Journal ol Abnormal Psychology 1975. Vol. 84, No. 2. 175-177
Ethical Considerations in the Application of Self-Control Techniques Paul Karoly University of Cincinnati Ethical questions are raised in regard to a case report by Levendusky and Pankratz. While it is asserted that the general issue of control in psychotherapy is specious in the present context, several potentially fruitful lines of inquiry are proposed. Readers are asked to consider the legality of withholding information relevant to a client's decision to remain in treatment, the subtle nature of contract negotiation in therapy, the roles of theory and assessment in the design of clinical intervention, and the need to pursue alternatives to deception in applied settings. As the furor over Watergate has served to sensitize citizens to excesses in the management of power and the plasticity of ethical systems in government, the case study by Levendusky and Pankratz (1975) raises analogous issues for those involved in the conduct of psychotherapy. Questions of how best to establish mutuality of influence and decision making in therapy require serious consideration, especially by behaviorally oriented practitioners, who are often accused of dehumanizing treatment and of seeking to gain ultimate control of their patients' lives (cf. Russell, 1974). Regrettably, what appears to be the most obvious dimension for ethical inquiry in the Levendusky and Pankratz case report may be a philosophical dead end. I refer to the broad issue of control. Readers sympathetic to the views of Thomas Szasz may interpret the case as an excellent example of the Therapeutic State in action, an embodiment of the Rule of Paternalism: "Doing unto others as we, in our superior wisdom, know ought to be done unto them, in their own best interests" (Szasz, 1974, p. 17). Flip the coin, however, and we are apt to find strict empiricists and utilitarians defending the ethical superiority of wisdom grounded in the documented facts of therapeutic efficacy. Can therapists ethically withhold a treatment that has a high probability of success? If, as Begelman (1973) has asserted, "ethical questions can arise over how we on occasion influence others, not over the fact that we do" (p. 413), then neither technical proficiency nor absolute respect (in the form of informed consent) can serve as particularistic criteria for judging the morality of clinical practice. Levendusky and Pankratz cannot logically be judged as unethical for being in Requests for reprints should be sent to Paul Karoly, Department of Psychology, University of Cincinnati, Cincinnati, Ohio 45221.
the business of behavior change nor for believing in the effectiveness of their methods. Neither would a disavowal of their clinical talents and expertise in favor of client consent affirm their virtues. Moral judgments are, by definition, absolute. Nevertheless, a social-learning position is founded on the premise that the act of moral evaluation is complex and contextually embedded; that morality is a condition, not solely of persons, but of persons-in-environments (Skinner, 1974), Behavior therapists are constrained to observe the rules and best interests of the behavior systems with which they make contact in the course of treatment, to assess the costs of intervening or not intervening in terms of legal, cultural, religious, familial, and patient-therapist contingencies. In addition, the psychologist is accountable to his profession. Some of these ecological parameters are considered below (cf. Baer, 1974; Willems, 1974). Legal Considerations Although Levendusky and Pankratz's client undertook a voluntary hospitalization, his legal right to sign himself out may well have been compromised by the withholding of information relevant to his decision to remain in treatment— an act apparently motivated by the therapists' awareness of their client's stated preferences regarding drug dosage. What does one do when confronted with a therapeutic regimen with a high likelihood of success and a patient with a high likelihood of refusing treatment? Legal precedents are rare. Might Mr. X have had a defensible case against his doctors had he decided to sue after being informed of the medical deception? Clearly the question of patients' rights is no less complex or crucial for the intact adult client in a voluntary treatment setting than it is for the legally committed wards of the state (Wexler,
175
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COMMENTS
1973). At a time when laws are being written and precedents set, it would behoove every psychologist 'to consider public reaction to what might be the most reasonable of therapeutic strategies.
