Like many of you the tensions surrounding the election and the renewed intensity of the pandemic sapped my creative energies for a while. So for the past couple of weeks I have been reading, knitting and watching Netflix to take care of myself. I hope that you have also been tending to your needs.

Today I woke up and I feel ready to write again. So here goes as I consider what to do when a patient presents a really thorny issue that might reach into  the territory of a moral dilemma.

A while back, someone asked me how a psychotherapist deals with the situation in which something the patient has come to understand she would really like to do to improve or change her life is likely to cause suffering to someone in that patient’s life? Situations like this are not uncommon, as for example someone wants to divorce her husband, an action which will doubtless cause upheaval and pain for all involved.  

But this questions contains, I believe, a misperception about what therapy is about and what the role of the therapist is.  

A new patient comes to me. I gather a bit of basic data and then ask her to tell me why she is here, to tell the story in whatever way makes sense for her. I listen. Very rarely is what I hear framed as a moral dilemma. I ask and ask many times during the time we work together “What is the life you want?”, because this is a pivotal issue. And as she frame possible actions, I ask if that action will take her closer to the life she wants. And we do that process again and again. I don’t tell anyone what to do. I am not really a problem solver.  

I deal with what is the life the person wants, what keeps them from having that life, and how/if it can be achieved and what the cost of achieving it might be. In my years of practice, to the best of my knowledge, I have never seen a pedophile or rapist or person who engages in behavior that I think is beyond the pale — those people don’t come in for therapy, at least not to me. Once I saw a person who might have been a murderer. I checked with colleagues and the appropriate state agency to see what my responsibility was to him and to the community. I saw him 3 times and discharged him to a more appropriate facility. That was a professional decision not a moral one.  

So how do psychotherapists navigate these waters?  

I don’t give answers when asked what people should do. I can help them look at why they want to do it and what the consequences are and whether it will get them what they want. But I do not make the decision.  

In two sets of conditions, I am bound to act on what I hear. If I am told by someone that they abuse someone or are abused, in most states, I am mandated to report the abuse. If someone threatens the life of another, case law says I must inform the authorities, but statute does not — so I consult and then report or not. Otherwise, my task is to listen.  

I am not Dr. Phil. I am not a priest. It is VERY hard sometimes not to try to tell people what to do. Because the work I do is not short term and because I usually work with people over the course of months, and  years, we have time to sort through issues, to examine them from as many sides as possible. And ultimately what they do is up to them. 

“The principle aim of psychotherapy is not to transport one to an impossible state of happiness, but to help (the client) acquire steadfastness and patience in the face of suffering. “
-C.G. Jung

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