The Oxford Handbook of Psychotherapy Ethics 0198817339, 9780198817338

Table of contents :
Cover
Psychotherapy Ethics
Copyright
Dedication
Foreword
Acknowledgements
Detailed Table of contents
Table of Contents
List of Contributors
Section I: Background And Historical Context
Chapter 1: Why Ethics Matter In Psychotherapy
Psychotherapy And Visions Of The Good: Beyond Effectiveness
Ethical Challenges In Psychotherapy
Goals Of The Oxford Handbook
Organizational Features Of The Oxford Handbook Of
Summary Reflections On The Sections Of The Oxford Handbook Of
Section I: Background and Historical Context
Section II: Concepts and Theories for Psychotherapy Ethics
Section III: Common Ethical Challenges in Psychotherapy
Section IV: Ethical Issues within Specific Psychotherapy Modalities and Formats
Section V: Ethical Challenges Involving Specific Settings and Populations
Section VI: Ethics of Psychotherapy Education, Training, Quality Assurance, and Research
Conclusion: The Future Of Psychotherapy Ethics
Psychotherapy as Treatment Modality and Professional Identity
The Ethical Fates of Psychotherapy Craft and Psychotherapy Science
Intersectional Psychotherapy Ethics
Ethics and Automated Psychotherapy
The Future of Psychotherapy Ethics Research
References
Chapter 2: A Brief Moral History of Psychotherapy
Introduction
The Moral Dimensions of Psychotherapy
Moral Concomitants of Changing Sociocultural Contexts
Moral Challenges to Certain Forms and Understandings of Morality
The Historical Origins of Moral Ideals/Practices
Psychotherapies’ Moral Dimensions: Some Historical Trajectories
Professions and Professional Ethics/ Moral Principles and Qualities
The Problems Psychotherapy Addresses
Goals/Outcomes
Psychotherapeutic Techniques and Relationships
Self and Society
Conclusion
References
Chapter 3: What Do Psychotherapists Need To Know About Ethics? Lessons From The History Of Professional Ethics
Introduction
Early History Of Professional Ethics (eighteenth Century Bce To Seventeenth Century Ce)
Ethical Values and Codes
The Concept of “Profession”
Expectations of Moral Character
Influence of Moral Theory
The History Of Professional Ethics During The Transitional Eighteenth And Nineteenth Centuries Ce
Ethical Values and Codes
The Concept of “Profession”
Expectations of Moral Character
Influence of Moral Theory
A Brief History Of Modern Professional Ethics (twentieth And Twenty-first Centuries Ce)
Attention to the Ethics of Psychotherapy
The Influence of World War II
Concerns Related to the Concept of “Profession”
Other Influences
Conclusion
References
Chapter 4:The History and Ethics of the Therapeutic Relationship
Introduction
Relationship as Method
Relationship as Skill
Relationship as Foundation
Discussion
Empathy as Therapist Attitude
Empathy as a Practice Resulting from a Nondirective Attitude
Empathy as a Conduit for Love
Empathy as a Relational Ethic or Morality
Empathy as Cooperative Intent/Power With and Minimizing Power-Over
Honesty: A Partial Synonym for Congruence
Honesty and Genuineness
Honesty and Transparence
Honesty: A Partial Synonym for Congruence
Integrity: Internal Empathy and Unconditional Positive Regard
Integrity: Extensionality and Fully Functioning
Practical Implications
Typical Implication: Practicing PCT
When the Unexpected Occurs: Avoiding Power-Over
Conclusion
References
Section II: Concepts And Theories For Psychotherapy Ethics
Chapter 5: Autonomy As A Goal Of Psychotherapy
Introduction
Autonomy
Respecting Autonomy
Promoting Autonomy
Autonomy As A Goal Of Psychotherapy
Conclusion
References
Chapter 6: Patient Protection And Paternalism In Psychotherapy
Introduction
Patient Protection, Psychotherapy, And Involuntary Hospitalization
Paternalism, Autonomy, Beneficence, And Nonmaleficence
“soft” Vs. “hard” Paternalism And The Challenge Of Assessing Competency
Paternalism, Involuntary Hospitalization, And Mental Illness
Conclusion
Acknowledgments
References
Chapter 7: Empathy, Honesty, And Integrity In The Therapist: A Person-Centered Perspective
Introduction
Empathy
Empathy as Therapist Attitude
Empathy as a Practice Resulting from a Nondirective Attitude
Empathy as a Conduit for Love
Empathy as a Relational Ethic or Morality
Empathy as Cooperative Intent/Power With and Minimizing Power-Over
Honesty: A Partial Synonym For Congruence
Honesty and Genuineness
Honesty and Transparence
Integrity: A Closer Synonym For Congruence
Integrity: Internal Empathy and Unconditional Positive Regard
Integrity: Extensionality and Fully Functioning
Practical Implications
Typical Implication: Practicing PCT
When the Unexpected Occurs: Avoiding Power-Over
Conclusion
References
Chapter 8: Fairness, Justice, and Economical Thinking in Psychotherapy
Introduction
Theories of Justice
Outcomes
Cost-Effectiveness
The Global Context
Summary and Conclusions
References
Chapter 9: Ethics of Care Approaches in Psychotherapy
Introduction
Caring and Care Ethics: A Brief History
Caring in Psychotherapeutic Approaches and their Antecedents
Implications of Ethics of Care Approaches for Psychotherapy Ethics
Society and Politics
Personhood
Autonomy
Boundaries
Conclusion
Acknowledgments
References
Chapter 10: Legitimate and Illegitimate Imposition of Therapists’ Values on Patients
Introduction
What Do We Mean by Values?
The Imposition of Values on Patients: Why Inevitable?
Values Appropriate and Inappropriate
Appropriate I-VValues/Situations
Fees and Appointments
Practice Specializing in Feminist Therapy
Practice Specializes in Christian Therapy
Couple Therapist Privately Advises Batteree to Seek Shelter
Therapist Wants to Practice EBP (Evidence-BasedPractice) with Alternative Treatment-Seeker
Therapist Treating a Family Discourages Spankings
Therapist Uses Motivational Interviewing to Promote a Denying Alcoholic Patient to Address Problem Drinking
Therapist Refuses to Remove Accurate Diagnosis from Medical Record
Inappropriate I-VValues/Situations
Therapist Practices Conversion Therapy (Homosexuality to Heterosexuality)
Therapist Has a Practice Restricted to the Care of Aryans
“Dubious” and “It Depends” Appropriateness of Imposing Values by Therapists
Dubious V-ICases
Military Therapist Imposes Return-to-DutyDate (or Commanding Officer Forces) on a Persistently Ill Soldie
Therapist Supports BIID Treatment by Affirming Amputation
“It Depends” V-ICases
Boundary-ViolatingT-Pin the Context of a Private, Self-Referred Therapy Relationship
Boundary-ViolatingT-Pin the Context of a Training-Program/ Institutional Referral
Therapist Recommends a Mode of Therapy (e.g., Psychodynamic, CBT, Medications)
The Training Director Tells You You Don’t Have Enough (Psychotherapy) Experience with a Particular Psychotherapy Modality to Graduate/ Qualify/Satisfy Requirements
Therapist Recommends Divorce to a Patient
Therapist Recommends Sexual Surrogacy Therapy for a Client with a Sexual Disorder
Therapist Arranges Involuntary Treatment of Suicidal Patient
Therapist Wants to Transition to New Therapy Approach
Summary/Conclusions
References
Chapter 11: Virtue Ethics In Psychotherapy
Introduction
Virtues And The Psychotherapist
Moral And Intellectual Virtues
Courage
Benevolence
Temperance
Phronesis
Sophia
Conclusion
References
Chapter 12: How Do People Make Moral Medical Decisions?
Introduction
Informed Consent And Bioethical Principlism
Contemporary Approaches To Moral Medical Decision Making
Theoretical Concerns
Empirical Investigations
Moral Decision Making In Psychotherapy Practice
Conclusion
References
Chapter 13: Existential Philosophy And Psychotherapy Ethics
Introduction
Key Concepts Of Existential Philosophy Relevant To Psychotherapy Ethics
Existential Philosophy And Phenomenology
Existential Philosophy And Authenticity
The Paradox Of Human Existence
Isolation
Freedom And Responsibility
Conclusion
References
Chapter 14: PhenomenologicalHermeneutic Resources For An Ethics Of Psychotherapeutic Care
Introduction
The Dialogical Principle
Attunement
Recognition
Intimacy
Conclusions
References
Chapter 15: Free Will, Responsibility, And Blame In Psychotherapy
Why Should We Consider Free Will In Psychotherapy?
Concepts Of Free Will
The Threat and the Commonsense Response
The Importance of Determinism
Pessimist View of Determinism
The Optimists’ Response
The Compatibilist Approach
Free Will And Mental Disorder
The Importance Of Free Will For Responsibility And Blame In Psychotherapy
Conclusion
Acknowledgments
References
Chapter 16: Dignity In Psychotherapy
Introduction
Respect For Human Dignity
Human Dignity In Medical Ethics And Law
The Importance Of Dignity In Psychotherapy
Conclusion
References
Section III: Common Ethical Challenges In Psychotherapy
Chapter 17: The Ethics Of Informed Consent For Psychotherapy
Introduction
History Of Informed Consent In Medicine And The Path To Informed Consent In Mental Health Care
Ethical Principles And Essential Components Of An Adequate Informed Consent
The Process Of Informed Consent In Psychotherapy
Therapeutic Benefits Of Informed Consent
Psychotherapists’ Challenges In Implementing Adequate Informed Consent
Conclusion
References
Chapter 18: Ethics Of The Psychotherapeutic Alliance, Shared Decision Making And Consensus On Therapy Goals
Background And Introduction
Legal Aspects
Ethical Framework: Issues
Reflecting The Practice Of Ethics In Psychotherapy: Particular Ethical Challenges
Illustration Of Ethical Difficulties And Support From Clinical Ethics
When the Psychotherapeutic Alliance is Challenged
When the Psychotherapeutic Alliance is Jeopardized and Shared Decision Making Fails
When Multiple Crises Occur: No Treatment Alliance, No Shared Decision Making, and No Consensus on Therapy Goals
Lessons Learned From The Examples
References
Chapter 19: Evidence, Science, And Ethics In Talk-based Healing Practices
Introduction
Non-clinical Counseling: Premises, Practices, Ethics, And Evidence/ Accountability
Philosophical Counseling
Peer-Support Services (Sometimes Called Service-User Support)
Existential Therapy
Mainstream Psychotherapy Practices
Evidence, Values, And Ethics In Caring For Mental Distress
Knowing What You Don’t Know in NCC Practices
Evidence and Accountability in Mainstream Practice
Philosophy Of Psychiatry As A Core Discipline Of Clinical Interpretation
References
Chapter 20: Patient Information on Evidence and Clinical Effectiveness of Psychotherapy
Introduction
Evidence and Ethics
Commitment to Evidence-Based Practice in Psychotherapy
Critical Responses to EBP
Challenges and Complexities of Psychotherapy Research
Placebo Effects and Placebos
Placebo Effects
Placebos as Controls
Placebos as Clinical Interventions
Placebo-ControlledRCTs in Psychotherapy Research
Specificity of Treatments and Common Factors
Ethical Debate about Disclosure of Evidence to Patients
The Nature and Timing of Information Disclosure
Up-to-Date,Impartial Disclosure about Treatment Options
Disclosure of Information about Specific and Common Factors
Disclosure of Harms
Patients as Sources of Evidence
Conclusions
appendices
Appendix 1: Disclosure of Common Factors
Appendix 2: Disclosure of Harms
References
Chapter 21: Ethical Dimensions Of Psychotherapy Side Effects
Helping And Harming In Medicine
Definition Of Psychotherapy Side Effects
What Is Negative Or Unwanted?
Where To Look For Unwanted Events?
What Is Treatment Related?
Identification And Management Of Side Effects
Patient Information, Informed Consent, And Patient Cooperation
Treatment Quality, Standards, And Progress In The Field Of Psychotherapy
References
Chapter 22: Privacy And Confidentiality In Psychotherapy: Conceptual Background and Ethical Considerations in the Light of Clinical Challenges
Introduction
What Are Privacy And Confidentiality?
Origins
On The Relevance Of Privacy And Confidentiality In Psychotherapy
How Can We Deal With Ethical Conflicts About Privacy And Confidentiality In Clinical Practice?
Scope and Limits of Privacy and Confidentiality
Considerations in Cases of Conflict
Summary And Final Remarks
References
Chapter 23: Dual And Multiple Relationships In Psychotherapy
Introduction: What Is Meant By Dual And Multiple Relationships?
Why Are These Problematic?
Types Of Dual/multiple Relationships
Personal/Friendship
Sexual