The Contractual Relationship The behavior therapist's repudiation of the traditional qualitative distinction between normal and abnormal processes, combined with an individualized approach to assessment, permits a recognition of the client's uniqueness in the context of a truly collaborative relationship. The contract between Levendusky and Pankratz and their client called for them to engage in self-control training to assist Mr. X to " 'get more out of life in spite of [his] pain' " (p. 166). In addition the authors report that "medication adjustment" but not "direct modification" of the Talwin dosage was expected by the client. Two problems are apparent. First, the contract seems quite vague, nonspecific, and informal. Second, a relatively specific contractual understanding appears to have been violated by the staff. On the first point, both theory (Kanfer & Karoly, 1972) and empirical research (Kanfer, Cox, Greiner, & Karoly, 1974) suggest that contract clarity contributes to the effectiveness of self-control training. Here the authors seem clearly to have erred. The question of contract violation, on the other hand, transcends theory and technique and cuts to the very heart of the collaborative relationship. It would be naive to assume, however, that collaboration implies a simple SO-SO split in decision making and total sharing of information. If Mr. X agreed to the rules of the psychosomatic ward, accepted the professional credentials of his therapists, and expected to be persuaded as well as consulted in the pursuit of therapeutic change, then it may be reasonable to assume that the staff were operating within the same acceptable limits afforded surgeons who must make numerous noncollaborative choices affecting the very lives of their patients. Yet, consider that in psychotherapy the clinician often acts as the arbiter of vague and changing social norms as well as the interpreter of his own esoteric methods. The situation bears little resemblance to the act of a physician objectively informing his patient of the risks of open heart surgery. The active or passive use of deception or miscommunication abridges many forms of client countercontrol, and in so doing brings the clinician dangerously close to the practice of coercion. In my opinion, contract specificity can go a long way to meet ethical as well
as technical ideals. And, in fairness to Levendusky and Pankratz, the publication of case reports and other forms of consultation with colleagues represents a further moral safeguard. Procedural Issues Psychologists owe their clients the best possible treatment they can give. While Levendusky and Pankratz deserve commendation for attempting to translate the social psychological insights of Schachter, Davison, Valins, and others into a viable treatment program (e.g., their use of an active self-control training package along with reattribution techniques is innovative), two problem areas emerge which deserve careful consideration. First, the distinction between pain management (the reduction of inappropriate forms of behavior constituting a client's adaptation to physiologically based pain) and operant conditioning of verbal behavior (assuming that pain reports are the equivalent of pain reactions) needs to be more clearly stated. Since pain reports can be manipulated independently of pain sensitivity (Clark, 1969), clinicians would be wise to attempt an independent assessment of both parameters and of the internal and external factors influencing their interrelationship. Levendusky and Pankratz tell us little about the measurement procedures they employed to establish (a) a base rate of pain complaints and painrelated behavior, (b) the nature of situational cues and social reinforcers for the target response-system, and (c) actual client attributions regarding the source, intensity, predictability, and controllability of physiological sensations labeled "pain." Indeed, the absence of continuous selfobservation by the client (via daily logs or a behavioral diary) makes any attribution of clinical success in this case somewhat premature. Finally, although the therapists' decision to attempt to train their client in self-controlling responses, cognitive relabeling, relaxation, and reattribution seems theoretically sound, for both pragmatic and ethical reasons the Levendusky and Pankratz procedure merits cautious imitation. I am confident that these authors would agree (a) that reattribution therapy is inappropriate when clients are correctly attributing problems to their own behaviors; (b) that the cumulative effects of 3 weeks of veridical selfattributions might have been more potent than the one-shot, after-the-fact reattribution employed by them (apparently because they had no other option); and (c) that had the self-control and relaxation training not taken hold, their client might have lost faith in the Talwin, which
177
