Clinicians In Pursuit of Ethics

Keynote Address Given by Bill Roller to the Dutch Group Psychotherapy Association Conference, March 25, 2021

Full transcription follows.


First of all, I want to thank the organizers of this fine conference for inviting me to participate this year and deliver the Keynote for the Dutch Group Psychotherapy Association. My wife, Vivian, and I have many reasons for loving the Netherlands and we look forward to a time beyond the pandemic when we may once again visit and make person to person contact with you.

I want to dedicate my talk this evening to Daniel Ellsberg, stalwart foe of the Vietnam War and harbinger of the global annihilation of the human species and all living things threatened by the ongoing thermonuclear war strategy of the United States and other nations who possess nuclear weapons. And to Saad Eddin Ibrahim and Barbara Lethem Ibrahim, distinguished professors of sociology, champions of racial justice internationally, and tireless defenders of human rights and civil society in Egypt. I am fortunate to call each of these individuals my friend.

I believe our duty and obligation to our patients as clinicians is to be fully engaged with the ethical issues and conflicts salient in our times.

The title of my talk is “L’Homme Engagé: A Clinician’s Lifetime Pursuit of Ethics.” The French, “L’Homme Engagé” is a reference and homage to Albert Camus, who has been an intellectual companion of mine as I have developed as a clinician and group therapist. It touches on what I believe is our duty and obligation to our patients: to be fully engaged with the ethical issues and conflicts salient in our times. I shall elaborate this premise for you by way of some examples.

I want to use this opportunity with you to speak of my own countrymen and women, my fellow citizens of the United States. Hopefully, you will find my reflections to be also pertinent to your practices here in the Netherlands.

What does it mean to be fully engaged in the world and what must be our ethical stance if we do? What specifically are these obligations?

Group therapists are expected to cherish truth, human welfare, democracy, human rights and social freedoms as expressed in the United Nations’ Declaration of Human Rights.

I turn first to the formal document, the Ethical Guidelines and Professional Standards for Group Psychotherapy which was ratified in 2009 by the membership of the International Association of Group Psychotherapy and Group Processes. As Chair of the Committee for the Ethics and Professional Standards, I helped in the final formulation of these Ethical Guidelines in consultation with group clinicians from more than 20 nations. While cognizant of other professional codes of ethics in various nations, our document aspired to be international in scope. Thus, group therapists are expected to cherish truth, human welfare, democracy, human rights and social freedoms as expressed in the United Nations’ Declaration of Human Rights. In the spirit of that high endeavor, the Guidelines are intended to enhance professional conscience and judgment and to guide clinical practice.

To give you an idea of the scope, I’ll reference just a few of the specific formal norms set forth:

  1. In accordance with Article I of the United Nations Declaration and Convention against torture and other cruel, inhuman, or degrading treatment and punishment, it condemns the participation of group therapists in the planning, execution, or passively witnessing torture, or participating in any procedure in which torture is threatened.
  2. Group therapists must not participate in group therapy sessions which force patients into humiliating or degrading conditions which compromise the integrity of the individual—such as conducting group sessions in prisons where patients are confined in cages or plexiglass boxes.
  3.  Group therapists are expected to value equality and tolerance between people, to esteem searching for truth, and striving to resolve conflicts within and between individuals, groups, and societies, applying these values in their practice as best they can.
  4. Group therapists have an obligation to attempt to meet the special requirements of patients with disabilities. Inclusion of these is essential to the integrity of the profession and the principle of equal opportunity for treatment.
  5. Group therapists are not allowed to impose on patients their personal, political, ethnic, religious, or other opinions or convictions, except those values inherent to the practice of group psychotherapy and mentioned in these guidelines.
  6. Accordingly, they must not discriminate against nor exploit their patients on grounds of age, gender, race, cultural background, sexual orientation, creed, political affiliation or religion and should respect their autonomy and integrity. Should such issues be likely to affect the therapeutic relationship adversely as a result of the therapist’s own convictions or biases, the therapist should be willing to refer the person to another psychotherapist.

These last two conditions of course put us in the dilemma of paradox. We are enjoined not to impose our values onto our patients—and yet the very discipline we practice is grounded and based on human rights and equality that we must uphold. The core of my presentation addresses this paradox that we all must face.

So, returning to my theme, what does it mean to be fully engaged in the world and what must be our ethical stance if we do? Let’s consider the following informal norms.

First, we must be willing to act and take a stand on the ethical issues directly affecting our patients and do so in public meetings like the one today. We must do so not from the “holier than thou” position or the “know it all” stance that sets us apart from our fellow citizens. We must do so from the position of shared responsibility and shared culpability.

