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Psychotherapy and the Ethics of Attention

Psychotherapy and the Ethics of Attention

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Published by PSICOANTRO
Una reflexión sobre la naturaleza de la facultad atencional
Una reflexión sobre la naturaleza de la facultad atencional

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Published by: PSICOANTRO on Mar 26, 2012
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 Hastings Center Report, January-February 199
Psychotherapy and the Ethics of Attention
by Michael Lipson and Abigail Lipson
Medical ethics tends to focus on the content of patients’ beliefsrather than concern itself with patients’ ethical development.An ethics of attention investigates the psychological processesthat are the prerequisite to moral action.
M
any psychological difficul-ties for which patients seek psychotherapy can be seenas requiring some kind of development in the ethical life of thepatient. Existing forms of therapy,whether implicitly or explicitly, pro-vide contexts for such development.The aspect we intend to explore isthe special role of 
attentional dynamics:
how our capacity to attend underliesour ethical abilities. By investigatingattentional dynamics, we do not seek to advocate a particular set of valuesor a particular brand of moral prac-tice (for example, consequentialist,deontological, virtue-based). Instead,the capacity to attend can be exercisedin the service of all the major theoriesof ethics as theycurrently exist.Our concern is the psychotherapyof ethics, rather than the ethics of psychotherapy, which represents some-thing of a departure from the norm.To date, discussions of ethics and psy-chotherapy have shared with othermedical ethical inquiry a nearly ex-clusive focus on ethical constraints onthe practitioner, with far less emphasison ethical processes within the pa-tient To some degree, this situationderives from the history of normative
Michael Lipson and Abigail Lipson, “Psychother-apy and the Ethics of Attention,”
 Hastings Center  Report 
26, no. 1 (1996): 17-22.
ethics in philosophy, which hastended to announce a principle ordiscuss a practice but not to investi-gate the intrapsychic and interper-sonal conditions under which personsaffect one another’s moral development
 for the good.
When medical ethics today con-cerns itselfwith the meeting point be-tween health care provider decisionsand patients’ moral sensitivities, ittends to focus on questions regardingchoice of treatment as mediated bypatients’ beliefs taken as fact, ratherthan on how techniques of treatmentinteract with patients’ ethical devel-opment. The perceived authenticityof a Jehovah’s Witness’s beliefs, forexample, may affect the decision tohonor or to supervene the patient’srefusal of blood transfusions. Yet itwill not, at least officially, affect thetechnical details of how blood is trans-fused, how other treatments are ap-plied, or how patient and physicianmight converse and modify theirviews. Nor does the evolution of pa-tient beliefs or the phenomenologyof moral decisionmaking on the partof the patient form a subject in stand-ard bioethical theory.In psychotherapy, however, whichconcerns itself with the patient as aself-aware and changing psyche, con-siderations of the patient’s ethicalstances and their development mightbe expected often to assume a centralrole and significantly to affect the de-tails of the course of psychotherapy.This is all the more to be expectedwhen we consider that certain recog-nized standards of mental health areprima facie ethical in nature. Thus,when the
 Diagnostic and Statistical Manual IV 
defines Antisocial Person-ality Disorder, it includes not only ly-ing, stealing, and cruelty among thediagnostic criteria, but also “lack of remorse.”