COMMENTS he believed he was receiving at full strength—a reaction akin to what Valins and Nisbett (1972) have termed the "negative placebo effect." And, finally, with respect to point (b), need we assume that alternatives to deception were unavailable? A scanning of the literature reveals numerous cautions against deception, and suggestive evidence on the power of such techniques as role playing (Kopel & Arkowitz, 1974), modeling, suggestion, persuasion, and cognitive distraction methods (Barber, Spanos, & Chaves, 1974). While I may be accused of arguing with success, my aim has been the constructive criticism of a complex and provocative clinical procedure. I trust these comments will serve to spur continued debate on the process of moral decision making in behavior therapy. REFERENCES Baer, D. A note on the absence of a Santa Claus in any known ecosystem. Journal oj Applied Behavior Analysis, 1974, 7, 167-170. Barber, T. X., Spanos, N. P., & Chaves, J. F. "Hypnosis," imagination and human potentialities. New York: Pergamon Press, 1974. Begelman, D. A. Ethical issues in behavioral control. Journal of Nervous and Mental Disease, 1973, 156, 412-419. Clark, W. C. Sensory-decision theory analysis of the placebo effect on the criterion for pain and thermal sensitivity (d'). Journal oj Abnormal Psychology, 1969, 74, 363-371. Kanfer, F. H., Cox, L. E., Greiner, J. M., & Karoly,
P. Contracts, demand characteristics, and self-control. Journal oj Personality and Social Psychology, 1974, 30, 605-619. Kanfer, F. H., & Karoly, P. Self-control: A behavioristic excursion into the lion's den. Behavior Therapy, 1972, 3, 398-416. Kopel, S. A., & Arkowitz, H. S. Role playing as a source of self-observation and behavior change. Journal of Personality and Social Psychology, 1974, 29, 677-686. Levendusky, P., & Pankratz, L. Self-control techniques as an alternative to pain medication. Journal of Abnormal Psychology, 1975, 84, 165-168. Russell, E, W. The power of behavior control: A critique of behavior modification methods. Journal of Clinical Psychology, 1974, 30, 111-136. Skinner, B. F. About behaviorism. New York: Knopf, 1974. Szasz, T. S. The second sin. Garden City, N.Y.: Anchor Books, 1974. Valins, S., & Nisbett, R. E. Attribution processes in the development and treatment of emotional disorders. In E. E. Jones, D. E. Kanouse, H. H. Kelley, R. E. Nisbett, S. Valins, & B. Weiner (Eds.), Attribution: Perceiving the causes oj behavior. Morristown, N.J.: General Learning Corporation, 1972. Wexler, D. B. Token and taboo: Behavior modification, token economies, and the law. California Law Review, 1973, 61, 81-109. Willems, E. P. Behavioral technology and behavioral ecology. Journal of Applied Behavior Analysis, 1974, 7, 151-165. (Received October 23, 1974)
Ethical Considerations in the Application of Self-Control Techniques Paul Karoly University of Cincinnati Ethical questions are raised in regard to a case report by Levendusky and Pankratz. While it is asserted that the general issue of control in psychotherapy is specious in the present context, several potentially fruitful lines of inquiry are proposed. Readers are asked to consider the legality of withholding information relevant to a client's decision to remain in treatment, the subtle nature of contract negotiation in therapy, the roles of theory and assessment in the design of clinical intervention, and the need to pursue alternatives to deception in applied settings. As the furor over Watergate has served to sensitize citizens to excesses in the management of power and the plasticity of ethical systems in government, the case study by Levendusky and Pankratz (1975) raises analogous issues for those involved in the conduct of psychotherapy. Questions of how best to establish mutuality of influence and decision making in therapy require serious consideration, especially by behaviorally oriented practitioners, who are often accused of dehumanizing treatment and of seeking to gain ultimate control of their patients' lives (cf. Russell, 1974). Regrettably, what appears to be the most obvious dimension for ethical inquiry in the Levendusky and Pankratz case report may be a philosophical dead end. I refer to the broad issue of control. Readers sympathetic to the views of Thomas Szasz may interpret the case as an excellent example of the Therapeutic State in action, an embodiment of the Rule of Paternalism: "Doing unto others as we, in our superior wisdom, know ought to be done unto them, in their own best interests" (Szasz, 1974, p. 17). Flip the coin, however, and we are apt to find strict empiricists and utilitarians defending the ethical superiority of wisdom grounded in the documented facts of therapeutic efficacy. Can therapists ethically withhold a treatment that has a high probability of success? If, as Begelman (1973) has asserted, "ethical questions can arise over how we on occasion influence others, not over the fact that we do" (p. 413), then neither technical proficiency nor absolute respect (in the form of informed consent) can serve as particularistic criteria for judging the morality of clinical practice. Levendusky and Pankratz cannot logically be judged as unethical for being in Requests for reprints should be sent to Paul Karoly, Department of Psychology, University of Cincinnati, Cincinnati, Ohio 45221.
