Detailed Table of contents
SECTION I: BACKGROUND AND HISTORICAL CONTEXT
1. Why ethics matter in psychotherapy 3
Manuel Trachsel, Jens Gaab, Şerife Tekin, Nikola Biller-Andorno, and John Z. Sadler
Only a few scholars regularly published on psychotherapy ethics from the 1990s (e.g., Knapp and VandeCreek 2006; Pope and Vasquez 1991; Welfel 1998). The publication of textbooks for practitioners in the last five to ten years (e.g., Koocher and Keith-Spiegel 2016), the increasing number of scientific papers (e.g., Curtis and Kelley 2020; Trachsel et al. 2015), and of article collections and special issues on psychotherapy ethics (e.g., Barnett 2019) reflect the increase in significance and scientific knowledge within the field (Gerger et al. 2020). With the present Oxford Handbook of Psychotherapy Ethics , as with other Oxford Handbooks, our aim is to provide a definitive resource covering the whole range of ethical issues in the heterogeneous field of psychotherapy. Although the Oxford Handbook of Psychiatric Ethics (Sadler et al. 2015) included some chapters on psychotherapy ethics, we had been convinced and reassured by the submitted chapters that psychotherapy ethics requires a special volume of its own, because of the scope, complexity, and various forms of psychotherapy. The present Handbook now includes 68 chapters from more than 100 authors.
2. A brief moral history of psychotherapy 31
Alan c. Tjeltveit
To grasp its moral history, psychotherapy’s profoundly and pervasively moral dimensions, its inextricable sociocultural connections, critics’ challenges to moral claims, the historical origins of moral ideas and practices, and some key historical trajectories of psychotherapy are addressed. Connections among professions, professional ethics, and morality (construed broadly); moral understandings of psychological problems and goals; and moral considerations concerning therapy techniques and relationship styles are emphasized. Finally, some changing interrelationships among psychotherapy, the self, society, and morality are reviewed.
3. What do psychotherapists need to know about ethics? lessons from the history of professional ethics
Carole Sinclair
Behaving ethically is at the core of what it means to be a professional. It is central to the contract that all professions have with the persons they serve and with the societies in which they function. This sense of ethical responsibility, and the practice of articulating the underlying values, principles, and behavioral manifestations of such a responsibility, both have a long history. By outlining the history of ethical values and codes, and the meaning of “profession,” from ancient times to the present, this chapter explores several major components involved in psychotherapists’ efforts to be ethical practitioners. This includes attention to the roles of ethics codes, ethical values and principles, moral theory, ethical reasoning, and moral character. Although there is sometimes a tendency to treat these components as separate entities (even in competition with each other as explanatory concepts), the emphasis in this chapter is on how history teaches us that they need to be seen and treated as an integrated whole in our efforts to be ethical practitioners.
4. The history and ethics of the therapeutic relationship
Ulrich Koch and Kelso Cratsley
This chapter reviews past and present debates about the therapeutic relationship in order to draw out the ethical implications of relational practices in psychotherapy. The therapeutic relationship has been understood differently across psychotherapeutic approaches, with each tradition responding to the attendant ethical challenges in distinctive ways. Aside from practitioners’ theoretical and practical commitments, the therapeutic relationship has also been, and continues to be, shaped by broader societal influences. The chapter discusses the shifting ethical implications of relational practices, then, as situated in their theoretical and historical contexts. The historical variability of concerns raised by the therapeutic relationship, we suggest, calls for continued ethical analysis in order to confront the diversity and complexity of contemporary clinical practice.
SECTION II: CONCEPTS AND THEORIES FOR PSYCHOTHERAPY ETHICS
5. Autonomy as a goal of psychotherapy
Paul Biegler
Personal autonomy describes the exercise of self-determination through informed and rational decisions that reflect an agent’s authentic values. The nexus between autonomy and psychotherapy is broad, with both respect for client autonomy through informed consent, and promotion of client autonomy through therapy itself representing key instances of the significance of autonomy in the consulting room. While inadequate disclosure of information poses a major threat to personal
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autonomy, so too do unjustified paternalism, coercion and the injudicious use of therapeutic privilege. The capacity of psychotherapy to promote client autonomy, evidenced by more effective decision making during periods where the risk of recurrent illness is high, is argued to be a key advantage of psychotherapy over treatment with medication alone. Ultimately, enhanced autonomy is a goal of treatment grounded in a more defensible conception of well-being for people with psychological disorder and, it is concluded, should be sought specifically through psychotherapy.