Business/Financial
Collegial
Supervisory
Time Frame
Relationships That Existed before Psychotherapy
Relationships That Develop during Psychotherapy
Relationships That Begin after Termination
Considerations
Avoidability
Client/Patient Autonomy
Boundary Violations Vs. Boundary Crossings
Violations
Incursions and Crossings
Relationships And The Supervisory Relationship
Other Issues
Bartering
Collegial
Conclusion
References
Chapter 24: Ethics Considerations In Selecting Psychotherapy Modalities And Formats
Introduction
A Mental Health Treatment Arc
Pragmatic Limitations And Constraints On Psychotherapy Modality And Format Choice
The Limits of Clinical Research
What Counts as Evidence?
The Personhood of the Therapist
The Client’s Values and Intentions
Training and Competence of the Therapist
Constraints and Limits on the Task of Participating in Therapy
The Translation of Theory into Practice
The Role of Psychotherapy within a Comprehensive Treatment Plan
Ethics And Values In Psychotherapy Modality/format Selection
Humility
Phronesis
Self-knowledge
Perseverance and Flexibility
Empathy
Integrity
Unselfing
Clinical Hermeneutics And The Ethics Of Psychotherapy Modality/format Choice
Conclusions
References
Chapter 25: Psychotherapist Self-disclosure
Introduction
Boundaries In Psychotherapy
Managing Boundaries In The Psychotherapy Relationship
Ethical Decision-making
The Slippery Slope
Self-disclosure
Unavoidable Self-Disclosure
Self-Disclosure as a Planned Therapeutic Intervention
Self-Disclosure and the Role of Treatment Setting
Self-Disclosure and Culture
Self-Disclosure in the Internet Age
Summary And Recommendations
References
Chapter 26: The Ethics Of Placebo And Nocebo In Psychotherapy
So Great An Interest Merits Sacrifices
Neglected Ancestors And Extinct Birds
Unwanted Proximity
The Need For Ethics To Make A Difference
The Possibility And Necessity To Go Open
Nocebo And Psychotherapy
Conclusion
Acknowledgment
References
Chapter 27: The Business Of Psychotherapy In Private Practice
Diving In
Fuel For The Private Practice
To Fb Or Not To Fb, That Is The Question
From Code To Practice
Minding The “pit” Of Social Media Marketing
Oh No!
How Much Do You Charge?
Navigating The Gray While Staying In The Black
Summing Up
References
Chapter 28: Mental Health Care Funding Systems And Their Impact On Access To Psychotherapy
Introduction
Principles Of Distributive Justice
Welfare-Based Principles
Egalitarian Principles
Desert-Based Principles
Libertarian Principles
Psychotherapy Access In Practice
Health Care Financing
Psychotherapy Coverage Criteria
Reimbursement Models
Conclusion
References
Chapter 29: Psychotherapeutic Futility
The Origins of Futility in Classical Greek Thought
Plato and Hippocrates
The Rise of the Modern Concept of Futility
Futility in Medicine
Words Matter
The Analogy of Futility in Psychotherapy
Futility in Psychiatry: The Paradigm Case of Anorexia Nervosa
A Challenge to Futility Judgments in Anorexia Nervosa
The Ethical Justification of Futility in Anorexia Nervosa
Pseudo-Futility in Psychotherapy
Social Justice and Psychotherapeutic Futility
Future Directions in Psychotherapeutic Futility
References
Chapter 30: The Moral Significance Of Recovery
“first, Do No Harm”
The Loss Of A Fundamental Sense Of One’s Own Selfhood In Psychosis: “i Felt Like A Nobody Nowhere”
Implications Of A First-person Perspective On The Loss Of A Sense Of Self For Psychotherapy With Persons With Psychosis: “a Pers
“the Whole Story Of My Health Was A Very Difficult Experience Because I Had To Really Reconstruct Myself As A Person”
Conclusion: “to Awaken The Silenced Self”
References
Chapter 31: Social Media Ethics For The Professional Psychotherapist
Introduction
Overview Of The Social Media Landscape
A Therapist’s Personal Use Of Social Media
The Therapist’s Interactions With Patients’ Social Media
The Use Of Social Media In Therapeutic Settings
References
Chapter 32: Relationship between Religion, Spirituality, and Psychotherapy: An Ethical Perspective
Dr. J: A Case Example of Challenges with Religion, Spirituality, and Psychotherapy
Definitions and History of Religion, Spirituality, and Psychotherapy Relationship
Contemporary Relationship between Religion, Spirituality, and Psychotherapy
Five Guiding Ethical Principles
Respect
Integrity
Competence
Concern
Three Prominent Ethical Challenges
Blurred Boundaries
Case Example 1: Dr. Z
Bias
Case Example 2: Dr. A
Destructive Beliefs and Practices
Case Example 3: Jim
Focusing on Best Practices
Conclusions and Future Directions
References
Chapter 33: Ethics And Expert Authority In The Patient– Psychotherapist Relationship
Introduction
Perspectives From The Consumer/ Survivor/ex-patient Movement
Preemptive Parentalism And Conflicting Claims To Epistemic Authority
Patient Expertise And The Therapeutic Relationship
Implications For Provider–patient Relationship In Mental Health Contexts
Applying The Modified Split-domain Account In The Clinic
Case 1
Case 2
Conclusions
References
Section IV: Ethical Issues With Specific Psychotherapy Approaches
Chapter 34: Ethical Issues in Cognitive-Behavioral Therapy
Introduction to Cognitive Behavioral Therapy
Part A: Ethical Issues in the Evaluation of Cognitions
Competence
Competence and Validity
Competence and Utility
Client Agency and the Therapeutic Alliance
Client Agency, the Therapeutic Alliance, and Validity
Client Agency, the Therapeutic Alliance, and Utility
Part A: Conclusion
Part B: Ethical Issues in Exposure-Based Treatments
Harm and Exposure-BasedTherapies
Current Issues with EBT and Informed Consent
Intending EBT: First- and Second-OrderPreferences
Motivational Interviewing and Informed Consent
Part B: Conclusion
Conclusion
Acknowledgments
References
Chapter 35: Ethical Processes In Psychoanalysis And Psychodynamic Psychotherapy
Introduction
Ethical Constructs In Psychoanalysis
Ethical Dimensions Of Psychoanalytic Process
Ethical Obligations In Psychoanalytic Technique
The Ethics of Unconscious Exploration
The Ethics of “Working in the Transference”
The Ethics of Exploratory Technique
The Ethics of Treatment Intensity
Conclusion
References
Chapter 36: Ethical Issues in Systemic Psychotherapy
Introduction
Types of Therapy Are Types of Culture
Ethics of Therapeutic Practice
Fundamental Stance
Professional Quality
Professional Self-Care
Confidentiality
Transparency and Information
Anti-Discriminationand Interdiction of Exploitation
Abuse of Psychological Knowledge
Basic Foundations and Ethical Demands in the Systemic Approach
Consider and Involve the Context: The Client Is Part of a System
Respect Complexity, Look for Circularity
Respect Self-Regulation,Enhance Self-Organization
Increase Viability, Foster Resilience
Encourage Capacity Building
Allow for Diversity, Expand to a Multi-PerspectiveStance
Practice Constructivist Modesty
Respect Client’s Expertise and Autonomy: Contract Orientation
The Stance of Not-Knowing
Information Regarding the Process
Contract Orientation
Conclusion of Contract
Find and Understand: Symptoms Carry a Meaning
Neutrality
Take a Neutral Stance, Sometimes
Neutrality with Regard to Outcome
Respect Family Secrets, Most of the Time
Ethical Discourse
References
Chapter 37: Ethical Issues in ExistentialHumanistic Psychotherapy
Introduction
An E-H Theory of Human Change Processes
The Principles of E-H Therapy and Related Ethical Challenges
Ethical Challenges of Cultivating Therapeutic Presence
Ethical Challenges of Intimate Therapeutic Relationships
Attending to Therapists’ Contexts: Ethical Boundaries in Supervision
Exploring Existential Issues and Related Ethical Challenges
Conclusion
References
Chapter 38: Ethical Considerations in Emotion-Focused Therapy
Introduction
General Practice Principles of Emotion-Focused Therapy as Instances of Broader Professional Ethical Principles
Empathic Attunement
Therapeutic Bond
Task Collaboration
Differential Emotional Processing
Emotional Deepening through Work on Key Therapeutic Tasks
Self-Development
Key Ethical Dilemmas in Emotion-Focused Therapy
Necessary Emotion Arousal versus Risks on the Path to Core Pain
Transient Emotional Dysregulation versus Protection of the Self
Freedom to Choose versus Process-Guidingor Control
Conclusions
References
Chapter 39: Ethical Considerations on Mindfulness-Based Psychotherapeutic Interventions
Introduction
Western Medicine Meets Buddhist Modernism
Modern and Traditional Definitions of Mindfulness
MBIs and Buddhism: Merging and Diverging
Considering Vicious Appropriation
MBIs, Attribution, and Informed Consent
Teaching MBIs or Referring Clients to MBIs
Conclusion
References
Chapter 40: Psychotherapy Integration as an Ethical Practice
Introduction
What is Psychotherapy Integration?
Four Forms of Psychotherapy Integration in More Detail
Technical Eclecticism
Theoretical Integration
Common Factor Integration
Assimilative Integration
Ethical Issues Encountered with Psychotherapy Integration
Ethical Issues Shared by the Four Forms
(1) Beneficence
(2) Respect for Autonomy
(3) Nonmaleficence
(4) Justice
Distinctive Ethical Issues Posed by Each of the Forms
(1) Theoretical Integration
(2) Technical Eclecticism
(3) Common Factors Approach
(4) Assimilative Approach
Framing Questions for Research into Integrative-Psychotherapy Ethics
Clinical Responses to Ethical Issues Raised in Integrative Therapy
References
Section V: Ethical Challenges Of Specific Settings And Populations
Chapter 41: Identifying and Resolving Ethical Dilemmas in Group Psychotherapy
Introduction
Challenges Created by Intimacies among Strangers
Competence
Confidentiality
Evaluation of Treatment Progress
Dual Relationships
Impediments to Sound Ethical Decision-Making in Group Psychotherapy
Lack of Knowledge and Skills
Human Factors Affecting the Decision-MakingProcess
The Therapist’s Biases
Processing Errors
Affect Stimulation
Laying the Foundation for Ethical Practice of Group Psychotherapy
Conclusions
References
Chapter 42: Ethics in Couple and Family Psychotherapy
Introduction
Multiple Relationships as a Fundamental Problem in Couple and Family Therapy
A Systemic Perspective
Ethical Codes and Principles as Bases of Ethical Behavior in Couple and Family Therapies
Ethical Codes by Professional Associations
Ethical Principles
Central Ethical Questions for Couple and Family Counselors
Autonomy
Justice
Beneficence and Nonmaleficence
Models of Help
The Four “Models of Help”
Pros and Cons of Each Model
A Shift from Principles and Codes to Relational Ethics
The Importance of Relationship
Relation-OrientedEthics
Relational Ethics in Practice
Ethics as a Therapeutic Process
Limits to an Ethics of the Therapeutic Process
Conclusion
References
Chapter 43: Psychotherapy with Children and Adolescents
Fundamental Conceptual Issues
Legal Age and Developmental Age
Main Ethical Challenges
Contextual Considerations
Competence
Practitioner Competence
Children’s Decisional Competence
Confidentiality
Mandated Reporting
Dangerousness
Bullying
Electronic Communications
Physical and Social Boundaries
Technique Based Ethical Issues
Conclusion
References
Chapter 44: Psychotherapy In Old Age: Ethical Issues
Introduction
Contexts And Cohorts
Cohort Issues
The Context of Psychotherapy
Decision-Making Capacity
Cognitive Impairment Including Dementia
Ageism and the Ethical Need for Equity of Service Provision
Moving Beyond Standard Ethical Theories And Approaches
Case Vignette 1: Mrs. Margaret Smith
Ethical Commentary on Case Vignette 1
Case Vignette 2: A Psychotherapy Group For People Who Have Recently Been Diagnosed With Dementia
Ethical Commentary on Case Vignette 2
Case Vignette 3: The Shah Family
Ethical Commentary on Case Vignette 3
Conclusion
Unknown
Informed Consent
Who Is the Client?
Competence
Practitioner Values
Identifying the Limits of Confidentiality
Integrity
References
Chapter 45: Ethical Considerations of Court-Ordered Outpatient Therapy
Introduction: Overview of Court-Ordered Outpatient Psychotherapy
The Efficacy of COT in Offenders
Ethical Principles Involved in COT
Respect for Autonomy
Informed Consent
Who Is the Client?
Beneficence and Nonmaleficence
Competence
Justice
Practitioner Values
Patient–Professional Relationships
Identifying the Limits of Confidentiality