And what is it exactly that we—and I am speaking now of my fellow citizens and clinicians in the U.S—share? We share a social unconscious and social matrix that encompasses the social interactions, beliefs, and self-defining myths and folklore peculiar to the United States. To quote S.H. Foulkes’ definition of the social matrix: “It is the common ground which ultimately determines the meaning and significance of all events and upon which all communications and interpretations, verbal and nonverbal, rest.

Quoting Hopper and Weinberg from their recent volume on the Social Unconscious: “The social unconscious emphasizes shared anxieties, fantasies, defences, myths, and memories of the members of a particular social system. Its most important building bricks are chosen traumas and chosen glories.”

The task of the clinician or analyst of the social unconscious is twofold:

To cast doubt on the national foundational myths while still affirming the essential dignity and resilience of the people whose myths are being questioned and deconstructed.

A clinician must approach this task with deep respect for the capacity of people to gradually re-imagine their foundational beliefs in the interest of making them more in line with the present social reality.

As an example, I will take into consideration what I believe to be one aspect of the social unconscious of my country—the United States. It’s called “American Exceptionalism” and it embraces a number of beliefs, including the notion that we are the only “American” state whereas we share the Western Hemisphere with a number of sovereign states that also rightly claim to be “American.”

Ironically, it all begins here in the Netherlands when a religious group called the Puritans arrived in Amsterdam as refugees from Great Britain. This was the early 17th century when they set sail in their ship, the Mayflower, on their way to North America with the belief they were to found a colony ordained by God. Perhaps it is time for Yankees like me to return to Holland and rethink this 400 year old enterprise that has produced the current United States—and explore the social unconscious that beneath the surface motivates its actions in the world.

These Puritans envisioned themselves establishing the “New Canaan” or the “New Jerusalem” and believed they were divinely called to occupy and inherit the North American Continent. They believed they were “ordained” or called to build a nation by whatever means necessary, including the genocide of its indigenous people and the capture and enslavement of African people to make them, the colonists, prosper.

The authors of the United States Constitution, the founding document of the United States used the word “ordained”—meaning the nation had been “called into being “ by divine Provenance. Therefore, we are forever exceptional, beyond the reach of human laws and subject only to God’s judgment, protection, and our Manifest Destiny to occupy the continent.

As clinicians and group analysts, I maintain we must challenge and resist the beliefs that flow from this cardinal principle of American Exceptionalism.

As clinicians and group analysts, I maintain we must challenge and resist the beliefs that flow from this cardinal principle of American Exceptionalism. They include the belief that we are forever innocent, since our intentions are always good. If a particular strategy does not work out as planned, we are not to blame. We take no responsibility for the unintended consequences of our wars and military invasions. This disclaimer includes the economic collapse of nations, the dislocation of populations as refugees, or the inestimable deaths and injuries caused by wars of aggression in Vietnam and Indo-China (1965-1975), Central America (1980-1989), Iraq (2003-present), and Afghanistan (2001-present).

Our resistance as clinicians and group analysts should not stop here. We have an obligation to the patients we serve who suffer as a consequence of these beliefs. In their behalf we must challenge the notion that we are not subject to International Law, since we can never commit war crimes by definition. If things turn out badly, we call them “mistakes.”

Those leaders in charge are never held accountable for their actions, whether it be war or torture. If we lose a war, we must never openly acknowledge it. To do so would mean we question our place as the Exceptional Nation. As a consequence, we learn nothing and we become mired in endlessly protracted wars, like Afghanistan and Iraq, once again to the detriment and moral hazard of those citizens who fight them and whom we subsequently treat in our therapy groups.

Camus was fond of the Greek goddess, Nemesis, and was aware of her role in punishing nations for excessive pride and arrogance. The current United States policy of “Full Spectrum Dominance” in international relations, combined with our excessive expenditures on military armaments and garrisons worldwide, mark us for retribution by the goddess Nemesis. We can pay for our Empire –but at the loss of our Democracy. We cannot have both.

How do we balance our genuine patriotism with our commitment to do no harm to our fellow countrymen and women caught up in these disasters?

I invite you to consider that we must not just pledge to do no harm –but we must act in ways that may prevent harm from being done. I say “may” because I realize the limits of our resistance as opposed to the enormous power of the nation state. And yet, I ask you: Are these considerations and obligations limited just to those clinicians at work in the United States? Or are they shared by clinicians and group analysts at work in every nation in the world who face the ethical conflict between professional values and acquiescence to the demands of authoritarian governments that do not represent the best interests of their citizens and countermand the United Nations’ Declaration of Human Rights.

Once we realize this dilemma, we must be willing in our public statements to expose ourselves to public criticism and actively engage in arguments with those who oppose our views. This requires courage because it may result in our being scapegoated by the very professional community we wish to activate to support the cause of human rights. We must be curious as social psychologists as well as clinicians as we explore the roots of our societies’ beliefs and the consequent behavior in the world that stems from these beliefs.

As clinicians and group analysts, we must not serve those who make history but those who suffer from it.