6. Patient protection and paternalism in psychotherapy
Marco Annoni
This chapter provides a synthetic overview of the ethics of paternalism in psychotherapy with a focus on involuntary hospitalization to protect patients from self-harm. Paternalism entails the intentional overriding of someone’s preferences or actions on grounds of beneficence and nonmaleficence. After the emergence of autonomy in medical ethics, paternalism is generally considered prima facie wrong, as it infringes on patient autonomy, trust, and right to informed consent. In particular, the use of paternalism in psychotherapy raises a host of complex and delicate ethical issues due to the nature of the therapeutic relationship and the difficulty to assess the autonomy of the person who will supposedly benefit from the paternalistic intervention.
7. Empathy, honesty, and integrity in the therapist: a person-centered perspective
Jeffrey H.
D. Cornelius-White and Gillian Proctor
Empathy, honesty, and integrity are essential concepts to ensure the quality of the therapy relationship and the client’s trust in the therapist. This chapter situates these concepts in relation to the necessary and sufficient conditions for therapy proposed by Carl Rogers in the late 1950s, and particularly in relation to the therapist attitudes of empathic understanding, unconditional positive regard, and congruence. In person-centered therapy (PCT), empathy is a moral, not instrumental, practice that nondirectively protects the self-determination of the client. It exemplifies power with others, avoiding power over others, and facilitating power from within, by providing a conduit for non-possessive love, the active ingredient in PCT. Honesty in PCT involves the sincerity of the therapist’s unconditional empathy and the transparence to be a full person in relation to a client. Integrity refers not only to the disciplined moral practice of empathy, but an extensional, fully functioning maturation.
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8. Fairness, justice, and economical thinking in psychotherapy 122 Marta Herschkopf and Rebecca Weintraub Brendel
Despite a robust and growing evidence-base to support the effectiveness of psychotherapy in treating mental illness and promoting mental health, funding and access is often limited. Psychotherapy’s claim on a share of individual and social resources must compete, on the one, hand with other mental health services
devoted to treating mental illness, and on the other hand, with a variety of social services that promote mental health and human flourishing. This chapter focuses on different theories of justice to consider (a) whether a case might be made for the unique value of psychotherapy amongst other competing services, and (b) if not, what criteria might be relevant in assessing its relative cost and value. The chapter begins by reviewing some relevant concepts of justice and how they might be applicable to allocation of psychotherapy resources, specifically, Rawlsian, capabilities, utilitarian, and communitarian theories. It then discusses how these concepts of justice can be used to navigate research about psychotherapy outcomes as well as its cost-effectiveness. Decisions about which outcomes to consider are not value-neutral and can be guided by relevant theories of justice. The chapter concludes with a brief discussion of lower-income countries.
9. Ethics of care approaches in psychotherapy
Anna Magdalena Elsner and Vanessa Rampton
The ethics of care poses a special case for psychotherapy. At first glance, key elements of care ethics such as acknowledging our dependence on others, attention to emotions, and creating a supportive environment for healing overlap substantially with key characteristics of psychotherapy. Care ethics’ emphasis on attentiveness and empathetic concern, and related acts such as listening and talking to patients point in the direction of salutary therapeutic relationships, and also of valorizing psychotherapy as a practice. Yet psychotherapy has a long history of critical engagement with the therapeutic relationship, using terms and concepts other than “care.” This chapter shows that while relatively little work has been done on care ethics approaches in psychotherapy, such approaches complement traditional attentiveness to the (psycho)therapeutic relationship by asking to what extent psychotherapists are practicing care and what this entails. Conversely, because psychotherapy has long been concerned with intersubjectivity, as exemplified by the concepts of transference and countertransference, it offers valuable theoretical and practical resources for care ethics approaches.