Integrity
Practitioner Values
Patient–Professional Relationships
Identifying the Limits of Confidentiality
Integrity
Conclusion
References
Chapter 46: Ethical Issues in the Psychotherapy of High Risk Offenders
Note to the Reader
Introduction: Moral Enhancement and Behaving Better
Psychotherapy for Offenders: Early Thinking
Changing Violent Minds: Models of Intervention
The Ethics of Violence Reduction
Autonomy
Welfare and Outcomes
Justice
Breaching Duties of Confidentiality to Decrease Risk
Tarasoff: A Duty to Warn and Protect
Victims’ Rights and Justice
Conclusion: Relational Autonomy and Changing for the Better
Acknowledgment
References
Chapter 47: Beyond the Office Walls: Ethical Challenges of Home Treatment, and Other Out-of-Office Therapies
Introduction
Home Visits, Home-Based Therapy, or In-Home Therapy
Reasons for Conducting In-Home Therapy
Physical and Practical Reasons
Clinical Reasons
Case Management Reasons
Cultural Reasons
Clinical Interventions Not Possible in the Office
Outdoor or Adventure Therapy
Ethical Issues: Confidentiality, Time, Location, Unpredictability, and Safety Considerations
Ethics, Standard of Care, and Risk Management Considerations
Conclusion
References
Chapter 48: Common Ethical Issues Associated With Psychotherapy In Rural Areas
Scope Of This Chapter
Overarching Rural Mental Health Resource Concerns In The United States
Overview Of Ethical Issues In Rural Areas
Common Ethical Issues In Rural Areas
Professional Competence
Confidentiality
Multiple Relationships
Overarching Recommendations
Conclusion
References
Chapter 49: Ethical Aspects of Online Psychotherapy
Introduction
Ethical Aspects of Online Psychotherapy
Ethical Arguments in Favor of Online Psychotherapy
Improvement of Psychotherapeutic Processes
Anonymity
Cost Effectiveness
Ethical Arguments against Online Psychotherapy
Impairment of the Therapeutic Process
Confidentiality, Security, and Privacy
Informed Consent
Patient Identification and Emergency
Legal Issues
Professional Competence
Fictitious Clinical Vignette
Conclusion
References
Chapter 50: The Ethics Of Artificial Intelligence In Psychotherapy
Background
Artificial Intelligence And Chatbot Apps For Mental Health
Artificial Intelligence Apps As Supplements To Psychotherapy Delivered By Persons Or As Supervised Primary Treatments?
Artificial Intelligence Apps as a Supplement to Psychotherapy
Artificial Intelligence Apps as Supervised Primary Treatments
Ethical Principles To Reflect On Artificial Intelligence In Psychotherapy
Global Landscape of Ethical Principles for Artificial Intelligence
Principles for Apps in Mental Health
Evidence-Based Research as the Gold Standard to Ensure Beneficence and Non-Maleficence
The Need For More Ethical Perspectives
Conclusion
References
Chapter 51: Ethical Issues in Psychotherapy of Other Therapists: Description, Considerations, and Ways of Coping
Introduction
Ethical Dilemmas
Managing Dual Relationship Dilemmas
Managing Boundary Issues
Boundary between Psychotherapy and Supervision
Boundary between Psychotherapy and Evaluation (between the Role of the Therapist and the Role of a “Professional Gatekeeper”)
Confidentiality and the Duty to Report
The Importance of Professional Organizations and Regulatory Bodies
Conclusion
References
Chapter 52: Ethics Of Psychotherapeutic Interventions In Palliative Care
Introduction
Psychotherapeutic Interventions In Palliative Care
Psychodynamic Psychotherapy
Systemic Psychotherapy
Cognitive and Behavioral Psychotherapy
Existential Psychotherapy
Indication For Psychotherapeutic Interventions In Palliative Care
Ethical Implications In Psychotherapy
Specific Ethical Challenges In Palliative Care Psychotherapy
Beneficence
Non-Maleficence
Respect for Autonomy
Justice
Conclusions
References
Chapter 53: Ethical Psychotherapeutic Management of Patients with Medically Unexplained Symptoms: The Risk of Misdiagnosis and Harm
Introduction
Diagnostic Uncertainty versus Diagnosis of Psychological Causes
First Do No Harm: Medical Risk and Medically Unexplained Symptoms
Do No Harm: Psychological Risk and Medically Unexplained Symptoms
Informed Consent, Care Access and Social Concerns
Conclusions: Ethical Psychotherapeutic Management of Medically Unexplained Symptoms
References
Chapter 54: Psychotherapy in a Multicultural Society
Introduction
The Stages of Migration
Transcultural Self-Concepts in the Globalized World
Generation Conflicts and Identity
Understanding Illness and Coping with It
Magical Ideas and Health
Psychotherapy and Ethical Aspects
Psychotherapeutic Treatment in the Transcultural Context
Casuistry
Summary
References
Chapter 55: Conducting Psychotherapy through a Foreign Language Interpreter: Ethical Dilemmas
Introduction
Interpretation versus Translation
Legal Requirements for Employing Interpreters
Ethical Codes and Accompanying Principles
Is Interpreter-Mediated Psychotherapy Effective?
How do Psychotherapists Determine if an Interpreter is Competent?
Linguistic Competence
Skills in the Process of Interpreting
The Tensions between Beneficence, Non-Maleficence and Competence
Training and Education for Psychotherapists
Defining the Interpreter’s Role
Dual Relationships and Confidentiality
Secondary Traumatization
Interpreters in the Context of Beauchamp and Childress’s Four Principles
Quality Interpretation, Organizational Factors, and Public Policy
Conclusion
References
Chapter 56: “Even Therapists Need Therapists”: Ethical Issues in Working with LGBTQ+ Clients
Introduction
Competence
The Problem
The Way Forward
Examples
Nonmaleficence
The Problem
The Way Forward
Example
Non-discrimination
The Problem
The Way Forward
Examples
Confidentiality
The Problem
The Way Forward
Examples
Navigating Multiple Relationships
The Problem
The Way Forward
Examples
Using and Conducting Research
The Problem
The Way Forward
Example
Financial Matters
The Problem
The Way Forward
Examples
Advertising
The Problem
The Way Forward
Example
Assessment and Diagnosis
The Problem
The Way Forward
Example
Supervision
The Problem
The Way Forward
Example
Conclusion
References
Chapter 57: Intersectionality and Psychotherapy with an Eye to Clinical and Professional Ethics
Introduction
Having an Eye to the “Multiple Sites” of Experience
The Concept of Intersectionality
Refusal of a “Single-Axis Analysis
Two Analogies to Explain Intersectionality
Intersectionality Is Opposed to Hierarchical Practices and Binary Logics
The Psychological Dimensions of Intersectionality
Intersectionality and the Matrix of Domination
Intersectionality: A Methodology and Practice
Conclusion
References
Chapter 58: Ethics Of AnimalAssisted Psychotherapy
Introduction
Animal-assisted Psychotherapy
Institutionalization And Ethics
Quality Assurance and Legal Situation
Ethical Standards for the Therapist
Ethical Standards for the Client
Ethical Standards for the Therapy Animal
Animal Ethics: Moral Obligations to Animals
Animal Welfare
The Ethical Dimension of Relationships in AAT: Negative and Positive Duties
Conclusion
References
Chapter 59: The Ethics Of Mindfulness-based Interventions: A Population-level Perspective
Introduction
The Ethics Of Mindfulness-based Interventions
What are Mindfulness-Based Interventions?
MBIs through Thick and Thin?
A Normative Framework
Thinness Worries
Thickness Worries And MindfulnessBased Interventions In Schools
Religious Thickness
Axiological and Ethical Thickness and MBIs in Schools
Conclusions
References
Section VI: Ethics Of Psychotherapy Education, Training, Quality Assurance, And Research
Chapter 60: Virtue Ethics and the Multicultural Clinic
Introduction
Defining “Psychotherapy”
Cases
Case 1: Post-PartumDepression and Breast-Feeding
Case 2: Adult Daughter’s Mother Will Not Leave
Case 3: Suspected FBI Attention
Case 4: Disability Waiver Request
Case 5: Clan Status and Mother-in-Law
Virtues
Some Key Additional Virtues in Cross-Cultural Psychotherapy
Open-Mindedness,Intellectual Curiosity, and Other Epistemic Virtues
Additional Virtues to Avert Burnout
Conclusion
References
Chapter 61: Toward an Evidencebased Standard of Professional Competence
Introduction
The Empirical Status of the Current Competence Criterion
Adding Effectiveness to the Criteria for Competence
The Trouble with Thresholds
Operationalizing a Dynamic, Evidence-Based Competence Standard
Improving the Outcome of Psychotherapy One Clinician at a Time
Implementing an Evidence-Based Standard of Professional Competence
Summary Conclusions
References
Chapter 62: Ethical Importance Of Psychotherapists’ Self-care And When It Fails
Introduction
Self-care
Research On Self-care
Self-care As An Ethical Imperative
The Complexities Of Psychotherapy Practice And Self-care
When Self-care Is Strained Or Fails
Motivations For Self-care
Self-care As Personal Self-care A Form Of Self-compassion
Recommendations for Personal Self-Care
Personal Therapy
Being Gentle and Kind to Ourselves
Social Support
Taking Time Away from Work
Personal Health and Well-Being
Self-care As A Professional Responsibility: A Form Of Risk Management
Recommendations for Professional Self-Care
Leaving Work at Work
Setting Boundaries and Saying “No”
Using Technology
Supervision and Consultation
Malpractice Insurance
The Good Enough Therapist
Self-care As A Shared Responsibility: Community Self-care
Recommendations for Community Self-Care
Joining Associations and Unions
Conclusion
References
Chapter 63: The Metaethics of Psychotherapy Codes of Ethics and Conduct
Introduction
The Roles of Professional Organizations
The Regulation of Psychotherapy in the UK
Ethics, Law, and Professional Influences on Action
Codes of Ethics or Conduct?
Must, Should, Shall, Will
Guidance and Disclosure of Confidential Information
Conclusion
References
Chapter 64: Professional Conduct And Handling Misconduct In Psychotherapy: Ethical Practice Between Boundaries, Relationships, And Reality
Introduction
Definition Of Professional Conduct In Psychotherapy
Ethical Reasoning
Forms Of Misconduct
Sexual Misconduct
Non-Sexual Misconduct
Consequences
The Abusive Psychotherapist: Slipping, Stumbling Or Walking Across Boundaries?
Development of Professional Identity
Characteristics of Offending Professionals
Interventions
Teaching Professional Conduct
Education and Information
Ethics In Psychotherapy Training
What Can Be Done When One Is Confronted With Misconduct?
Conclusions
References
Chapter 65: Dealing with Moral Dilemmas in Psychotherapy: The Relevance of Moral Case Deliberation
Introduction
What is a Moral Dilemma?
Moral Case Deliberation and the Dilemma Method
A Clinical Case Example
Experienced Effects of Moral Case Deliberation
Comparing Moral Case Deliberation to Other Forms of Ethics Support
Conclusion
References
Chapter 66: Psychotherapy Ethics in Film
Introduction
Popular Images of Psychotherapy and Their Clinical Impact
A “Strange Bedfellowship”: Psychotherapy and Film
Psychotherapy Ethics in Film
Between Madness, Badness, and Sex: Psychotherapist Stereotypes as an Index of Ethical Misconduct
A Virtue out of Necessity: Film in Teaching Psychotherapy Ethics
References
Chapter 67: Psychotherapy Ethics In Twentieth-century Literature
Introduction
Confidentiality
Sexual And Nonsexual Boundary Crossings And Violations
Professionalism And Informed Consent
Anti-freudianism And Anti-psychiatry
Conclusion
References
Chapter 68: Ethical Issues in Psychotherapy Research
Introduction
Designing Ethical Psychotherapy Research
Balancing Risks and Benefits
Risk Monitoring and Management Strategies
Selection and Recruitment of Participants
Vulnerable Populations and Sensitive Topics: Striking an Ethical Balance
Informed Consent: More than a Signature
Evaluation of Decision-MakingCapacity
Knowledge is Power: Provision of Information in the Informed Consent Process
Voluntariness in the Informed Consent Process
Quantitative and Qualitative Research Designs: Ethical Questions and Processes
Quantitative Research Designs
Qualitative Research Designs
Documentation and Dissemination: Ethical Safeguards
Psychotherapy Research Ethics in Different Context
Diverse Cultural Settings
Research via Online Platforms
Ethical Decision Making: Committees and Regulatory Frameworks
Conclusions
References
Index of Names
Subject Index