I spoke of this earlier regarding our duty to engage with the social unconscious in each of our countries around the world. Our task is not to believe, condone, or support absurdities—but confront them with action no matter how powerless we may feel in doing so.

In the spirit of Camus and his affection for an imperfect humanity, we can assert the following: As clinicians and group analysts, we must not serve those who make history but those who suffer from it.

As group analysts, we explore the unconscious with our patients. By so doing, we encounter the limitations of human desire—the limitations on what we believe we can do. Our exploration of the unconscious in small groups reveals that our group members engage in the fantasy that we possess powers we do not have. An example is the group fantasy that if we just exclude this one member—whom we have designated as the scapegoat, we will ward off division and danger, making us all better off. And yet, once removed, another scapegoat emerges—another group member perceived as the stranger or the Other that we must also exclude. Unchecked, this process will continue to be acted out until it leads to the dissolution of the group, its destruction.

As task leaders and group clinicians, we know that accepting the stranger, the other, the scapegoat, is not just a moral imperative—but a survival imperative. The work of integrating the scapegoat, the stranger among us, is the ethical work we must do. As Task Leaders of our small groups, we have the ability and obligation to direct this process of integration. In this process, the group therapist must ask each group member to speak out about his or her desire to scapegoat—or not scapegoat the member. No one must remain silent. There is no room for passive complicity in this process.

But how do we translate this essential learning about group development to the much larger society outside our small group? This is the great challenge for the international community and its political leaders. As group analysts, we can show the way—but we cannot do it alone. Our allies must become legion, that is, encompass a great many individuals.

As clinicians, we must recognize and proclaim that many of the maladies and mental illnesses that our patients suffer, stem from systemic problems in the larger society. Humanity is plagued by the conditions of poverty, war, refugees, racism, sexism, homophobia, climate change, avarice, and homelessness. To ignore these factors as we treat our patients is to maintain the illusion that they do not contribute to the anxiety, depression, rage, hopelessness, and other mental disturbances that our patients bring to group therapy.

Until the international community and its leaders agree to take responsibility for and confront these human plagues, our task as clinicians and healers appears Sisyphean. This means our task will seem like the labor of the Greek mythological character, Sisyphus—always rolling a stone up the hill only to watch as it rolls back down the hill. And yet, as Camus notes, we must imagine that Sisyphus is happy as he walks down the hill to renew his labor once more.

Camus also affirms that to be engaged with our times, our country and our history, we citizens of the United States must accept that we have been implicated in murder and genocide.

We must summon our courage to advocate for those persecuted as a result of our social beliefs, unconscious or otherwise.

We who speak out and point out the social unconscious are not immune to its effects. Neither are we innocent of its depredations. We too are guilty of murders sanctioned by our history of common beliefs, our social unconscious. We must summon our courage to advocate for those persecuted as a result of our social beliefs, unconscious or otherwise.

A specific case in the United States is the incarceration of large numbers of mentally ill in our prisons—or  the abandonment of men and women to the streets of the United States as homeless refugees in their own land— refugees in their own land, I emphasize.

We must also refine and further develop our capacity to learn from others and believe “the opinions of mankind” matter, as stated in the U.S. Declaration of Independence. I’ll give a small example of how even the most learned can miss the mark of learning from others. In the winter of 2019, Vivian and I attended a lecture by a brilliant, liberal professor of comparative politics at the University of California, Berkeley.

The lecturer was speaking of modern day People’s Republic of China. I posed to him the following question: “What can we in the United States learn from the People’s Republic?”

This highly informed professor appeared not to know how to respond. It seemed he could not fathom the notion that we might have something to learn from our prime economic rival.

After a pause, I suggested that perhaps the People’s Republic of China is a good model for the United States in the realm of Thermonuclear War Planning. The Chinese have developed a war deterrent strategy with only a stockpile of 350 Thermonuclear weapons—whereas the United States has roughly 3,800 Thermonuclear weapons, many with first strike capability.

On reflection, the professor agreed that the Chinese strategy for deterrence was much more prudent, much less expensive, and presented much less risk of ‘accidental’ deployment of these fearsome weapons.

I focus on this story because it is pertinent to Camus’ central question for human beings: Suicide, or why we don’t just kill ourselves when we believe that life is not worth living? Have we—as the world’s people—committed ourselves to the belief that life is not worth living by allowing such existential threats to exist? Have we—the world’s people—committed ourselves to a mutual suicide pact? Martin Luther King, in his 1967 speech condemning the Vietnam War, stated that “a nation that spends more on military armament than on human and social uplift was a nation approaching spiritual death.”

I want to compare the task of those clinicians who choose to engage in the crises of their times with the task Camus ascribed to that of the writer:

“It is the commitment to serve the truth and to serve liberty.”