10. Legitimate and illegitimate imposition of therapists’ values on patients
Susana
Fehr Lampley and John Z. Sadler
The understanding that psychotherapists should not impose their values on their patients is a shared belief in the field. However, little has been written about how not to impose one’s values on patients. Here we diagram an approach to evaluate justified and unjustified impositions of values in therapy with various examples. These examples are not intended to be comprehensive, but to provide an introductory overview. The case discussions will function to: (a) to provide rough guidance about how to analyze one’s own unique cases, (b) illustrate areas of consensus within the broad psychotherapy field, (c) to highlight the large areas of ambiguity and lack of consensus about what constitutes the legitimate and illegitimate imposition of values on patients and (d) provide sample
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references from the literature illustrating particular values-imposition discussions and policies. Our conclusions emphasize the limitations of this exploratory work, and point to areas where additional analysis would be of benefit for clarifying ambiguities of practice.
11.
Virtue ethics in psychotherapy
Michael Laney and Adam Brenner
The ethical pressures on a therapist are great, particularly since effective therapy demands that we become deeply and affectively involved in a patient’s life as told to us such that we become part of their stories and conflicts as well. While deontology and consequentialism provide guidance with respect to a therapist’s acts in themselves or in their consequences, another ethical perspective focuses squarely on the character of the therapist him or herself. This chapter reviews this perspective—called virtue theory—and applies it to the work of therapy, especially how a virtuous character and the virtuous actions that emanate from it are more than just moral prescripts but necessary to and partly constitutive of effective therapy itself.
12. How do people make moral medical decisions?
Eleanor Gilmore-Szott and Thomas V. Cunningham
This chapter describes moral decision making in clinical relationships. Section 2 covers the contributions made by bioethics to health care decision making, including the historical, legal, policymaking, and scholarly background to contemporary conceptions of moral choice, which culminate in the concept of informed consent. Section 3 then canvases the contemporary landscape of ethical decision making by focusing on the important concept of decisional capacity and empirical approaches for evaluating and supporting the capacity to make ethical decisions through improvements in health literacy, values clarification, and shared decision making. Section 4 provides a case analysis to demonstrate the numerous challenges that come with applying frameworks of moral medical decision making to actual patient care and possible means for resolving those challenges by appealing to the concepts defined throughout the chapter.
13. Existential philosophy and psychotherapy ethics
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207 Alexander Noyon and Thomas Heidenreich
This chapter introduces five central concepts of existential philosophy in order to deduce ethical principles for psychotherapy: phenomenology, authenticity, paradoxes, isolation, and freedom vs. destiny. Phenomenological perspectives are useful as a guideline for how to encounter and understand patients in terms of individuality and uniqueness. Existential communication as a means to search and face the truth of one’s existence is considered as a valid basis for an authentic life. Paradoxes that cannot be solved are characteristic for human existence and should be dealt with to turn resignation into active choices. Isolation is one of the “existentials” characterizing human life between two paradox poles: On the
one hand we are deeply in need of relationships to other human beings; on the other hand we are thrown into the world alone and will always stay like this, no matter how close we get to another person. Further, addressing freedom and destiny as two extremes of one dimension can serve as a basis for orientation in life and also for dealing with the separation between responsibility and guilt.
14. Phenomenological-hermeneutic resources for an ethics of psychotherapeutic care
Giovanni Stanghellini
I will introduce and discuss four concepts that seem to be relevant to develop a phenomenologically- and hermeneutically-based ethics for psychotherapeutic care: ‘dialogue’, ‘attunement’, ‘recognition’ and ‘intimacy’. Dialogue is the essential happening of language, not a mere exchange of information; in it subjectivity is displaced and something new about the interlocutors is revealed. Attunement is a modulation of the emotional field in-between myself and the other. Attunement is also the capacity to coordinate my tempo with that of the other. Attunement— inter-emotionality—inter-temporality are grounded in corporeality as a form of intercorporeality. Recognition is the epistemic and ethic capacity to acknowledge the alterity in myself and of the other person. Self-recognition is the acknowledgement of the pre-individual elements not yet appropriated by myself; other-recognition is the acknowledgement of the other person as a fellow man to whom I attribute value, life and consciousness. Intimacy is an atmospheric experience of alonenesstogetherness, self- and other-recognition: envelopped in an atmosphere of intimacy I get in touch with myself via getting in touch with each other.