Citation preview

OUP CORRECTED AUTOPAGE PROOFS – FINALS, 27/05/21, SPi

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T h e Ox f o r d H a n d b o o k o f

PSYC HOT H E R A PY ET H IC S

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Oxf ord H a ndb o ok s in Philo sophy a nd P sychiat ry Series editors: K.W.M. Fulford, Lisa Bortolotti, Matthew R. Broome, Katherine Morris, John Z. Sadler, and Giovanni Stanghellini

Volumes in the Series:

The Oxford Handbook of Philosophy and Psychiatry

Edited by K.W.M. Fulford, Martin Davies, Richard Gipps, George Graham, John Sadler, Giovanni Stanghellini, and Tim Thornton

The Oxford Handbook of Psychiatric Ethics

Edited by John Z. Sadler, Werdie (C.W.) Van Staden, and K.W.M. Fulford

The Oxford Handbook of Philosophy and Psychoanalysis Edited by Richard Gipps and Michael Lacewing

The Oxford Handbook of Phenomenological Psychopathology

Edited by Giovanni Stanghellini, Matthew R. Broome, Anthony Vincent Fernandez, Paolo Fusar-­Poli, Andrea Raballo, and René Rosfort

The Oxford Handbook of Psychotherapy Ethics

Edited by Manuel Trachsel, Jens Gaab, Nikola Biller-­Andorno, Şerife Tekin, and John Z. Sadler

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the oxford handbook of

PSYCHOTHERAPY ETHICS Edited by

MANUEL TRACHSEL, JENS GAAB, NIKOLA BILLER-ANDORNO, ŞERIFE TEKIN and

JOHN Z. SADLER

1

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1 Great Clarendon Street, Oxford, ox2 6dp, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2021 The moral rights of the authors have been asserted First Edition published in 2021 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2020952081 ISBN 978–0–19–881733–8 Printed and bound in the UK by TJ Books Limited Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

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To all those who seek help and support through psychotherapy, and to those who seek to provide it to the best of their knowledge and ability.

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Foreword Bruce E. Wampold, Ph.D. Madison, WI, USA Professor Emeritus, University of Wisconsin—Madison and Senior Researcher, Research Institute, Modum Bad Psychiatric Center, Vikersund, Norway

In an evidence-based world, the emphasis in health services is on finding the most effective treatment for a particular disorder. In the latest iteration of the application of evidence to improve health, the notion of personalized medicine has been introduced, turning the focus on what is the most effective treatment for this particular patient with this particular disorder. In many ways this has been a technological endeavor, with attempts to increase longevity by days, it seems, and mortality by minute percentages. In this technological effort to make incremental advances by focusing on treatments, or even for treatments for individual patients, the patient and their context are secondary, if not ignored. Lip service is paid to patient preferences and the “psycho” and “social” aspects of the biopsychosocial, but the person as an agentic participant is too frequently ignored. If health service is to retain the essence of healing practices, with a respect for the patient, health care ethics must be central to all aspects of health systems. Ethical considerations are not simply “add-ons” to satisfy society’s demands for such services—rather they should be endemic to the study of services, to the training of clinicians, to the delivery of services, to the evaluation of quality—all aspects of health services must be saturated with a consideration of ethics. This is an imperative for an effective health care system—one that not only demonstrates caring and respect for the patient, but one that is sustainable, is utilized by those who need services, and effective. Too many mistakes in health care have been committed by ignoring ethics. Much has been written about ethics generally and, despite the focus on treatments, in health care specifically. Indeed, there is a name for the field in health care—bioethics. There are bioethics academic programs (usually in medical schools), graduate degrees, and professors of bioethics. There is a plethora of experts to comment on thorny problems in bioethics that are raised in public. Although bioethics is ubiquitous, the ethics of psychotherapy is neglected. This is quite surprising, and frankly disturbing, because the practice of psychotherapy raises ethical issues by its very nature. Psychotherapy is an intimate relationship between two persons but a very specialized one—and this raises a host of ethical issues. Moreover, each type of therapy creates a different type of relating. In each, the therapist takes a different stance.

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viii   Foreword The psychotherapy field desperately needs a comprehensive volume dedicated to psychotherapy ethics. The editors of The Oxford Handbook of Psychotherapy Ethics Manuel Trachsel, Jens Gaab, Şerife Tekin, Nikola Biller-Andorno, and John Z. Sadler, collectively have thought and written about this subject to a greater extent that the remainder of the field, most likely. The volume they have created and edited covers the ground comprehensively, with sections and topics as follows: • • • • • • •

Why Ethics Matter in Psychotherapy The Historical Context Concepts and Theories for Psychotherapy Ethics Common Ethical Challenges in Psychotherapy Ethical Issues with Specific Psychotherapy Approaches Ethical Challenges of Specific Settings and Populations Ethics of Psychotherapy Education, Training, Quality Assurance, and Research

This volume is a must read for everyone in the psychotherapy field: clinicians, educators, trainees, researchers, policy makers, and managers of mental health care. Unless this ­material is read and understood, we are “flying blind” when it comes to becoming ethical professionals.

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Acknowledgements

An Oxford Handbook requires strong leadership as well as an integrated, smoothly functioning team. We, the editors, have enjoyed both of these through the support Oxford University Press has provided. Senior Commissioning Editor Martin Baum has provided steady guidance, extraordinary liberty of content, and practical wisdom for each step in developing the Oxford Handbook of Psychotherapy Ethics. Senior Assistant Commissioning Editor Charlotte Holloway provided prompt and thorough assistance in every practical detail and question we could send her way, with encouragement and cheer. We’re also grateful to Assistant Commissioning Editor Janine Fisher for stepping in for Charlotte when the demands of a growing family pulled her away from us. We thank Project Manager Sandhiya Purushothaman and Senior Project Manager Ramani Venkatesan from SPi Global for their guidance in the production stage of the manuscripts. We are much obliged to the authors of the Oxford Handbook of Psychotherapy Ethics who provided substance, patience, and flexibility in responding to our editorial demands, even when on short notice. Dr. Manuel Trachsel would like to thank his great fellow editors for their constant engagement, support, and hard work in developing the present Oxford Handbook of Psychotherapy Ethics over the last four years. I have very much enjoyed all the excellent discussions and creative exchanges with them that made it such a pleasure to work on this groundbreaking volume. I am also indebted to the members of my research group at the Institute of Biomedical Ethics and History of Medicine (IBME) at the University of Zurich, where lively debate on issues of medical ethics with my colleagues and my PhD and MD students has been a source of ongoing delight. I am especially grateful to my mentor and role model Nikola Biller-Andorno, who has provided constant and trustful support in shaping my career. I am also grateful to the Swiss Academy of Medical Sciences for supporting my research. I could not have brought this work to fruition without tapping into the intellectual inspiration provided by some great earlier thinkers, including Aristotle, Epicurus, Marcus Aurelius, Michel de Montaigne, David Hume, John Stuart Mill, Søren Kierkegaard, Arthur Schopenhauer, Friedrich Nietzsche, Jean-Paul Sartre, Albert Camus, William James, Carl R. Rogers, and Irvin D. Yalom. I thank my family and friends for their emotional support over the years, among them my parents Elsbeth and Kurt, my sister Rahel, my nephews Joshua and Aaron, my parentsin-law Elisabeth and Hansueli, my friends Gieri Maissen, Simon Lieberherr, Sebastian Haas, Tobias Krieger, and Tobias Zürcher. Finally, my wholehearted thanks to my wonderful wife Barbara, and to my children Liv, Jon, May, and Eli.

