The Only Way is Ethics?
Psychotherapy is currently under enormous pressure to justify its activities via the production of credible research. Developing a research capacity and culture is widely accepted as a necessary survival strategy, if therapy is to prosper in an uncertain economic and political climate. Outcome-based measures, such as CORE, are offered as a way of demonstrating effectiveness, in a policy climate now heavily dominated by the IAPT agenda (Cooper, 2011). Psychotherapy training and education are increasingly linked to universities, in order to gain validation at Master’s level and beyond. Therapists are discovering a requirement to negotiate arcane and unfamiliar procedures for gaining ethical approval for their research, via university ethics committees. These committees, in turn, are often consciously modelled on their NHS counterparts, with a predominantly positivist epistemology, and risk-averse mind-set. This situation is now posing major constraints to the growth of a robust and dynamic research practice for psychotherapy.
NHS clinical research practice has been massively overhauled, in the wake of the Alder Hey and Bristol Royal Infirmary scandals, where medical practice and research was judged to be defective and unaccountable, in professional and ethical terms. A comprehensive research governance framework was developed to rectify this, to reassure the public of respect for patients’ rights and maintain high standards of research practice (DoH, 2010). Universities, particularly those with close links to medicine and nursing, then adopted many of these standards. These were quickly translated into procedures for approval of postgraduate research proposals involving access to persons, rather than those involving purely audit- or library-based research.
However, the actual template of research at the heart of this enterprise is itself problematic, if still largely unquestioned. Research is closely defined as ‘the attempt to derive generalisable new knowledge by addressing clearly defined questions with systematic and rigorous methods’ (DoH, 2010:3). Qualitative psychotherapy researchers might not dispute the relevance of system or rigour here, but the cornerstone assumption of generalisability has more than a whiff of natural science positivism about it. Qualitative research, often exploring the experience and meaning of events for therapy participants, may be robust and valid, but may well be limited in terms of its immediate applicability to wider populations.
Psychotherapy research clearly embraces both quantitative and qualitative methods. However, it is in the latter field that problems can be experienced by researchers seeking formal ethical approval for their work. Behavioural and social constructivist researchers have a long and chequered history of undertaking projects which, while adding to the sum total of human knowledge, breached basic ethical standards of respect for individual autonomy and avoidance of harm. Many of the classic, often laboratory-based, investigations, ranging from Watson simulating anxiety in the case of ‘Little Albert’, to the work of Milgram and Zimbardo on deference to authority, would no longer be ethically acceptable, outside the confines of a Derren Brown reality TV show (De Boese, 2010).
Avoiding risk of harm
Ethics committees therefore do have a role to play in considering and deciding on research proposals which involve contact with human participants, in order to protect their rights, avoid risk of harm and promote ethically sound work. Psychotherapy research, however, can raise some particularly difficult issues for ethical approval, not least in terms of gaining informed consent from participants. Informed consent, as we know from the Research Governance Framework, is seen as a critical issue, lying “at the heart of ethical research” (DoH, 2010: 7). Gaining informed consent requires giving participants sufficient prior information on advantages and disadvantages of taking part, in order to make a reasoned choice to take part, or withdraw. This is essentially based on a cognitive, legalistic and contractual model of decision-making. Consent also requires capacity and consideration of the specific needs of groups designated as vulnerable by means of their age, level of understanding, or social situation.
Ethics committees are particularly vigilant, in my experience, to avoid any suggestion of social pressure on individuals to take part in research, and to avoid any risk of harm, for example, by causing emotional distress, by interviewing on subjects deemed to be sensitive. Given these concerns, gaining direct access to NHS or social care patients for research is becoming increasingly problematic. Hence we witness the frequent fall-back scenario of therapists being restricted to just interviewing other therapists, as the sole acceptable proxy route into researching the nature of the therapeutic experience.
Research with vulnerable groups
Psychotherapy researchers seem to encounter particular problems in two key areas – applying the concept of informed consent within certain therapeutic modalities and gaining access to ‘vulnerable’ groups. For instance, ethics committees are often very wary of granting approval to undertake research with children under the age of 16, save for the proviso of also obtaining prior parental consent. This may seem self-evident as a protective device, in tune with the ethical principle of avoiding harm. Viewed from another perspective, this restriction is paternalist, if not patriarchal, in effect. It is also significantly at odds with developing case law on adolescent autonomy, following the Gillick and Axon cases. These cases found an overriding public interest in protecting young people’s rights to confidentiality. If a young person under the age of 16 with ‘sufficient understanding’ can now consent to a termination without parental knowledge or consent, they can certainly complete a questionnaire, or take part in an interview, on their own terms.