15. Free will, responsibility, and blame in psychotherapy
Tobias Zürcher
Freedom of the will is not only an issue in the attribution of moral and legal responsibility—it also fundamentally shapes how we look at ourselves and how we interact with others. This is essential in everyday life but even more so in psychotherapy. In the debate on freedom of will, the main controversy is concerned with the relationship between determinism and free will. In this chapter, different positions will be presented and discussed. The compatibilist viewpoint, which claims determinism and freedom of will to be compatible, is defended against competing theories and will be applied to psychotherapeutic work. Mental disorders affect free will in many ways, as is demonstrated by the examples. Nevertheless, a compatibilist approach to free will can be used as a resource to increase the patient’s autonomy. As a result, it is justified and sometimes appropriate within the therapeutic context to ascribe responsibility and, within certain limits, to express blame.
16. Dignity in psychotherapy
Roberto Andorno
The notion of human dignity conveys the idea that every human being has inherent worth and therefore, ought to be accorded the highest respect and
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consideration. In health care, dignity provides an overarching moral framework that is called to guide the physician-patient relationship in a great variety of issues, and especially in the promotion of the patient’s well-being and selfdetermination. Dignity plays also an important role in psychotherapy as the patient-therapist relationship involves confidences of intimate nature and about very personal decisions and attitudes, and may lead to a patient’s overdependence on the therapist. Taking seriously, the patient’s dignity imposes on the therapist some specific moral duties, such as respecting and promoting patients’ selfdetermination, as well as patients’ values, beliefs and life plans. Another direct consequence of the principle of respect for dignity is the requirement to avoid exploitative interactions with patients, in particular, any form of sexual harassment and abuse.
SECTION III: COMMON ETHICAL CHALLENGES IN PSYCHOTHERAPY
17. The ethics of informed consent for psychotherapy
Alastair J. McKean, Manuel Trachsel, and Paul E. Croarkin
Informed consent, enshrined in many of the codes of conduct of psychology and psychiatry professional organizations, is an integral component behind the ethical practice of psychotherapy. Foundationally, informed consent respects patient autonomy and should be a knowledge sharing process that allows patients greater agency and improved alliance with their clinician. Psychotherapy differs from medical and surgical interventions in that it is a longitudinal, collaborative and interpersonal treatment. As many psychotherapists are not trained in traditional medical models of care, a medically based framework for informed consent may not be as familiar and appropriate for psychotherapy. These nuances do not diminish the need for informed consent but rather emphasize the distinctiveness of psychotherapy and necessity of adapting to this treatment modality. In this chapter, the informed consent process for psychotherapy is examined, detailing its historical development, legal and ethical foundations, as well as the subtleties and challenges regarding implementation.
18. Ethics of the psychotherapeutic alliance, shared decision making and consensus on therapy goals
Stella Reiter-Theil and Charlotte Wetterauer
The ethics of the psychotherapeutic alliance (a), shared decision making (b), and consensus on therapy goals (c) is discussed in the context of a legal overview in three Germanspeaking countries. Particular ethical challenges are identified in different settings. Clinical Ethics Support (CES) has gained importance beyond acute medical patient care, but is still new in psychotherapy. Three examples present ethical issues underlying the basic concepts of psychotherapy (a, b, and c) that often go unnoticed or remain implicit. Addressing ethical questions in a practical psychotherapy context may lead to acknowledging more complexity
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than expected. At the same time, meta-level ethical reflection can help to coordinate previously diverging interests and efforts and remove obstacles towards problem-solving. Complexity as well as problem solving will be illustrated by referring to problems with confidentiality concerning sexual abuse, coercion in treating dependency disorders, and responding to wishes of assisted suicide.
19. Evidence, science, and ethics in talk-based healing practices
James Phillips and John Z. Sadler
This chapter considers the role of knowledge and evidence in comparing and contrasting the ethics of non-clinical counseling (NCC) and mainstream mental health care as practiced by psychiatry, clinical psychology, and social work. As helping traditions which mostly eschew diagnostic categorization and approach mental distress from different values, practices, and metaphysical standpoints, the three NCC traditions considered here are found to be prone to errors of omission, e.g., not knowing what one does not know. While mainstream mental health is also subject to these errors, the mainstream’s allegiance to evidencebased practices leaves it prone to neglecting the crucial role of the clinician in dialogue with the patient. The authors conclude by arguing for wider appreciation of the contributions of clinical interpretation from the philosophy of psychiatry.