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x   Acknowledgements Dr. Biller-Andorno would like to thank the wonderful administrative team of the Institute of Biomedical Ethics and History of Medicine of the University of Zurich, who has been tremendously helpful with the many searches, mails and calls that were needed to bring this volume together. Special thanks to my children – Sophia, Leticia and Luca – , who are at the same time relentless critics and a wonderful source of inspiration. Dr. Tekin would like to thank her fellow editors. Dr. Sadler would like to thank his fellow editors for their creativity, collegiality, and hard work. I also want to thank my steadfast and highly competent assistant, Ruth Vinciguerra, for her help with this book and all the other goings-on in our office in the four years that went into developing the Oxford Handbook of Psychotherapy Ethics. I am also grateful for my department chair, Carol Tamminga, MD for her encouragement and commitment to a strong ethics presence in our department and our field. As always, my family is a source of renewal and joy, making affairs private and professional more glorious: Abbie, Evan, and Cole.

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Detailed Table of contents SE C T ION I :   BAC KGROU N D A N D H I S TOR IC A L C ON T E X T 1. Why ethics matter in psychotherapy

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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 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.

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xii   Detailed Table of contents

3. What do psychotherapists need to know about ethics? lessons from the history of professional ethics 

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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

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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.

SE C T ION I I :   C ONC E P T S A N D T H E OR I E S F OR P S YC HO T H E R A PY E T H IC S 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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Detailed Table of contents   xiii 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

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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 perspective111 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.

8. Fairness, justice, and economical thinking in psychotherapy 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

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xiv   Detailed Table of contents 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

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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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Detailed Table of contents   xv 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

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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?

189

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 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

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xvi   Detailed Table of contents 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

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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

230

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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Detailed Table of contents   xvii 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.

SE C T ION I I I :   C OM MON E T H IC A L C H A L L E NG E S I N P S YC HO T H E R A PY 17. The ethics of informed consent for psychotherapy

259

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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xviii   Detailed Table of contents 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

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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 psychotherapy312 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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Detailed Table of contents   xix 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

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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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Kevin S. Doyle 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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xx   Detailed Table of contents 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

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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 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

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Detailed Table of contents   xxi 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

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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

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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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xxii   Detailed Table of contents 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

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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

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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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Detailed Table of contents   xxiii 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 relationship496 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. ​

SE C T ION I V:   E T H IC A L I S SU E S W I T H S PE C I F IC P S YC HO T H E R A PY A PPROAC H E S 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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xxiv   Detailed Table of contents 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 psychotherapy529 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 psychotherapy

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Orah T. Krug and Troy Piwowarski 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

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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 interventions591 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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xxvi   Detailed Table of contents provenance of the practices need be disclosed to clients. I argue that while the practices are not problematically appropriative from Buddhists, the failure to disclose the religious origins of the practices violates informed consent obligations owed to clients.

40. Psychotherapy integration as an ethical practice

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Martin grosse Holtforth, Juan Martín Gómez Penedo, Cosima Locher, Charlotte Blease, and Louis G. Castonguay This chapter aims to analyze which ethical challenges clinicians face when practicing different forms of psychotherapy integration. With this purpose, we first define psychotherapy integration and differentiate four types of integrative approaches. Drawing on Beauchamp and Childress’s (2013) principles of biomedical ethics, we highlight important common and particular ethical issues in the four types of integrationist psychotherapy practice. Finally, we frame questions for future research into integrative-psychotherapy ethics and consider possible clinical responses to ethics issues raised in integrative therapy.

SE C T ION V:   E T H IC A L C H A L L E NG E S OF SPE C I F IC SE T T I NG S A N D P OPU L AT ION S 41. Identifying and resolving ethical dilemmas in group psychotherapy625 Virginia M. Brabender This chapter focuses upon the major ethical issues that emerge in the practice of group psychotherapy. Four issues are given particular attention: Competence, Confidentiality, Evaluation of Progress, and Dual Relationships. It discusses these issues in terms of the core ethical principles that they engage, and considers how the therapist would go about resolve a conflict between these principles in a given practice situation. The chapter also explicates the impediments that exist to good ethical reasoning in the group situation. These include two broad categories: lack of knowledge and skills, and human factors affecting ethical decision-making. The latter include cognitive biases such as overshadowing, processing errors, and affective stimulation. Ways of surmounting these obstacles are suggested.

42. Ethics in couple and family psychotherapy Marcel Schaer and Célia Steinlin In couple and family therapy, the focus is on relationships, interactions and the dynamics within the system. The therapist should strive to maintain a balanced and trustful relationship with all members of the system, and at the same time do justice to their individual wishes and perspectives. Couples and families usually present themselves with conflicts of interest that they have failed to resolve. Dealing with conflicts of interest is therefore an important element of

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Detailed Table of contents   xxvii couple and family therapy. The existing ethical guidelines, defined by psychological professional associations and medical ethics experts, are not specific enough at representing the complexities which family and couple therapists are confronted with. As an alternative to the ethical guidelines, Beauchamp and Childress (2008) have worked out general ethical principles: respect for autonomy, nonmaleficence, beneficence and justice. In this chapter, a number of ethical problems in couple and family therapy are discussed against the backdrop of these principles. Problems in family and couple therapy can be addressed based on the question who of the system members carries more blame and who can execute more control. Four models of help, i.e. the medical model, the compensatory model, the enlightenment model and the moral model, are discussed with regard to this question. Finally, it is argued that ethical issues in couple and family therapy are relational and context-dependent. They must therefore be resolved in the encounter with each other.

43. Psychotherapy with children and adolescents

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Ashley S. Castro, Gerald P. Koocher, and Eric Peist Psychotherapy with children and adolescents presents its own set of unique ethical challenges and considerations. Unlike psychotherapy with adults, children are often referred to therapy by adults (e.g. parents or teachers), meaning that the circumstances and context for which they present to therapists or clinicians differ from the circumstances of most adults. This chapter provides an overview of ethical considerations specific to children and adolescents including issues of competence, confidentiality, boundaries, use of specific therapeutic techniques, and attention to diversity. Authors advocate for moving away from a traditional bioethical or risk management approach with clients, towards a relational approach to child and adolescent psychotherapy ethics, in which therapists and clinicians pay special attention to context, family dynamics, and culture. It is essential that mental health professionals involved in psychotherapy with children and adolescents engage in continuous reflection on ethical issues and work to best understand their clients in context so they can provide optimal services.

44. Psychotherapy in old age: Ethical issues Julian C. Hughes and Richard Cheston Old age brings challenges which affect the process and content of psychotherapy; not that older people should be thought of as being the same, for they are individual. There are particular cohort effects and contexts that might affect the ways in which older people react to stressors in old age. Cognitive impairment and dementia will sometimes be a consideration. Good psychotherapeutic approaches to older people tend to reflect good ethical approaches. These can be described by the main ethical theories: utilitarianism, deontology and virtue ethics. But a better and more nuanced way is perhaps to use ethical approaches that stress narrative, communication, interpretation and meaning, as well as care and relationships. These approaches seem more realistic: they accommodate

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xxviii   Detailed Table of contents the real situation for the person concerned, recognizing him or her as a situated and embodied agent. We shall use vignettes to highlight the usefulness of these nuanced approaches to ethical problems.

45. Ethical considerations of court-ordered outpatient therapy

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Josh E. Becker, Audrey Cecil, and Michael C. Gottlieb Court-ordered outpatient psychotherapy (COT) has been used in the criminal justice system for treatment of adolescents and adults for a number of problems such as mental illness, substance use, and sex offenses, and the number and frequency of such orders has grown at a dramatic rate. Practitioners are being asked to treat someone even though they are not free to exercise the normal duties they would have toward their voluntary patients. This circumstance creates a number of potential ethical dilemmas regarding informed consent, potential loyalty conflicts, violations of confidentiality, and the risk of therapeutic ruptures that clinicians typically do not encounter on daily basis. This chapter will explore these ethical issues and provide examples of questions practitioners should take into account when working with this population.

46. Ethical issues in the psychotherapy of high risk offenders

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Gwen Adshead In this chapter I discuss the ethical dilemmas that arise in the psychotherapy of high risk offenders i.e. those offenders who have caused serious harm to others and who may be at risk of doing so again. These offenders may be detained in prison or in secure psychiatric facilities; but wherever they are, they are expected to take part in activities that will reduce their risk to others as well as improve their mental health. In this chapter, I start by assuming that these ‘activities’ are intended to bring about a change of mind in offenders. I explore the ethical issues raised by this assumption; and review previous work covering related themes. I conclude with discussion of the four ethical issues in therapy with offenders: (a) autonomy and coercion (b) welfare and outcomes (c) justice and (d) disclosure of risk and confidentiality.

47. Beyond the office walls: Ethical challenges of home treatment, and other out-of-office therapies Ofer Zur and Manuel Trachsel Interactions between patients and therapists outside the walls of the office include different forms, for example, home visits, outdoor or adventure therapy, and clinical interventions not possible in the office such as in vivo desensitization in the treatment of phobias. Such interactions pose particular ethical questions pertaining to confidentiality, time, location, flexibility, complexity, unpredictability and safety considerations. Furthermore, they raise complex issues in regard to the standard of care, the acceptability of such intervention and its legitimacy as a reimbursable medical procedure. Professional organizations’ codes of ethics neither specifically mention out-of-office experiences nor state that they are

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Detailed Table of contents   xxix unethical. It is argued that clinically driven, out-of-office interventions with the patient’s welfare in mind are clearly within the standard of care, and are neither unethical per se nor lead to exploitation or harm. Sometimes, not leaving the office can even be unethical as it deprives patients of the best possible care.

48. Common ethical issues associated with psychotherapy in rural areas

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Alysia Hoover-Thompson, Brandon C. Bogle, and James L. Werth, Jr. Ethical issues are not uncommon in the course of psychotherapy. However, the setting in which the counseling takes place can have an impact on the types of ethical dilemmas that arise. Because of the very nature of work in rural areas, concerns regarding professional competence, confidentiality, and multiple relationships are frequent when working in these types of communities. This chapter covers these topics and several others with an emphasis on special considerations with children/adolescents and with older adults. The chapter reviews common complications that may arise when providing psychotherapy, utilizing sample dilemmas, providing possible solutions, and offering recommendations for best practice when therapists are working in rural areas.

49. Ethical aspects of online psychotherapy

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Julia Stoll and Manuel Trachsel Online psychotherapy is a fast-growing, low-threshold option to deliver mental healthcare services. In the present chapter, the different terminologies and definitions of online psychotherapy are discussed and a broad overview of the used information technologies is given. Furthermore, the most important ethical arguments debated in the literature are discussed by reviewing, on the one hand, the arguments in favor of online psychotherapy like increased access to care, improvement of treatment, anonymity, and cost effectiveness and, on the other hand, arguments against online psychotherapy like impairment of treatment, confidentiality issues, issues with informed consent, patient identification and emergency situations, legal issues and additionally required skills.

50. The ethics of artificial intelligence in psychotherapy Tania Manríquez Roa, Nikola Biller-Andorno, and Manuel Trachsel Current developments in artificial intelligence (AI) for mental health have raised important ethical debates around its uses in psychotherapy, including how and under what circumstances AI may be valuable to improve and expand access to psychotherapy. We discuss the use of chatbots and AI tools as supplements to psychotherapy delivered by persons, and as supervised primary treatments. We present ethical guidelines and standards for AI and mobile apps in mental health, and discuss how these developments are relevant in the ethics of AI in psychotherapy. Current discussions on the role of chatbots and other AI tools for mental health rely mostly on a perspective of justice. We aim to enrich the

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xxx   Detailed Table of contents debate by complementing the perspective of justice by the one of care and using them to reflect on the respect of autonomy, access to treatment, nondiscrimination, fulfillment of people’s needs and establishment of caring relationships. This chapter argues that trustworthy AI tools may help to establish caring relationships between therapist and patient, and contribute to the therapeutic process.