1
Similarly, the exclusive fo-cus on one’s own body, self, and self-states reflected in the diagnostic cri-teria for Narcissistic Personality Dis-order—and the inclusion of “lacksempathy” among the diagnostic cri-teria—implies that the correspondinghealthy adaptation involves respon-sive relatedness to other human be-ings (p. 661). Even the
 DSM IV,
then,seems at times to invoke, as one cri-terion of health or pathology, the be-havioral and experiential correlativesto commonsense and philosophicalconceptions of ethics.If mental health practitioners advo-cate high ethical standards for them-selves, and if diagnostic
categories are
founded in part on a moral dimen-sion to psychological health, then itseems appropriate for psychothera-pists explicitly to engage ethical issuesin the lives of those they treat. In-deed, one of the American Psychological Association’s remedies forethical lapses in psychologists’ prac-tice is to mandate psychotherapy forthe offender, demonstrating that ethi-cal development
can
be fostered bypsychotherapy. There is no reason forthis morally regenerative capacity of psychotherapy to operate exclusivelyfor patients who happen also to bepsychotherapists.Yet in the literature of psychother-apy and ethics, despite claims (at leastsince the 1970s
2
) that every interac-tion and every intervention is “value-laden,” very little is written about thedetails of ethical development in thepatient. Many theorists have an-nounced overarching goals of treat-ment in quasi-moral terms: as self-actualization (Rogers and Maslow),loving creativity (Fromm-Reichmannand Fromm), purpose (Frankl), loveand work (Freud), or social related-ness (Winnicott, Mitchell and Green-berg), and even “intimacy” (Ehren-berg). Still, the articulated details of 
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treatment, the moment-to-momentphenomenology of the patient’s ethi-cal experience or of the psychothera-peutic session as a context for ethicaldevelopment, are often passed overcursorily almost shamefacedly.
3
The Ethics of Attention
The place to work validly in thearea of psychotherapy patients’ ethi-cal development is rarely in terms of specific values and beliefs, rarely interms of behavioral outcomes, butoften in terms of the psychologicalprocesses of attention. How the pa-tient attends, rather than what thepatient intends, becomes a key focusof psychotherapeutic intervention.While a description of the technicalaspects of this field is not possible inso brief a format, we hope to pointout some of its primary conceptualfeatures. It is not the individual tech-niques, which will vary with the prac-titioner’s style,- school, and skill, butrather their aim that interests us here.Some ethical theorists, Iris Mur-doch and Simone Weil in particular,have already given special weight tothe psychological category of 
attention
as a foundation for ethical conduct.Their works provide a starting pointfor psychotherapy’s potential to ad-dress attentional style as an aspect of adult ethical development. That is,rather than focus on the content of moral beliefs, on this or that substance of moral reasoning, they con-sider the neglected area of the mo-ment-to-moment placement of a per-son’s attention. “Attention” here hasno technical definition distinct fromfamiliar usage: it refers to directingone’s awareness to specific objects.We must emphasize at the start thatthe kind of development to whichWeil and Murdoch (and we) refer isexplicitly normative, not descriptive.It is not “developmental,” then, in thesense in which this term is currentlyused in psychology. Rather, it rec-ognizes the possibility, for patientswho desire to exercise it, of increas-ing the frequency and changing thetone of certain kinds of psychologi-cal acts of attention. Along with Weiland Murdoch, we understand thiskind of transformation of attentionalcapacity to be a development in
ethi-cal
life.
 Hastings Center Report, January-February 1996 
Weil and Murdoch argue for an“inner” ideal of goodness. In contrastto a behaviorist ethics in the positivisttradition, Murdoch has appealed tocommon sense conceptions of mentalacts.
4
Among these is the view thatattention immersed in its object car-ries a higher moral value than atten-tion directed toward the subject. ForMurdoch, the attention given to theRussian language when studying it,for example, represents a moral actIt is not the content of the attentionalfocus (Russian) but only the act of attending that is morally effective. AsMurdoch writes, “Moral changecomes from an
attention
to the worldwhose natural result is a decrease inegoism through an increased senseof the reality of, primarily of courseother people, but also other things.”