20. Patient information on evidence and clinical effectiveness of psychotherapy
Charlotte Blease, John M. Kelley, and Manuel Trachsel
This chapter focuses on what information should be provided to patients about the evidence base supporting the clinical effectiveness of psychotherapy. In particular, we consider whether research on the relative efficacy of different forms of psychotherapy should be provided to patients, as well as whether patients should be provided with information on the relative importance of common factors versus specific factors as the causal agents of clinical improvement. After a critical review and discussion of the relatively few scholarly papers that have previously addressed this question, we conclude that patients should be provided with an honest, transparent, and impartial summary of the evidence related to their treatment options including information about the common factors. We draw this conclusion even while acknowledging that considerable controversy persists about how to interpret the psychotherapy research evidence base. Finally, we strongly support continued research into these questions, especially given the relatively limited scholarly attention they have received to date.
21. Ethical dimensions of psychotherapy side effects
Michael Linden
Side effects are unwanted events caused by appropriate treatment. They must be discriminated from negative developments which are unrelated to treatment or which are caused by improper treatment. The assessment of side effects requires
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several professional but also value decisions: what is negative? What is proper treatment? What is treatment related? Scientifically there is a lack of generally accepted instruments and of guidelines on how to assess side effects in clinical trials. There is growing evidence that about 10% of psychotherapy patients experience relevant negative consequences of psychotherapy. Therapist should be aware of the possibility of side effects and inform patients. Acknowledgement of side effects can improve treatment and also advance the development the field of psychotherapy.
22. Privacy and confidentiality in psychotherapy: conceptual background and ethical considerations in the light of clinical challenges
Anke Maatz, Lena E. Schneller, and Paul Hoff
This chapter situates privacy and confidentiality as central ethical, legal and anthropological concepts for psychotherapeutic practice. It first provides some conceptual background and clarification of the concepts before considering their specific relevance in the context of psychotherapy. In particular, it explores a unique significance that, it is argued, privacy and confidentiality acquire in the therapeutic process to do with the anthropological dimension of privacy, its psychological function and the specific dynamics of the therapeutic relationship. Based on four case vignettes, potential ethical conflicts about privacy and confidentiality are then discussed. Finally, principles that can guide practitioners in responding to ethical conflicts about privacy and confidentiality in clinical practice are provided.
23. Dual and multiple relationships in psychotherapy
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Maintaining appropriate boundaries with clients/patients is a fundamental ethical obligation of the helping professions. Known as dual relationships or multiple relationships, holding more than one relationship with a past or current client/patient can be ethically challenging at a minimum and highly unethical in certain circumstances. Ethical professionals are aware of the potential risks associated with having more than one relationship with a client or patient and consider these both at the onset of therapy and during the therapeutic relationship. This chapter explores some of the common issues relating to dual/ multiple relationships and presents ways in which the helping professions frame the appropriate and the inappropriate. Avoiding inappropriate relationships is balanced with the goal of maintaining access to services in situations such as those posed by rural areas.
24. Ethics considerations in selecting psychotherapy modalities and formats
John Z. Sadler
Little discussion has appeared in the literature regarding the ethical and value considerations when clinicians select a psychotherapy modality (e.g., CBT,
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psychoanalytic therapy, family systems, etc) and format (group, individual, couple, family, systems) to offer to clients before formal treatment negotiations begin. This chapter offers a virtue-ethics framework to consider these ethics and values issues in psychotherapy modality/format selection, and embeds this virtue-ethics framework in a series of seven clinical factors to consider when doing modality/format deliberations. Karl Jaspers’ principles of clinical interpretation (hermeneutics) provide an illustrative framework for the thinking process in making modality/format decisions. The interactions between the seven factors to consider in modality/format deliberations and the eight relevant clinician virtues provide for numerous, but brief, clinical examples of how the factors, the virtues, and clinical hermeneutics combine to provide for conscientious psychotherapy modality/format deliberations.