51. Ethical issues in psychotherapy of other therapists: Description, considerations, and ways of coping

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Gaby Shefler, Shai Lederman, and Refael Yonatan-Leus What are the specific ethical aspects of psychotherapy with patients who are themselves therapists (patient-therapists)? We argue that the main difference between psychotherapy with patient-therapists and non-therapist patients is that in the former, the therapist is both the patient’s therapist and colleague. Potential multiple relationships may arise in such cases since the therapist and the patient are both members of the same professional community. In addition, therapists are faced with the challenges of maintaining boundaries between the therapeutic and other professional roles. The most complex dilemma in this situation concerns the therapist’s duty to report patient-therapists’ professional impairment, incompetency, ethical violations or suspected illegal behavior. We suggest that the therapist’s primary ethical duty in this case is to the patient and that reporting should only be as a last resort. We conclude with a call to professional organizations and other regulating bodies for establishing guidelines for managing such dilemmas.

52. Ethics of psychotherapeutic interventions in palliative care

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Mathieu Bernard, Sonia Krenz, and Ralf J. Jox Psychotherapeutic interventions are a cornerstone of modern palliative care. In this context, they are as diverse as psychotherapeutic approaches in general and encompass modalities from the psychoanalytic, cognitive-behavioral, systemic, and existential traditions. All of these psychotherapies are based on inherent and often implicit values and are closely interrelated with philosophical traditions. In psychological practice in palliative care, professionals encounter a wide range of ethical questions that can be classified according to the four principles of biomedical ethics: beneficence, nonmaleficence, respect for autonomy, and justice. In this article, our aim is to highlight some of the most salient of these ethical questions and help the reader become aware and reflect on them.

53. Ethical psychotherapeutic management of patients with medically unexplained symptoms: The risk of misdiagnosis and harm Diane O’Leary and Keith Geraghty Management of medically unexplained symptoms (MUS) is undergoing a period of change. We see this in the recent breakdown of consensus on mental health management of quintessential medically unexplained conditions (like myalgic

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Detailed Table of contents   xxxi encephalomyelitis/chronic fatigue syndrome), and in recent work in bioethics suggesting that the issue of biological versus mental health management of MUS is fundamentally an ethical matter. For these reasons, it’s important to think carefully about ethical aspects of MUS management in psychotherapeutic settings. In Part 1 of this chapter, we show how ambiguity in the term “MUS” leads to routine conflation of diagnostic uncertainty with psychological diagnosis for unexplained symptoms in medical settings. In Part  2, we explore evidence suggesting that substantial harm results from a failure to draw that distinction in medical settings, and we clarify the psychotherapist’s obligations to avoid those harms. In Part 3, we explore the risk for psychological harms when psychotherapists conflate diagnostic uncertainty with psychological diagnosis. Finally, in Part 4 we consider challenges to informed consent in psychotherapy for MUS. We conclude with principles for ethical psychotherapeutic management of MUS.

54. Psychotherapy in a multicultural society

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Jan Ilhan Kizilhan In the psychotherapeutic treatment of migrants from family-oriented societies, cultural identity and the role of the family are very significant. The different biographies mean that the family-oriented ideas of the first generation differ from those of the second and third generations in the strength of the cultural identity which they feel and the bonds which they have with traditional values. In addition to the effects of generation and cultural conflicts, any psychotherapeutic treatment of these groups is made more difficult by two further aspects: namely, language barriers and the different way of understanding illness and coping with it. The systemic perspective with a systematic involvement of the family in the treatment and use of family-oriented and cultural resources, including a full consideration of ethical aspects, are vital for an adequate therapy.

55. Conducting psychotherapy through a foreign language interpreter: ethical dilemmas H. Russell Searight Current demographic and migration trends in many developing countries are increasing the demand for foreign language interpreters in metal health settings. Most mental health professionals have not been formally trained in providing psychotherapy through an interpreter. The addition of this third party to the therapist-patient dyad raises a number of ethical issues. While psychotherapists assume that interpreters are fluent in at least two languages , this fluency may not extend to the unique demands of mental health settings. While ethical guidelines indicate that the therapist bears responsibility for the interpreter’s competence, most interpreters will not have received formal training in facilitating psychotherapy. Since many patients with limited English Proficiency (LEP), have sustained psychological trauma related to migration and war in their home counties, are at-risk for secondary traumatization during psychotherapy.

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xxxii   Detailed Table of contents Ethically, psychotherapists must consider the relative risks and benefits of interpreter mediated psychotherapy and work towards reducing barriers to optimal treatment.

56. “Even therapists need therapists”: ethical issues in working with LGBTQ+ clients

835

Sheila M. Addison and Whit Ryan “Ethical issues in working with LGBTQ+ clients’’ examines the complex interplay of ethical and clinical considerations in psychotherapy, research, and supervision with sexual and gender minority (SGM) clients. Using ethical codes and “best practices” documents from mental health organziations throughout the Anglophone world, the authors explore topics such as clinical competence, nonmaleficence, non-discrimination, confidentiality, multiple relationships, using and conducting research, financial matters, advertising, assessment and diagnosis, and supervision through a feminist, queer lens. Ethical considerations are illuminated through brief vignettes grounded in affirmative clinical practices and a cultural humility approach.

57. Intersectionality and psychotherapy with an eye to clinical and professional ethics Suryia Nayak Clinical and professional ethics is primarily an issue of power. Born out of the historical anti-racist, anti-sexist and class struggles of women of color, intersectionality is a theory and method for actively attending to issues of power, which function through social constructions of difference and diversity. Whilst intersectionality is not a form of psychotherapy, intersectionality provides a framework of thinking and practice that explicitly addresses the mutually constitutive relationship between social contexts of inequality due to divisions based on difference and the psychological impact of inhabiting divisive contexts. In a world where fragmentation, categorization and division are dominant discursive frames of understanding experience, it is incumbent upon psychotherapy to provide forms of therapeutic interventions that offer insight and recovery from destructive fragmentary ways of being. Whilst, there are a range of therapeutic methods that proactively encourage and require a holistic approach to working with individuals, such as, humanistic, existential, systemic, eclectic, and integrated therapy, the value of intersectionality is that it explicitly names and foregrounds the issue of social inequality and unequal power relations. Furthermore, intersectionality goes beyond naming or recognizing multiple parts of identity to encompass specific reference to the play of power dynamics arising from context. Intersectionality locates the (re)production of identity in the conditions of context; thereby resisting reductionist formulations of mental distress, which stigmatize individuals and

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Detailed Table of contents   xxxiii groups. The importance of emphasizing location or context enables a re-positioning of shame and blame from the individual to the situations they inhabit. If the experience of oppression is intersectional, it could be argued that, an ethical position for psychotherapy is an intersectional position. Significantly, the Black feminist historical roots of intersectionality enable a psycho-social therapeutic approach that foregrounds the political dimension of the lived experience of inequality. Thus, the ethical contribution of intersectionality to psychotherapeutic approaches is the insistence that there is nothing neutral psycho-social experience of oppression.

58. Ethics of animal-assisted psychotherapy

904

Karin Hediger, Herwig Grimm, and Andreas Aigner Animal-assisted psychotherapy is increasingly popular and attracts considerable attention in science. Integrating animals into therapy aims at generating added value in health and well-being of humans as well as non-human animals. This approach is reflected in the One Health perspective. However, animal-assisted psychotherapy raises issues regarding the ethical standards in the therapy setting in general and ethical reflections about our responsibilities towards therapy animals in particular. According to a dominant account in animal ethics, our moral obligations are based on welfare concerns. But this approach can be supplemented by a contextual view that highlights the moral relevance of particular relationships in animal-assisted psychotherapy. Therapy animals place moral duties on the therapist that go beyond welfare considerations and can be based on relation-based reasoning in the therapeutic context.

59. The ethics of mindfulness-based interventions: a population-level perspective Andreas T. Schmidt and Lovro Savić When applied in population-level contexts, such as schools or business, mindfulness-based interventions (MBIs) find themselves in a crossfire between two different kinds of criticisms. On one side, some worry that MBIs’ normative commitments might be “too thick,” worrying that MBIs might come with a particular conception of the good, and significant ethical and religious commitments. On the other side, some worry that contemporary MBIs are ethically “too thin,” as they shed too many of their original Buddhist ethical and soteriological goals. In this chapter, it is argued that contemporary MBIs should remain normatively thin, as that makes them more suitable for population-level contexts. Against “thickness worries,” it is argued that MBIs are compatible with liberal respect for autonomy, as the benefits are often autonomy-enhancing, which makes MBIs potentially valuable across a broad range of conceptions of the good. The second line of argument is developed through a discussion of MBIs in schools.

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xxxiv   Detailed Table of contents

SE C T ION V I :   E T H IC S OF P S YC HO T H E R A PY E DUC AT ION , T R A I N I NG , QUA L I T Y A S SU R A NC E , A N D R E SE A RC H 60. Virtue ethics and the multicultural clinic

933

Jennifer Radden and Jerry Kroll Virtue ethics and the multicultural clinic expands on recent research applying a character-focused, virtue ethics framework to psychotherapeutic practice by introducing some distinctive demands made on the character of those who undertake psychotherapy with immigrant populations. These demands are illustrated using case examples taken from the clinic of one of the authors (JK), where Southeast Asian and East African patients are seen in an inner-city clinic in Minneapolis. In five sections, (1) offers preliminaries about the definition of “psychotherapy”; (2) describes brief case vignettes; (3) introduces virtue ethics, and the role of virtues in psychiatric practice; (4) refers to the cases introduced earlier to illustrate when and how character virtues, both those that are familiar and some that are not, play a part in effective psychotherapeutic treatment in this setting; and (5) explores the virtues likely to avert or diminish the effects of practitioner burnout that is a particular hazard of working in these settings.

61. Toward an evidence-based standard of professional competence

951

Scott D. Miller, Joshua W. Madsen, and Mark A. Hubble Psychotherapists are ethically bound to provide services within the boundaries of their competence traditionally delimited by their education, training, and supervised experience. Throughout this chapter, two historical examples illustrate the shortcomings of the current standard as well as the promise of an alternative. The guidelines now in place are critiqued in light of the empirical evidence. We propose that effectiveness become the foundation of any formulation and assessment of competence. Developments over the last two decades make it possible for clinicians to measure their results and compare them to international norms – a process known as Routine Outcome Monitoring. However, mere measurement and comparison to benchmarks are insufficient. To be ethical, to protect public welfare, practitioners must also act on the data provided by routine outcome monitoring. Using Feedback Informed Treatment and the deliberate practice therapists can both enhance their responsiveness to individual clients and continuously improve their outcomes. Challenges of implementation are discussed. A case study of an agency that successfully adopted routine outcome monitoring coupled with deliberate practice using best practices gleaned from the implementation science literature is offered.