Ethics committees may thus be in danger of prioritising non-maleficence, or avoidance or harm, over the competing principle of respect for (the child or young person’s) autonomy. This stance may also lack a firm evidence base as justification. Research carried out by the National Centre for Social Research found that, in the view of some children and young people, parental consent need not be automatically thought necessary (Reeves et al, 2007). This research also contests the common-sense notion of what constitutes a ‘sensitive topic’ for children, thereby requiring parental consent. Some children felt that the level of ‘sensitivity’ varied significantly, by virtue of topic, age and interview location.
Research into sensitive topics
Sexual orientation for young people might seem another such self-evident ‘sensitive topic’, where the additional safeguard of parental consent would be even more essential to obtain. However, this procedure again diminishes the rights of young people to have their own distinctive voice within research. It can also lead to substantially flawed research findings. One example is where research on teenage sexual orientation, as being heterosexual, lesbian, gay, bisexual or transgendered, relies heavily on retrospective self-report as adults, rather than on contemporaneous surveys. McDermott, in researching this topic, refers to US studies which dispensed with the need for parental consent with this ostensibly ‘vulnerable’ group, ie LGBT young people. This was justified in ethical terms on the utilitarian grounds of the public interest and with the provision of enhanced safeguards for the well-being of its young participants (McDermott, 2010).
Research governance can constrain innovative research in other ways. Halse and Honey (2005) describe their own frustrating experiences, in trying, unsuccessfully, to frame an acceptable multi-site research proposal. This was intended to explore the experiences of young women with anorexia, when the very definition of ‘anorexia’ itself was being unpacked and critiqued. The net impact of this adverse ‘compliance culture’, exercised by ethics committees, was to substantially “constrain the possibility and practice of feminist research” (2005: 2159).
Informed consent, so central to research governance, is implicitly based on the model of the research participant as a ‘rational consumer’, weighing up information, in order to make a reasoned choice. Reliance on informed consent can, however, present major difficulties for psychotherapists wanting to use a case study mode of reporting (Winship, 2007) and for those working within the psychodynamic (Lear, 2003), or analytic, traditions (MacKenna, 2003; Wharton, 2003). Levin, for example, refers to informed consent as an ‘ethico-bureaucratic device’, which fails to take proper account of unconscious transferential processes (2003: 64). This stance is, however, perhaps unlikely to sway an unsympathetic ethics committee, thus further limiting the prospects for research within these therapeutic modalities.
Despite all this, university ethics committees are here to stay. No doubt, they do perform some useful functions, in defining extensive protocols and devising ever-more complex electronic forms for completion. Seen from a wider perspective, ethics committees are clear evidence of a paradigm shift, in Weber’s terms, from permission-giving by charismatic consultants and researchers, towards classic bureaucracy as the prime source of authority. In this shift, ethics committees perhaps share some of the less desirable traits of the genre. Positivism seems to be the default epistemology du jour, displacing and hedging qualitative enquiry by slow degrees. Ethics committees also represent the developing hegemony of the medical profession over psychotherapy as an emerging profession. Many committees will point to the Declaration of Helsinki of 2008 as a key reference document, when this is explicitly restricted in scope to medical research on human subjects.
Litigation and complaint
Ethics committees justify their activity with regard to ethical principles, but this can mask the apparent self-interest of the institution on occasion. Halse and Honey, for example, recount their efforts to obtain approval for research with teenage girls with anorexia, but without specifying the need for prior parental approval. However, “all ethics committees were immovable on these issues. The concern was not with the legitimacy of the arguments we presented but with the financial threat of a litigious parent or care-giver” (2005: 2152).
This is, perhaps, a crunch issue for understanding the role of ethics committees, namely to serve as a first line of defence against potential hostile litigation. This stance shows the limitations of transposing the NHS ethics tradition to a non-NHS university setting. Fear of litigation may be a major factor for the NHS, even if this not an easily identifiable ethical principle as such. This is much less applicable within the university environment, where the likelihood is much more of action for breach of contract, than for negligence as such. Classically, this takes the form of complaint, or legal action, by students for inadequate research supervision, rather than as action for negligence by aggrieved research participants (Farringdon, and Palfreyman, 2006). Recorded complaints by research participants to professional therapy associations are also noticeably rare.
If self-protection is a major factor in ethics committees’ decision-making, it is based on a massive over-estimation of the actual risks involved. Some empirical research would clearly be useful here, to clarify the real extent of the risk to the researcher, participants and institution, and to provide some testable evidence of the effectiveness of the committees themselves, in their chosen role. This would seem all the more valuable, given the type of major recent ethical controversies related to research, which have received most publicity. The two most obvious include the damaging social effects of The Lancet’s publication of Andrew Wakefield’s paper on the MMR vaccine (Butler, 2010), and the ‘data wars’ unleashed against environmental researchers at the University of East Anglia (Pearce, 2010). Neither of these key media events, raising substantial adverse comment on research ethics, have involved psychotherapy research in any way.