25. Psychotherapist self-disclosure
Jeffrey E. Barnett
Psychotherapist self-disclosure is addressed as a potentially important psychotherapeutic technique. Different types of self-disclosure are explained, to include deliberate self-disclosure, unavoidable self-disclosure, and accidental self-disclosure, illustrating their potential value and benefits to clients and to the psychotherapy process. Self-disclosure is examined as a boundary issue and ethics issues relevant to the use of self-disclosure are addressed. Illustrative examples are provided and a decision-making process is provided to assist psychotherapists to utilize self-disclosure with clients in an ethically appropriate and clinically effective manner. Relevant factors to be considered in the decisionmaking process are reviewed to include cultural factors, treatment setting, and the client’s treatment plan. Ethical challenges relevant to having an online presence are addressed and potential pitfalls for psychotherapists to be cognizant of are shared. Recommendations for the ethical and clinically appropriate use of self-disclosure are provided.
26. The ethics of placebo and nocebo in psychotherapy
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398 Jens Gaab, Cosima Locher, and Manuel Trachsel
There is as little doubt as much as there is empirical proof that psychotherapy is an effective intervention for psychological problems and disorders. However, there is ongoing controversy about the mechanisms underlying these often impressive, but also often over-estimated effects, reaching back to the very origins of psychotherapy research. While this “great psychotherapy debate” vivifies both psychotherapy research and practice, it finally poses an ethical challenge for both psychotherapists and psychotherapy scholars. Basically, the lack of agreed and validated mechanisms impedes the attempt to inform patients about how changes of psychotherapy are brought about. Thus, even though patients can readily be furnished with possible and expectable benefits, costs and strains, the situation becomes more complex and less certain with regard to the specific mechanisms and determinants of change. In the following, psychotherapy scholars’ strivings and troubles for specificity will be briefly
covered, touching the uncomfortable relationship with placebo and nocebo and finishing with an ethical plea for transparency in psychotherapy and of psychotherapists.
27. The business of psychotherapy in private practice
Anna R. Brandon
The business of private practice requires navigating ethical professionalism alongside personal needs and values. Advertising, marketing, self-promotion, and the setting/collecting of fees can pose angst by challenging the altruistic values that likely influenced the choice of psychotherapy as a profession. In addition, the majority of marketing in today’s society is through the use of social media (SM), itself a vehicle of information that poses risk to ethical principles affecting therapist and patient. Outside of SM, more traditional methods of growing a psychotherapy practice such as advertisements in printed materials, personal visits to community professionals to increase referrals, and speaking engagements still involve a level of self-promotion that may bring discomfort to the therapist. Further, the exchange of money impacts the client-psychotherapist relationship; with this in mind, direct communication about fees may be a difficult conversation for clinicians to initiate. The following discussion reviews position statements by professional associations and highlights gray areas for values-based consideration.
28. Mental health care funding systems and their impact on access to psychotherapy
Joelle
Robertson-Preidler, Nikola Biller-Andorno, and Tricia Johnson
Resource scarcity forces health care systems to set priorities and navigate tradeoffs in how they choose to fund different services. Distributive justice principles can help guide health systems to fairly allocate scarce resources in a society. In most countries, mental health care and psychotherapy, in particular, tend to be under-prioritized even though psychotherapy can be an effective treatment for mental health disorders. To create ethical funding systems that support appropriate access to psychotherapy, health care funding systems must consider how they allocate and distribute health care resources through health care financing, coverage criteria, and reimbursement mechanisms. Five health care systems are assessed according to how they finance and reimburse psychotherapy. These health systems use various and often pluralistic approaches that encompass differing distributive justice principles. Although distribution priorities and values may differ, fair and transparent processes that involve all key stakeholders are vital for making ethical decisions on access and distribution.
29. Psychotherapeutic futility
Cynthia Geppert
The formal concept of futility has been inchoately explored in psychotherapeutic scholarship and only recently has a small body of work focused primarily on
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anorexia nervosa and schizophrenia emerged. Therefore, this chapter must be considered an exploratory investigation of the meaning of the concept of futility in the practice of psychotherapy. The exploration will begin with a tracing of the intellectual history of the concept and a review of attempts to develop definitions and typologies of futility. It will then outline the fundamental ethical arguments debated in the medical futility literature with reference to anorexia nervosa. Medical, philosophical, legal and ethical critiques of the idea of futility and its use in medicine and psychiatry will be examined. Finally, a tentative initial effort will be made to apply the ethical principles and values inherent in the debate regarding these discussions of futility to psychotherapy.