the business of behavior change nor for believing in the effectiveness of their methods. Neither would a disavowal of their clinical talents and expertise in favor of client consent affirm their virtues. Moral judgments are, by definition, absolute. Nevertheless, a social-learning position is founded on the premise that the act of moral evaluation is complex and contextually embedded; that morality is a condition, not solely of persons, but of persons-in-environments (Skinner, 1974), Behavior therapists are constrained to observe the rules and best interests of the behavior systems with which they make contact in the course of treatment, to assess the costs of intervening or not intervening in terms of legal, cultural, religious, familial, and patient-therapist contingencies. In addition, the psychologist is accountable to his profession. Some of these ecological parameters are considered below (cf. Baer, 1974; Willems, 1974). Legal Considerations Although Levendusky and Pankratz's client undertook a voluntary hospitalization, his legal right to sign himself out may well have been compromised by the withholding of information relevant to his decision to remain in treatment— an act apparently motivated by the therapists' awareness of their client's stated preferences regarding drug dosage. What does one do when confronted with a therapeutic regimen with a high likelihood of success and a patient with a high likelihood of refusing treatment? Legal precedents are rare. Might Mr. X have had a defensible case against his doctors had he decided to sue after being informed of the medical deception? Clearly the question of patients' rights is no less complex or crucial for the intact adult client in a voluntary treatment setting than it is for the legally committed wards of the state (Wexler,
175
176
COMMENTS
1973). At a time when laws are being written and precedents set, it would behoove every psychologist 'to consider public reaction to what might be the most reasonable of therapeutic strategies.
The Contractual Relationship The behavior therapist's repudiation of the traditional qualitative distinction between normal and abnormal processes, combined with an individualized approach to assessment, permits a recognition of the client's uniqueness in the context of a truly collaborative relationship. The contract between Levendusky and Pankratz and their client called for them to engage in self-control training to assist Mr. X to " 'get more out of life in spite of [his] pain' " (p. 166). In addition the authors report that "medication adjustment" but not "direct modification" of the Talwin dosage was expected by the client. Two problems are apparent. First, the contract seems quite vague, nonspecific, and informal. Second, a relatively specific contractual understanding appears to have been violated by the staff. On the first point, both theory (Kanfer & Karoly, 1972) and empirical research (Kanfer, Cox, Greiner, & Karoly, 1974) suggest that contract clarity contributes to the effectiveness of self-control training. Here the authors seem clearly to have erred. The question of contract violation, on the other hand, transcends theory and technique and cuts to the very heart of the collaborative relationship. It would be naive to assume, however, that collaboration implies a simple SO-SO split in decision making and total sharing of information. If Mr. X agreed to the rules of the psychosomatic ward, accepted the professional credentials of his therapists, and expected to be persuaded as well as consulted in the pursuit of therapeutic change, then it may be reasonable to assume that the staff were operating within the same acceptable limits afforded surgeons who must make numerous noncollaborative choices affecting the very lives of their patients. Yet, consider that in psychotherapy the clinician often acts as the arbiter of vague and changing social norms as well as the interpreter of his own esoteric methods. The situation bears little resemblance to the act of a physician objectively informing his patient of the risks of open heart surgery. The active or passive use of deception or miscommunication abridges many forms of client countercontrol, and in so doing brings the clinician dangerously close to the practice of coercion. In my opinion, contract specificity can go a long way to meet ethical as well