5
Murdoch’s argument is that “good-ness” inheres not in works but infaith, not in faith but in purpose, notin purpose but in mental devotednessto something other than the self. Thisdevotedness is what she means by at-tention. As a standard of morality, ittends to make all ethics situational,in the sense that good acts are theoutcome of a willed mental respon-siveness, neither applications of uni-versal rules nor inner promptings of the solitary reasoner. It also tends tomake ethics a matter of consciousnessfirst and behavior second. She em-phasizes this aspect of moral reason-ing, and champions its advocates(Weil, Rainer Maria Rilke).We may reasonably doubt that themere other-directedness of attentionis sufficient to qualify it as ethical. Nodoubt it is “good” for us in the senseof mental exercise and cultural en-richment to learn a difficult foreignlanguage. But is it really “good” inan ethical sense? Can we not arrangethe details of a deception, even of amurder, with terrific attentional fo-cus? Murdoch never engages thesequestions in detail, but elements of her implicit argument will emerge inwhat follows.The bridge between attention andmorality can most easily be seen byreflecting on “selfishness” as an at-tentional style. In acts of self-interest,attention tends to revert from the ob- ject to the subject Consider this ex-ample: I am learning an irregularverb, then I think how well I am doing, then I continue and note a par-
ticular use of the verb. It is the middle
term here, the rebound from ab-
sorbed study to self-concern, that rep-
resents an attentional and, in Mur-doch’s view, a
moral
lapse. RalphWaldo Emerson worked the sametheme: “I have done well, I see thatI have done well, and lo, it is thebeginning of ill.” (It is of course ir-relevant whether one’s attention tothe task recoils to a self-orientationof positive or negative valuation: “Ihave done well” and “I have donebadly” are ethically equivalent in thissense.)The rebound to one’s own self, therecoil of attention from object to sub- ject, is not a matter only of whereattention is directed. It coincides withthe sense that the object of attentionis
known
in a finalizing sense—thatis, fixed or finished. In contrast, theethically devoted attention is not benton the sameness of its object frommoment to moment.Here we have a partial answer tothe apparent problem of the “atten-tive criminal.” The murderer, thoughterribly intent on his object (theplanned murder), is failing to mani-fest a moral attentiveness precisely be-cause the object cannot be freshly un-derstood. Murderers
must 
have mur-der take place (that is, in their mo-ments of doubt they are not quitemurderers). Moral agents, as they as-cend to the Good, maintain a pro-gressively looser grip on the proteanobject of their regard The supplenessof object-oriented attention allows theobject itself the freedom to change,while also reducing the frequency of attentional recoil to the attendingsubject. Martha Nussbaum, in her dis-cussion of Henry James’s novels, de-scribes this tendency of moral atten-tion to present us with what is newto us, variously referring to it as “per-ception”and “imagination.” Onesees, and the moral landscape is onlywell-seen when, like a well-seen physi-cal landscape, it is full of surprises.Nussbaum’s view of attention, alongwith the other terms she uses for it,belong to her general project of bal-ancing duty, rules, and universals withsensitivity to the unique facts of agiven case. Her discussions of Jamesaim in part at showing the need tograsp particular details and imagine
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 Hastings Center Report, January-February 1996 
other people’s minds in their specificpeculiarities:Moral knowledge, James suggests,is not simply intellectual grasp of propositions; it is not even simplyintellectual grasp of particularfacts; it is perception. It is seeinga complex, concrete reality in ahighly lucid and richly responsiveway; it is taking in what is there,with imagination and feeling. Toknow Maggie is to see and feelher separateness, her felicity; torecognize this is to miss least of all. If he had grasped the samegeneral facts without these re-sponses and these images, in alltheir specificity, he would not re-ally have known her.