30. The moral significance of recovery
Larry Davidson
Given the loss of a sense of self long-associated with psychosis, this chapter argues that preserving and helping to reconstruct the person’s sense of personhood becomes a primary objective, and ethical imperative, of the psychotherapeutic relationship. Not to do so serves to perpetuate both the negative effects of the illness and its stigmatized status in society, adding to, rather than counteracting, the damage that is already being done to the person by this combination of factors. Drawing inspiration from Desmond Tutu’s use of the African concept of Ubuntu, I argue that psychotherapy for psychosis should embody an appreciation of how persons only become persons through other people. Based on first-person accounts and qualitative research on recovery, I then describe ways in which the person’s sense of self can be restored and reconstructed through small steps in everyday life activities and with the loving support of others, including psychotherapists.
31. Social media ethics for the professional psychotherapist
Kristi Pikiewicz
This chapter explores the ethical considerations that can guide a therapist’s personal and professional use of social media. The incredible pace of change in the social media landscape has led many institutions to delay the development and distribution of specific guidelines or recommendations; however, the literature establishing the boundaries and best practices for the patient-therapist relationship, along with privacy concerns in both directions, and the termination of this relationship, offer a context in which to develop personal competency in the use of social media, both to avoid detrimental entanglements and to enhance progress toward therapeutic goals.
32. Relationship between religion, spirituality, and psychotherapy: an ethical perspective
Thomas G. Plante
Spirituality and religion are typically a critically important element of most people’s lives. They offer an overarching framework for making sense of the world and a strategy to cope with life’s stressors. They provide a community and
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a way to wrestle with life’s biggest questions regarding meaning, purpose, and suffering. Mental health professionals are mandated to behave in an ethical manner defined by their codes of ethics. These codes typically understand religion and spirituality a multiculturalism issue. Professionals need to be respectful and responsible and pay close attention to potential implicit bias, boundary crossings, and destructive beliefs and practices. Working with religious professional as helpful collaborative partners also achieves ethically minded best practices. Numerous resources are now available to help professionals develop and maintain their skills in ethically minded clinical practice with spiritual and religious clients. This chapter highlights these issues and offers suggested guidelines toward high quality professional practice.
33. Ethics and expert authority in the patient–psychotherapist relationship
Laura Guidry-Grimes and Jamie Carlin Watson
The consumer/survivor/ex-patient movement contends that individuals diagnosed with mental health conditions are routinely doubted or dismissed when they make claims about their needs, values, and interests. Too many therapists, the claim goes, take a parentalist stance toward their patients. Recent work on expertise shows how some patients can acquire competence with their medical condition sufficient for sophisticated participation in management of their care; that is, they can become “patient experts.” We argue that many psychotherapy patients can become patient experts and, thereby, benefit from attempts at robust shared decision-making (SDM). In these cases, attitudes of distrust and protectionism can lead to the moral failure of epistemic injustice, thereby harming both the patient and the therapeutic relationship. Drawing on recent literature on epistemic injustice, SDM, and expertise from epistemology, we contend that the success of SDM relies largely on the therapist’s appreciation of the varying types and degrees of expertise and epistemic advantage involved in decision-making.
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SECTION IV: ETHICAL ISSUES WITH SPECIFIC PSYCHOTHERAPY APPROACHES
34. Ethical issues in cognitive behavioral therapy
Sahanika Ratnayake and Christopher Poppe
In this chapter, we identify ethical challenges in Cognitive Behavioral Therapy (CBT). This chapter consists of two parts, where we will focus on cognitive and behavioral techniques separately as they present distinct ethical challenges.
The first part examines cognitive techniques, and we shall show that evaluating cognitions in terms of validity and utility entails evaluating failures of epistemic and practical rationality, respectively. Considering the cognitive component in this light reveals a variety of professional ethics concerns. For instance, it is
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unclear whether clinicians are currently adequately trained to evaluate epistemic failure, which raises concerns about working outside one’s area of competence. If evaluating cognition for utility involves evaluating practical rationality, then CBT’s evaluation of cognitions is far more value laden than first supposed and consequently presents a richer set of challenges for the therapeutic alliance than is often discussed.
