and she would pick and choose and use what she wished or could use.   The hypnosis I was doing moved in that direction -- of offering many suggestions including the suggestion that she would pick and choose what would work for her.  

In her story, as she developed as an empath, she became increasingly unable to be around other people.   She couldn't tolerate their misery and pain and absorbed it into her body, eventually becoming dysfunctional.   She could no longer do counseling because she couldn't tolerate the pain and suffering she absorbed from the people who came to her office.   She had taken to shopping for groceries at 2 am since that was when the store was emptiest.   She had taken leave from her job and had failed to go back within the specified length of time, thereby becoming unemployed.   In my new freedom from being impressive, I could joke with Amy.   "Do you mean to tell me," I asked, "that no one is ever having a good day?   No one is ever uplifting, funny, or even downright inspiring?"

"No," she said.

"That's not what I hear," I responded.   "Why, just the other day, some ghosts were telling me about some of their favorite sitcoms on Spirit TV.   It turns out that we're all characters in reality TV shows and every spirit has their favorites, some of which are hilarious, making them roll all over the clouds or all over the floor where they are."   She laughed.   "Don't you think you could find one funny person?"

"No," she said.   "All people terrify me.   Animals, though, they're ok.   I can be around them.   They only have a pleasant impact on me."   That gave me an idea.

"Could you pretend I was an animal right now?" I asked.   "Could you visualize me as an animal here on the spot?"  

"I guess so," she said.

"Let's try it," I said.   "Watch me transforming into an animal.   What am I?"

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
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