6
Of course, lapses of attention areunavoidable. Moreover, they are un-measurable, even at times unobserv-able, both for the person experienc-ing them and all the more so for anyone else. Indeed, the status of ourattention is often ambiguous; atten-tional patterns tend to be hetero-genously composed of many chang-ing constituents. Where we place ourawareness, and how it recoils to our-selves, will both vary moment to mo-ment and interact with every area of the psyche: with habits of thoughtand feeling, momentary new intui-tions, susceptibility to the influenceof diverse environments, and otherfactors too numerous to mention.Above all, we want to note the varietyof such elements from one momentto the next; observable actions areonly the“macro” aspect, the summedoutcome, of many impulses, deci-sions, regrets, alertnesses, and som-nambulisms.Yet despite the apparent incom-mensurability of these states andqualities of consciousness, they canall nevertheless be seen as rangedalong a continuum, from more to lessattentionally immersed. In the abilityto move along this continuum lies thepotential for a psychotherapy thatwould promote optimal developmentof the capacity to attend. Attentionalprocess remains analogous across awide range of contexts and content,from trivial to grave, and attentional
exercise
is the common currency of human activities in their ethically in-structive dimension, whether playinga musical instrument, representing aclient at bar, or helping a fallen pe-destrian. Thus, do I play the instru-ment, sum up the case to the jury,or lift the fallen pedestrian, with aneye toward my own glory (“lo, it isthe beginning of ill”) or with an eyetoward the activity itself? Let us as-sume it is both at once: self-regardand other-regard. The question thenbecomes one that, like so many ques-tions in ethics, is quantitative yet un-quantifiable:
 How much
do I focus onmy fortune, image, future, appear-ance—and how much on the activityat hand? For it has long been clearto artists, and to some moral thinkers,that the extent of my self-focus harmsmy “performance.”In her essay “On the Right Use of School Studies with a View toward theLove of God,” Weil makes of atten-tional focus the whole of morality andalmost the whole of human life.
7
Shemaintains that school studies (notethe parallel to Murdoch’s Russian)are valuable precisely because of theirexercise of the capacity to attend andnot because of their content. Shegoes so far as to say that subjects towhich one is not naturally drawn are(“almost”) superior. To attend to whatdoes not interest us is to exercise aparticularly self-less mental skill: wehave little gain, in
this
sense, fromindulging our interests. School stud-ies should be understood as impor-tant precisely for this reason: not tolearn substantive content, but tolearn how to attend.Weil’s insistence on the development of attention tends, ultimately,toward prayer: the direction of atten-tion toward the divine. But she re-serves a special place for the interhu-man uses of this capacity, which, likeall its uses, are based on “self-empty-ing,” that is, the paradoxical (becauseintentional) abandonment of one’sown intentionality with a view towardwhat is other: “Attention consists insuspending our thought, leaving itdetached, empty and ready to bepenetrated by the object” (p. 49).In her essay’s closing reference tothe legend of the Grail, Weil makesit clear that we can best know andhelp our neighbors when we ap-proach them from a foundation of attentional expertise:In the first legend of the Grail, itis said that the Grail belongs to thefirst comer who asks the guardianof the vessel, a king three-quartersparalyzed by the most painfulwound,What are you goingthrough?”. . . This way of looking[at another person] is first of allattentive. The soul empties itself of all its own contents in order toreceive into itself the being it islooking at, just as he is, in all histruth.Only he who is capable of at-tention can do this. (p. 51)We could also reach still furtherback than the Grail legends and con-sider the role of Aristotle’s
epistemikon,
the organelle within the psyche thatcan perceive Forms, and as to whichAristotle says that it is itself formless.
8
That is, we require a form-free cog-nitive capacity to be capable of know-ing new forms. This can be seen toapply to forms of human, natural, orother objects.
9
For moral action to take place, Weilmakes clear, attention is the prereq-uisite, rather than any other quality:Those who are unhappy have noneed for anything in this worldbut people capable of givingthem their attention. The capac-ity to give one’s attention to asufferer is a very rare and diffi-cult thing; it is almost a miracle;it is a miracle. Nearly all thosewho think they have this capacitydo not possess it. Warmth of heart, impulsiveness, pity are notenough.
10
The psychotherapy of attentionconsiders the range of adaptive andmaladaptive, painful and pleasurableuses of our attentional styles. In doingso, it addresses the moral life of thehuman being in its intimate, phe-nomenological roots. Rather than as-sume that positions or beliefs are thefundamental elements of a patient’smoral life, it calls them all into ques-tion indirectly, by working in the fieldof attentional capacity. As attentionredirects itself, strengthens and deepens, the patient’s ethical life changes,confirming or supervening previousconceptions of the Good.Yet we do not propose a specifickind of attention as the endpoint in
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