If university ethics committees are indeed cultivating a ‘culture of compliance’, then this may have serious consequences for developing psychotherapy research in the future. On the one hand, it would be useful to allay fears that qualitative research in therapy is inherently unsound in methodology, risky for participants, or disadvantageous to vulnerable populations, such as children and young people. We also need to unpack the concept of informed consent as a primarily cognitive process, exercised by participants as rational consumers of research. Abrahams argues persuasively, in her research with survivors of domestic violence, that establishing trust was crucial in facilitating their participation (2007). Participants from marginalised groups need to feel that they can trust researchers, just as in the case of establishing the therapeutic alliance, before they will give informed consent. This therefore requires, crucially, a relational understanding of the research process into therapy, rather than simply a procedural one, requiring the simple evidence of a signature on a consent form.
To conclude, ethics committees are classically risk-averse bureaucratic organisations. Nevertheless, psychotherapy research must entail some limited degree of risk, either to the researcher, or to participants. Minimising risk of harm is clearly important, but this can reach absurd levels on occasion – in one instance I came across, ethical approval for participants visiting the university to take part in interviews was rejected because car parking had not been fully risk-assessed as an activity. There is rich and promising material here, for a new comic novel by Malcolm Bradbury set on campus, perhaps entitled The Ethics Man, or even a new reality TV show, The Only Way Is Ethics.
Peter Jenkins is a Senior Lecturer in Counselling at the University of Manchester and a member of the UKCP Ethics Committee. This article was first printed in The Psychotherapist, Autumn 2011, www.ukcp.org.uk.
Abrahams, H. (2007) Ethics in counselling research fieldwork, Counselling and Psychotherapy Research, 7(4), pp. 240-244.
Butler, C. (2010) Lessons of a health scare Guardian, 25th October
Cooper, M. (2011) Meeting the demand for evidence-based practice, Therapy Today, 22(4), pp. 10-16.
De Boese, A. (2010) Elephants on Acid and Other Bizarre Experiments. London: Pan MacMillan.
Department of Health (DoH) (2010) Research Governance Framework for Health and Social Care. Second edition. London: DoH.
Farringdon, D and Palfreyman, D. (2006) The Law of Higher Education. Oxford: Oxford University Press.
Halse, C. and Honey, A. (2005) Unraveling ethics: Illuminating the moral dilemmas of research ethics in Signs: A Journal of Women in Culture and Society, 30(4), pp. 2141-2187.
Lear, J. (2003) Confidentiality as a virtue” pp. 4-17, in Levin, C., Furlong, A. and O’Neill, M.K. (Eds) Confidentiality: Ethical Perspectives and Clinical Dilemmas. Hillsdale, N.J.: Analytic Press.
Levin, C. (2003) Civic confidentiality and psychoanalytic confidentiality, pp. 52-75, in Levin, C., Furlong, A. and O’Neill, M.K. (Eds) Confidentiality: Ethical Perspectives and Clinical Dilemmas. Hillsdale, N.J.: Analytic Press.
MacKenna, C. (2003) Ethical pressures on the analytic alliance, pp. 51-64, in Solomon, H.F. and Twyman, M. (Eds) The Ethical Attitude in Analytic Practice. London: Free Asociation.
McDermott, E. (2010) Researching and Monitoring Adolescent Sexual Orientation. London: Equalities and Human Rights Commission.
Pearce, F. (2010) The Climate Files: The Battle for the Truth about Global Warming. London: Guardian Books.
Reeves, A., Bryson, C., Ormston, R. and White, C. (2007) Children’s Perspectives on Participating in Survey Research. London: National Centre for Social Research.
Wharton, B. (2003) The reporting of clinical material: Ethical issues” pp. 99-122, in Solomon, H.F. and Twyman, M. (Eds) The Ethical Attitude in Analytic Practice. London: Free Association.
Winship, G. (2007) The ethics of reflective research in single case study inquiry, Perspectives in Psychiatric Care, 43(4), pp. 174-182.
For a link to a 30 minute video of Peter’s keynote talk on Research ethics in counselling and psychotherapy, presented in July 2011, at the Manchester University School of Education Research Conference,
Image: The last Judgement by Ben Rimmer: The dome of the Duomo, Florence, Italy. The fresco of the Last Judgement is by Vasari and Federico Zuccari