62. Ethical importance of psychotherapists’ self-care and when it fails Andrés J. Consoli, Heidi A. Zetzer, and Himadhari Sharma The practice of psychotherapy can be as rewarding as challenging. Psychotherapists are likely to find themselves inspired by their work at times,

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Detailed Table of contents   xxxv while at others, demoralized. The clients they serve can be a source of encouragement, even admiration in their abilities to overcome their difficulties; they can also be a source of great stress and discouragement. Considering the sizable range of emotions psychotherapists will experience in their daily practice, the ability of providers to proactively engage in self-care while striving towards congruence is paramount. In this chapter, we elaborate on the  constructs of personal and professional self-care as meaningful ways to cope with, if not right out prevent, distress, burnout, and impairment. Moreover, we advance an institutional, organizational, and communitarian view of self-care that acknowledges psychotherapists as members of a sociallyneeded workforce, with their own rights to associate and unionize, while affirming their well-being.

63. The metaethics of psychotherapy codes of ethics and conduct

985

Paul Snelling Codes of ethics and conduct are important documents in health care practice, and must be evaluated alongside an understanding of the role of the organizations which write and publish them. In the UK, established professions like medicine and nursing are subject to statutory regulation and codes which delineate ethical best practice from minimum conduct. However, the regulation of psychotherapists in the UK has been the subject of changes in government policy during the last decade, resulting in a fragmented regulatory environment where a number of organizations function both as regular and professional body. There are about 40 codes of ethic and/or conduct in the UK relating to the various professions of psychotherapy. The chapter details the regulatory framework in the UK, and the places of codes within it. The codes’ regulatory role in establishing minimum practice is difficult to assess because so few cases of malpractice are brought, and their role in guiding practice is questioned by using disclosure of confidential information as an example. Psychotherapists are invited to assess whether the codes and associated guidance they operate under are sufficiently detailed to guide practice.

64. Professional conduct and handling misconduct in psychotherapy: Ethical practice between boundaries, relationships, and reality Irina Franke and Anita Riecher-Rössler The special nature of the professional relationship in psychotherapy requires a code of conduct that protects the patient, but also allows therapeutic flexibility. However, the limits of professional conduct are transgressed when a psychotherapist goes beyond his or her professional boundaries to satisfy his or her own needs. The implications of misconduct are considered to be particularly severe in psychotherapy. Misconduct has various faces and facets. Sexual misconduct is the most drastic form of boundary violation; however, this should not detract attention from other forms of misconduct, especially because they often precede the more severe boundary violations.

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xxxvi   Detailed Table of contents Any form of misconduct is profoundly connected with the person of the therapist. Nevertheless, research often addresses the question of what professional misconduct is, rather than how ethical professional conduct can be facilitated. This chapter aims to give an overview of the current literature to (1) define professional conduct and outline ethical reasoning, (2) describe different forms of misconduct, (3) discuss options for prevention and intervention and (4) discuss options for improving training of future psychotherapists.

65. Dealing with moral dilemmas in psychotherapy: The relevance of moral case deliberation

1019

Guy A. M. Widdershoven and Andrea M. Ruissen The chapter ‘Dealing with moral dilemmas in psychotherapy’ addresses the nature of moral issues in psychotherapy, and the way in which psychotherapists can be supported in dealing with them. It first explains the notion of moral dilemma, making use of the work of the philosopher Martha Nussbaum. Next it addresses Moral Case Deliberation (MCD) as an approach to support healthcare professionals. In MCD, a group of healthcare professionals deliberates on a moral issue in a concrete case. The deliberation is guided by a facilitator, who applies a deliberation method. The method presented here is the Dilemma Method. The chapter provides an example of a deliberation on a case in psychotherapy, concerning a patient with a request for euthanasia. It also describes experienced effects of MCD, and compares the approach with ethics consultation.

66. Psychotherapy ethics in film

1027

Tobias Eichinger Cinematic depictions of psychotherapy and its practitioners have been very popular since the beginning of film history. Most of these portrayals are not realistic or commendable, but rather obey the laws of film narration, entertainment, and pleasure of spectatorship. Regarding psychotherapy ethics, the quartet of stereotypical images of the crazy (“dippy”), the bad (“evil”), the good (“wonderful”) and the sexually suggestive (“horny”) therapist refers to the ethical requirements of the profession and constitutes an index of ethical misconduct.

67. Psychotherapy ethics in Twentieth-century literature Anna Magdalena Elsner Ethical issues arising in the practice of psychotherapy, such as confidentiality, boundaries in the therapeutic relationship and informed consent, figure prominently in a range of twentieth-century literary texts that portray psychotherapy. This chapter analyses the portrayal of these conflicts, but also stresses that they are often marginal to the overall plot structures of these narratives and that literary depictions of psychotherapy are often vague or even inaccurate concerning key characteristics of psychotherapeutic practice. Focusing on examples that either illustrate professionalism and the absence of ethical challenges in psychotherapy, or take up the ethical reservations that

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Detailed Table of contents   xxxvii fueled anti-Freudianism or the anti-psychiatry movement, the chapter proposes that selected literary depictions of psychotherapy can play a key role in sensitizing therapists to the complex make-up of ethical dilemmas as well as illustrating the cultural and historical contexts of these dilemmas.

68. Ethical issues in psychotherapy research

1051

Violette Corre, Poornima Bhola, and Manuel Trachsel Psychotherapists treat vulnerable persons in the context of a particular patienttherapist relationship in which the most serious and sensitive topics of human existence are talked about. In conducting psychotherapy research, it can be a challenge to align the ethical prerequisites of practicing psychotherapy with the particular methodological requirements for meaningful studies. In the present contribution, we discuss the following topics in the context of psychotherapy research ethics based on current guidelines and a narrative review of the literature: study designs, the process of informed consent to research, confidentiality, different cultural paradigms, internet-based research, and the role of research ethics committees.

Index of Names Subject Index

1071 1081

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Table of Contents List of Contributorsxlvii

SE C T ION I :   BAC KGROU N D A N D H I S TOR IC A L C ON T E X T 1. Why Ethics Matter in Psychotherapy

3

Manuel Trachsel, Jens Gaab, Şerife Tekin, Nikola Biller-­Andorno, and John Z. Sadler

2. A Brief Moral History of Psychotherapy

31

Alan C. Tjeltveit

3. What Do Psychotherapists Need to Know about Ethics? Lessons from the History of Professional Ethics

47

Carole Sinclair

4. The History and Ethics of the Therapeutic Relationship

65

Ulrich Koch and Kelso Cratsley

SE C T ION I I :   C ONC E P T S A N D T H E OR I E S F OR P S YC HO T H E R A PY E T H IC S 5. Autonomy as a Goal of Psychotherapy

87

Paul Biegler

6. Patient Protection and Paternalism in Psychotherapy

99

Marco Annoni

7. Empathy, Honesty, and Integrity in the Therapist: A Person-­Centered Perspective

111

Jeffrey H. D. Cornelius-­White and Gillian Proctor

8. Fairness, Justice, and Economical Thinking in Psychotherapy Marta Herschkopf and Rebecca Weintraub Brendel

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9. Ethics of Care Approaches in Psychotherapy 

140

Anna Magdalena Elsner and Vanessa Rampton

10. Legitimate and Illegitimate Imposition of Therapists’ Values on Patients 

154

Susana Fehr Lampley and John Z. Sadler

11. Virtue Ethics in Psychotherapy 

177

Michael Laney and Adam Brenner

12. How Do People Make Moral Medical Decisions? 

189

Eleanor Gilmore-­Szott and Thomas V. Cunningham

13. Existential Philosophy and Psychotherapy Ethics 

207

Alexander Noyon and Thomas Heidenreich

14. Phenomenological-­Hermeneutic Resources for an Ethics of Psychotherapeutic Care 

219

Giovanni Stanghellini

15. Free Will, Responsibility, and Blame in Psychotherapy 

230

Tobias Zürcher

16. Dignity in Psychotherapy 

245

Roberto Andorno

SE C T ION I I I :   C OM MON E T H IC A L C H A L L E NGE S I N P S YC HO T H E R A PY 17. The Ethics of Informed Consent for Psychotherapy 

259

Alastair J. McKean, Manuel Trachsel, and Paul E. Croarkin

18. Ethics of the Psychotherapeutic Alliance, Shared Decision Making and Consensus on Therapy Goals 

271

Stella Reiter-­Theil and Charlotte Wetterauer

19. Evidence, Science, and Ethics in Talk-­Based Healing Practices 

288

James Phillips and John Z. Sadler

20. Patient Information on Evidence and Clinical Effectiveness of Psychotherapy  Charlotte Blease, John M. Kelley, and Manuel Trachsel

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21. Ethical Dimensions of Psychotherapy Side Effects 

330

Michael Linden

22. Privacy and Confidentiality in Psychotherapy: Conceptual Background and Ethical Considerations in the Light of Clinical Challenges 

340

Anke Maatz, Lena E. Schneller, and Paul Hoff

23. Dual and Multiple Relationships in Psychotherapy 

352

Kevin S. Doyle

24. Ethics Considerations in Selecting Psychotherapy Modalities and Formats 

363

John Z. Sadler

25. Psychotherapist Self-Disclosure 

381

Jeffrey E. Barnett

26. The Ethics of Placebo and Nocebo in Psychotherapy

398

Jens Gaab, Cosima Locher, and Manuel Trachsel

27. The Business of Psychotherapy in Private Practice 

412

Anna R. Brandon

28. Mental Health Care Funding Systems and their Impact on Access to Psychotherapy  

430

Joelle Robertson-­Preidler, Nikola Biller-­Andorno, and Tricia Johnson

29. Psychotherapeutic Futility 

447

Cynthia Geppert

30. The Moral Significance of Recovery 

461

Larry Davidson

31. Social Media Ethics for the Professional Psychotherapist 

473

Kristi Pikiewicz

32. Relationship between Religion, Spirituality, and Psychotherapy: an Ethical Perspective 

484

Thomas G. Plante

33. Ethics and Expert Authority in the Patient–Psychotherapist Relationship 496 Laura Guidry-­Grimes and Jamie Carlin Watson

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SE C T ION I V:   E T H IC A L I S SU E S W I T H S PE C I F IC P S YC HO T H E R A PY A PPROAC H E S 34. Ethical Issues in Cognitive Behavioral Therapy

515

Sahanika Ratnayake and Christopher Poppe

35. Ethical Processes in Psychoanalysis and Psychodynamic Psychotherapy 529 Robert P. Drozek

36. Ethical Issues in Systemic Psychotherapy 

545

Andreas Fryszer and Rainer Schwing

37. Ethical Issues in Existential-­Humanistic Psychotherapy 

562

Orah T. Krug and Troy Piwowarski

38. Ethical Considerations in Emotion-­Focused Therapy 

579

Ueli Kramer and Robert Elliott

39. Ethical Considerations on Mindfulness-­Based Psychotherapeutic Interventions 

591

Abigail Levin

40. Psychotherapy Integration as an Ethical Practice 

606

Martin grosse Holtforth, Juan Martín Gómez Penedo, Cosima Locher, Charlotte Blease, and Louis G. Castonguay

SE C T ION V:   E T H IC A L C H A L L E NG E S OF SPE C I F IC SE T T I NG S A N D P OPU L AT ION S 41. Identifying and Resolving Ethical Dilemmas in Group Psychotherapy 

625

Virginia M. Brabender

42. Ethics in Couple and Family Psychotherapy 

642

Marcel Schaer and Célia Steinlin

43. Psychotherapy with Children and Adolescents  

660

Ashley S. Castro, Gerald P. Koocher, and Eric Peist

44. Psychotherapy in Old Age: Ethical Issues  Julian C. Hughes and Richard Cheston

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45. Ethical Considerations of Court-­Ordered Outpatient Therapy 

687

Josh E. Becker, Audrey Cecil, and Michael C. Gottlieb

46. Ethical Issues in the Psychotherapy of High Risk Offenders 

697

Gwen Adshead

47. Beyond the Office Walls: Ethical Challenges of Home Treatment, and Other Out-­of-­Office Therapies 

709

Ofer Zur and Manuel Trachsel

48. Common Ethical Issues Associated with Psychotherapy in Rural Areas 

722

Alysia Hoover-­Thompson, Brandon C. Bogle, and James L. Werth, Jr.