In the second part, ethical challenges are highlighted in exposure-based therapy (EBT) for behavioral therapy. The initiation of EBT provides particular ethical concerns relating to the issues of harm and informed consent. We argue that under a will-oriented conception of harm, EBT involves some harm to the client. Therefore, clients encounter EBT with rational ambivalence towards undergoing treatment. This ambivalence should be understood as a mismatch between firstand second-order preferences. We discuss the possibility of using motivational interviewing (MI) to resolve this ambivalence.
35. Ethical processes in psychoanalysis and psychodynamic psychotherapy
Robert P. Drozek
This chapter explores the foundational role of ethical experience in psychoanalysis and psychodynamic psychotherapy, from the perspective of theory as well as technique. The author reviews seminal ethical constructs across the range of analytic perspectives, including classical psychoanalysis, object relations theory, self psychology, and contemporary relational/intersubjective thought. While all forms of psychotherapy recognize the importance of ethically grounded principles of care, psychoanalysis is unique in its theorizing about the relevance of ethics to fundamental aspects of the clinical process itself, including therapeutic goals, therapeutic outcomes, and “how change happens” in psychotherapy. These areas of theory are surveyed, along with some basic ethical tensions generated by defining aspects of psychodynamic praxis: the ethics of unconscious exploration, the ethics of “working in the transference,” the ethics of exploratory technique, and the ethics of treatment intensity.
36. Ethical issues in systemic psychotherapy
Andreas Fryszer and Rainer Schwing
Ethical codes in systemic therapy are discussed drawing on cultural, professional, legal and complexity-oriented perspectives. First, a cultural framework is established to describe systemic perspectives on ethics following cultural codes in systemic science. Legal issues are discussed as are professional ethical formulas, which function as mandatory sets of rules for systemic practice. The description of a European systemic association’s ethical code serves as an example of systemic practice and is supplemented by medical sources. The adoption of systems science and complexity model perspectives demonstrate similarities of ethical discussion within various systemic approaches. A detailed outline of ethical guidelines in concrete systemic practice is provided, drawing on ideas of neighboring systemic models in natural and social sciences.
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37. Ethical issues in existential-humanistic
Orah T. Krug and Troy Piwowarski
psychotherapy
A set of principles underlie Existential-Humanistic (E-H) therapy and guides the therapeutic change process. These principles uphold the ethical values of dignity of human beings and the sanctity of human connections. Moreover, their implementation, it is presumed, effectively transforms lives. The practice of E-H therapy presents ethical challenges for its practitioners because it relies not on a medical treatment model but rather on an existential-humanistic healing model. This model does not focus on diagnosing and treating symptoms. Instead, it supports an understanding of how each client is uniquely coping with his or her existence. Practicing therapy in this way, may be more challenging ethically, precisely because there are no standardized protocols or treatment interventions to rely upon. In the first section of this chapter, four ethical principles of E-H therapy are paired with several potential ethical challenges arising from them. In subsequent sections, these principles and related challenges are explored more extensively, illuminated with relevant case vignettes.
38. Ethical considerations in emotion-focused therapy
Ueli Kramer and Robert Elliott
The present chapter discusses ethical principles underlying Emotion-Focused Therapy (EFT). We show that the six intervention principles of EFT, empathic attunement, therapeutic bond, task collaboration, differential emotional processing, emotional deepening through work on therapeutic tasks and selfdevelopment, are grounded in the more basic ethical requirements of psychotherapy and counseling, in particular beneficence and nonmaleficence. There is an overall tension in EFT between providing a productive therapeutic relationship and task facilitation. As examples, we discuss three specific key ethical dilemmas of EFT: a) necessary emotion arousal versus risks on the path to core pain, b) transient emotional dysregulation versus protection of the self and c) freedom to choose versus process-guiding or control. We illustrate with clinical examples, and discuss research implications.
39. Ethical considerations on mindfulness-based psychotherapeutic interventions
Abigail Levin
This paper examines ethical issues arising from the widespread trend, originated by Jon Kabat-Zinn, towards using mindfulness-based practices, such as meditation, for relief of psychological symptoms, such as anxiety and depression. These techniques are adapted from Buddhist practices and are prescribed for quite different ends—such as enlightenment—in that context. Further, psychotherapeutic mindfulness clients are often not informed of the religious provenance of the techniques. These circumstances give rise to psychotherapeutic ethical considerations, such as whether psychotherapeutic mindfulness practices are problematically appropriative from Buddhism, and whether the religious
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