as technical ideals. And, in fairness to Levendusky and Pankratz, the publication of case reports and other forms of consultation with colleagues represents a further moral safeguard. Procedural Issues Psychologists owe their clients the best possible treatment they can give. While Levendusky and Pankratz deserve commendation for attempting to translate the social psychological insights of Schachter, Davison, Valins, and others into a viable treatment program (e.g., their use of an active self-control training package along with reattribution techniques is innovative), two problem areas emerge which deserve careful consideration. First, the distinction between pain management (the reduction of inappropriate forms of behavior constituting a client's adaptation to physiologically based pain) and operant conditioning of verbal behavior (assuming that pain reports are the equivalent of pain reactions) needs to be more clearly stated. Since pain reports can be manipulated independently of pain sensitivity (Clark, 1969), clinicians would be wise to attempt an independent assessment of both parameters and of the internal and external factors influencing their interrelationship. Levendusky and Pankratz tell us little about the measurement procedures they employed to establish (a) a base rate of pain complaints and painrelated behavior, (b) the nature of situational cues and social reinforcers for the target response-system, and (c) actual client attributions regarding the source, intensity, predictability, and controllability of physiological sensations labeled "pain." Indeed, the absence of continuous selfobservation by the client (via daily logs or a behavioral diary) makes any attribution of clinical success in this case somewhat premature. Finally, although the therapists' decision to attempt to train their client in self-controlling responses, cognitive relabeling, relaxation, and reattribution seems theoretically sound, for both pragmatic and ethical reasons the Levendusky and Pankratz procedure merits cautious imitation. I am confident that these authors would agree (a) that reattribution therapy is inappropriate when clients are correctly attributing problems to their own behaviors; (b) that the cumulative effects of 3 weeks of veridical selfattributions might have been more potent than the one-shot, after-the-fact reattribution employed by them (apparently because they had no other option); and (c) that had the self-control and relaxation training not taken hold, their client might have lost faith in the Talwin, which
177
COMMENTS he believed he was receiving at full strength—a reaction akin to what Valins and Nisbett (1972) have termed the "negative placebo effect." And, finally, with respect to point (b), need we assume that alternatives to deception were unavailable? A scanning of the literature reveals numerous cautions against deception, and suggestive evidence on the power of such techniques as role playing (Kopel & Arkowitz, 1974), modeling, suggestion, persuasion, and cognitive distraction methods (Barber, Spanos, & Chaves, 1974). While I may be accused of arguing with success, my aim has been the constructive criticism of a complex and provocative clinical procedure. I trust these comments will serve to spur continued debate on the process of moral decision making in behavior therapy. REFERENCES Baer, D. A note on the absence of a Santa Claus in any known ecosystem. Journal oj Applied Behavior Analysis, 1974, 7, 167-170. Barber, T. X., Spanos, N. P., & Chaves, J. F. "Hypnosis," imagination and human potentialities. New York: Pergamon Press, 1974. Begelman, D. A. Ethical issues in behavioral control. Journal of Nervous and Mental Disease, 1973, 156, 412-419. Clark, W. C. Sensory-decision theory analysis of the placebo effect on the criterion for pain and thermal sensitivity (d'). Journal oj Abnormal Psychology, 1969, 74, 363-371. Kanfer, F. H., Cox, L. E., Greiner, J. M., & Karoly,
P. Contracts, demand characteristics, and self-control. Journal oj Personality and Social Psychology, 1974, 30, 605-619. Kanfer, F. H., & Karoly, P. Self-control: A behavioristic excursion into the lion's den. Behavior Therapy, 1972, 3, 398-416. Kopel, S. A., & Arkowitz, H. S. Role playing as a source of self-observation and behavior change. Journal of Personality and Social Psychology, 1974, 29, 677-686. Levendusky, P., & Pankratz, L. Self-control techniques as an alternative to pain medication. Journal of Abnormal Psychology, 1975, 84, 165-168. Russell, E, W. The power of behavior control: A critique of behavior modification methods. Journal of Clinical Psychology, 1974, 30, 111-136. Skinner, B. F. About behaviorism. New York: Knopf, 1974. Szasz, T. S. The second sin. Garden City, N.Y.: Anchor Books, 1974. Valins, S., & Nisbett, R. E. Attribution processes in the development and treatment of emotional disorders. In E. E. Jones, D. E. Kanouse, H. H. Kelley, R. E. Nisbett, S. Valins, & B. Weiner (Eds.), Attribution: Perceiving the causes oj behavior. Morristown, N.J.: General Learning Corporation, 1972. Wexler, D. B. Token and taboo: Behavior modification, token economies, and the law. California Law Review, 1973, 61, 81-109. Willems, E. P. Behavioral technology and behavioral ecology. Journal of Applied Behavior Analysis, 1974, 7, 151-165. (Received October 23, 1974)