“It is the refusal to lie about what we know to be true and our willingness to resist oppression in the societies in which we practice.”

“It is the commitment to forge an art of living in time of catastrophe”

“It is the commitment to fight openly against the instinct of death at work in our history”

“It is a commitment to confront a world threatened by disintegration, in which our Grand Inquisitors run the risk of establishing forever the Kingdom of Death.”

How daunting is Camus’ challenge to us because “truth is mysterious, elusive and must always be pursued in order to be comprehended—and liberty is dangerous, as hard to live with as it is invigorating.”

As clinicians who pledge to do no harm, we must consider each of us a pledge to prevent the harm of Thermonuclear war—as surely as it were the final and last plague of humanity. Since the dawn of the nuclear age in 1945, there has never been a Hearing in either the United States Senate or the House of Representatives debating or challenging the current Thermonuclear War Strategy of the United States Armed Forces: First Strike Capability, Civilian Targets, and acceptable levels of civilian deaths approaching billions of human beings.

As I write these words, the United States passed the mark of one half million dead as a result of Covid-19. That figure, once unimaginable, is now tolerable. But let’s suppose a limited exchange between Thermonuclear powers left 50 million people dead. That’s just 100 times more than our current Covid deaths. So what was once unimaginable could also become tolerable, and therefore, doable. Where does this logic end?

As Robert J. Lifton, the psychiatrist that interviewed the Nazi doctors reminds us: humans can be gradually socialized to evil. Will citizens gradually become accustomed to outrageous losses? In the interest of what? Their “safety”? Their “freedom”? How many millions would have to die before we reach a limit that was considered “acceptable”?

We must never succumb to the illusion that we are like “gods” in our technical ability to manipulate nature and the world. As Camus says, to fall under the spell of that illusion leads us to the loss of our true humanity. What do gods know about death? Or compassion and empathy for others—even the stranger in our midst?

As clinicians and group therapists, we cannot afford to be strangers to ourselves or to our true nature as human beings. In the end we are but “little beings” with many skills but limited in wisdom and time. As group analysts, we know the unconscious limits not only our destiny from birth but also gives us an indication of what we must account for as we face the limits of our desires. Whenever we choose the path of moderation, we pay tribute to Nemesis, the goddess of retribution, who demands we be accountable for all our excesses. It teaches us to let go of our hubris, our excessive pride, and our wish to have god like powers. The unconscious is at work in that moment as well, defining a part of the human condition we all share and marking our temptation to deny the power we do have.

Even when life seems not worth living, we refuse to kill ourselves or consign ourselves to a spiritual death of passivity and withdrawal in the face of injustice.

This, then, is the challenge of Camus. Even when life seems not worth living, we refuse to kill ourselves or consign ourselves to a spiritual death of passivity and withdrawal in the face of injustice.

In the spirit of Martin Luther King, we pursue justice “until it rolls down like waters and freedom like a mighty stream”. We join with our friends and colleagues and commit ourselves to resisting autocratic and plutocratic rule even when to resist seems absurd. When the struggle seems futile, hopeless, and devoid of meaning, we step into the void and create meaning for each other. In this way we embrace the absurd rather than flee from it in terror—the terror of always having to choose in the face of uncertainty and in the absence of divine authority—or in the face of what Camus calls the “silence of nature” We affirm the essential integrity of humanity.

In the spirit of Martin Luther King, we pursue justice “until it rolls down like waters and freedom like a mighty stream”.

Finally, we must fully embrace the ever present challenge to be joyful and seek deep relationships with our colleagues and others as we work together. These are not easy prescriptions to follow nor ones that we will ever do perfectly. But they are more than aspirational. In our daily lives we must act as if our small actions have larger effects than we can ever comprehend—that we are becoming by our lives the end we seek.

Camus said, “I should like to love my country and still love justice” embracing France without forgiving its many faults and crimes. How does one maintain such a stance in the world? How does one set out on a lifelong engagement with ethics?

I believe we clinicians and group therapists have a special role to play as human beings dedicated to the possibility of creating a world where freedom and justice and equality abide. We have the extraordinary opportunity –by our intensive work in groups—to see in a small way the panorama of human behavior and the wide spectrum of action that our fellow human beings take. Everyday we witness others struggle within the limits of their freedom and their fate—to make choices and try to comprehend the destiny that limits their choices.

Clinicians and group therapists have a special role to play as human beings dedicated to the possibility of creating a world where freedom and justice and equality abide.

Charles Darwin, at the close of his manuscript The Descent of Man, expresses this vision of humanity. I’ll paraphrase: At last we humans see that we are one with our brothers in the field— all natures’ creatures in the animal world—with whom we share a common inheritance and a common mortality. Let us always remember that we are those small beings balanced for a time on the edge of mortality and yet with a view of eternity.

Thank you. Bill Roller Berkeley, California

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