49. Ethical Aspects of Online Psychotherapy 

731

Julia Stoll and Manuel Trachsel

50. The Ethics of Artificial Intelligence in Psychotherapy 

744

Tanía Manríquez Roa, Nikola Biller-­Andorno, and Manuel Trachsel

51. Ethical Issues in Psychotherapy of Other Therapists: Description, Considerations, and Ways of Coping

759

Gaby Shefler, Shai Lederman, and Refael Yonatan-­Leus

52. Ethics of Psychotherapeutic Interventions in Palliative Care 

773

Mathieu Bernard, Sonia Krenz, and Ralf J. Jox

53. Ethical Psychotherapeutic Management of Patients with Medically Unexplained Symptoms: The Risk of Misdiagnosis and Harm 

789

Diane O’Leary and Keith Geraghty

54. Psychotherapy in a Multicultural Society 

803

Jan Ilhan Kizilhan

55. Conducting Psychotherapy through a Foreign Language Interpreter: Ethical Dilemmas 

818

H. Russell Searight

56. “Even Therapists Need Therapists”: Ethical Issues in Working with LGBTQ+ Clients  Sheila M. Addison and Whit Ryan

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57. Intersectionality and Psychotherapy with an Eye to Clinical and Professional Ethics 

890

Suryia Nayak

58. Ethics of Animal-­Assisted Psychotherapy 

904

Karin Hediger, Herwig Grimm, and Andreas Aigner

59. The Ethics of Mindfulness-Based Interventions: A Population-Level Perspective  

917

Andreas T. Schmidt and Lovro Savić

SE C T ION V I :   E T H IC S OF P S YC HO T H E R A PY E DUC AT ION , T R A I N I NG , QUA L I T Y A S SU R A NC E , A N D R E SE A RC H 60. Virtue Ethics and the Multicultural Clinic 

933

Jennifer Radden and Jerry Kroll

61. Toward an Evidence-­Based Standard of Professional Competence 951 Scott D. Miller, Joshua W. Madsen, and Mark A. Hubble

62. Ethical Importance of Psychotherapists’ Self-­Care and When It Fails 

969

Andrés J. Consoli, Heidi A. Zetzer, and Himadhari Sharma

63. The Metaethics of Psychotherapy Codes of Ethics and Conduct 

985

Paul Snelling

64. Professional Conduct and Handling Misconduct in Psychotherapy: Ethical Practice between Boundaries, Relationships, and Reality

1001

Irina Franke and Anita Riecher-­Rössler

65. Dealing with Moral Dilemmas in Psychotherapy: The Relevance of Moral Case Deliberation 

1019

Guy A. M. Widdershoven and Andrea M. Ruissen

66. Psychotherapy Ethics in Film  Tobias Eichinger

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67. Psychotherapy Ethics in Twentieth-­Century Literature 

1041

Anna Magdalena Elsner

68. Ethical Issues in Psychotherapy Research 

1051

Violette Corre, Poornima Bhola, and Manuel Trachsel

Index of Names Subject Index

1071 1081

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List of Contributors

Sheila Addison, Couple and Family Therapy, Antioch University Seattle, USA Gwen Adshead, Consultant forensic psychiatrist and psychotherapist, Broadmoor Hospital, West London Trust, UK Andreas Aigner, Unit of Ethics and Human–Animal Studies, Messerli Research Institute, University of Veterinary Medicine, Medical University of Vienna, University of Vienna, Austria Roberto Andorno, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland Marco Annoni, Centro Interdipartimentale per l’Etica e l’Integrità nella Ricerca, National Research Council, Italy Jeffrey E. Barnett, Loyola University Maryland, USA Josh E. Becker, North Texas VA Health Care System, Dallas, TX Mathieu Bernard,  Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Switzerland Poornima Bhola, National Institute of Mental Health and Neurosciences, Bangalore, India Paul Biegler, Monash University, Victoria, Australia Nikola Biller-­Andorno, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland Charlotte Blease,  General Medicine and Primary Care Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA Brandon C. Bogle, Stone Mountain Health Services, Jonesville, Virginia Virginia M. Brabender, Widener University, USA Anna  R.  Brandon,  University of Texas Southwestern Medical Center, USA and the University of Iowa, USA Rebecca Weintraub Brendel, Center for Bioethics, Harvard Medical School, Boston, USA Adam Brenner, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Louis G. Castonguay, Penn State University, USA

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xlviii   List of Contributors Ashley S. Castro, DePaul University, USA Audrey L. Cecil, Ochsner Health, New Orleans, LA Richard Cheston, University of the West of England, UK Andrés J. Consoli, University of California, Santa Barbara, USA Jeffrey H.D. Cornelius-­White, Missouri State University, USA Violette Corre,  Doctoral Student (MD), Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Switzerland Kelso Cratsley, Department of Philosophy and Religion, American University, USA Paul E. Croarkin, Mayo Clinic, Rochester, Minnesota, USA Thomas V. Cunningham, Director of Bioethics, Kaiser Permanente Southern California Bioethics Program, Los Angeles, California, USA Larry Davidson, Yale School of Medicine, USA Kevin S. Doyle, Longwood University, USA Robert P. Drozek, McLean Hospital, Harvard Medical School, USA Tobias Eichinger,  Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland Robert Elliott, University of Strathclyde, UK Anna Magdalena Elsner, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland Irina Franke, Psychiatric Services of Grisons, Chur, Switzerland and Department of Forensic Psychiatry and Psychotherapy, University of Ulm, Germany Andreas Fryszer, Independent Practice, Institut Praxis, Hanau, Germany Jens Gaab, Faculty of Psychology, University of Basel, Switzerland Cynthia Geppert, University of New Mexico, USA Keith Geraghty, University of Manchester, UK Eleanor Gilmore-­Szott,  Clinical Ethics Fellow, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston Texas, USA Michael C. Gottlieb, Independent Practice, Dallas Texas, USA Herwig Grimm, Unit of Ethics and Human–Animal Studies, Messerli Research Institute, University of Veterinary Medicine, Medical University of Vienna, University of Vienna, Austria  Martin grosse Holtforth, University of Bern, Switzerland

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List of Contributors   xlix Laura Guidry-­Grimes, University of Arkansas for Medical Sciences, USA Karin Hediger, Faculty of Psychology, University of Basel, Switzerland Thomas Heidenreich, Esslingen University of Applied Sciences, Germany Marta Herschkopf, Harvard Medical School, USA Paul Hoff, Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Switzerland Alysia Hoover-­Thompson, High Country Community Health,Boone, North Carolina Mark A. Hubble, International Center for Clinical Excellence, Chicago, IL USA Julian C. Hughes, Population Health Sciences, Medical School, University of Bristol, UK Tricia Johnson, Department of Health Systems Management, Rush University, USA  Ralf  J.  Jox, Institute of Humanities in Medicine and Chair in Geriatric Palliative Care, Service of Palliative and Supportive Care, Lausanne University Hospital and University of Lausanne, Switzerland John M. Kelley, Psychology Department, Endicott College and Department of Medicine, Harvard Medical School, USA Jan Ilhan Kizilhan, Institute for Transcultural Health Science, State University BW, Stuttgart, Germany  Ulrich Koch, George Washington University, USA Gerald P. Koocher, DePaul University, USA Ueli Kramer, Department of Psychiatry, University of Lausanne, Switzerland and Department of Psychology, University of Windsor, Canada Sonia Krenz, Psychiatric Liaison Service, Lausanne University Hospital and University of Lausanne, Switzerland Jerry Kroll, Department of Psychiatry, Medical School, University of Minnesota, USA Orah T. Krug, Saybrook University, USA Susana Fehr Lampley, UT Southwestern Medical Center, Psychiatry Department, in Dallas, Texas Michael Laney, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Shai Lederman, Department of Psychology, The Hebrew University of Jerusalem, and Hebrew University of Jerusalem Psychological Services, Israel Abigail L. Levin, Niagara University, USA Michael Linden, Department of Psychosomatic Medicine, Charité University Medicine Berlin, Germany

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l   List of Contributors Cosima Locher, Faculty of Psychology, University of Basel, Switzerland & Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich Alastair J. McKean, Mayo Clinic, Rochester, Minnesota, USA Anke Maatz, Psychiatric Hospital – Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich  Joshua W. Madsen, Department of Psychology, University of Calgary, Canada Tania Manríquez Roa, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland Scott D. Miller, Director, International Center for Clinical Excellence Chicago, USA Suryia Nayak, University of Salford, UK  Alexander Noyon, Mannheim University of Applied Sciences, Germany Diane O’Leary, Rotman Institute of Philosophy, Western University, Canada  Eric Peist, DePaul University, USA Juan Martin Gómez Penedo, Universidad de Buenos Aires (CONICET), Argentina James Phillips, Yale School of Medicine, USA Kristi Pikiewicz, Mackintosh Academy Boulder, USA Troy Piwowarski, Existential-­Humanistic Institute, Oakland, USA Thomas G. Plante, Department of Psychology, Santa Clara University, USA Christopher Poppe, Institute for Biomedical Ethics, University of Basel, Switzerland Gillian Proctor, University of Leeds, UK Jennifer Radden, University of Massachusetts, USA Vanessa Rampton, Institute for Health and Social Policy & Department of Philosophy, McGill University, Canada Sahanika Ratnayake, Philosophy Faculty, University of Cambridge, UK Stella Reiter-­Theil, University of Basel, Switzerland Anita Riecher-­Rössler, Medical Faculty, University of Basel, Switzerland Joelle Robertson-­Preidler, Institute of Biomedical Ethics, University of Zurich, Switzerland Andrea M. Ruissen, CL psychiatrist and philosopher, Haaglanden MC, The Hague, The Netherlands Whit Ryan, University of Denver, USA  John Z. Sadler, The University of Texas Southwestern Medical Center, Dallas, Texas, USA

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List of Contributors   li Lovro Savić, Ethox Centre; Wellcome Centre for Ethics and Humanities, University of Oxford, UK Marcel Schaer, IAP Institute of Applied Psychology, ZHAW Zurich University of Applied Sciences, Switzerland Andreas T. Schmidt, Faculty of Philosophy, University of Groningen, The Netherlands Lena E. Schneller, Psychiatric Hospital – Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Switzerland Rainer Schwing, Psychotherapist, CEO praxis institut for systemic counseling, Hanau, Germany H. Russell Searight, Lake Superior State University, USA Himadhari Sharma, Department of Counseling, Clinical, & School Psychology, University of California, Santa Barbara, USA Gaby Shefler, Achva Academic College, and Department of Psychology, The Hebrew University of Jerusalem, Israel Carole Sinclair, Independent Scholar, Toronto, Canada Paul Snelling, Three Counties School of Nursing and Midwifery, University of Worcester, UK Giovanni Stanghellini, Università degli Studi G. d’Annunzio Chieti e Pescara, Italy Célia Steinlin, IAP Institute of Applied Psychology, ZHAW Zurich University of Applied Sciences, Switzerland Julia Stoll, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland Şerife Tekin, University of Texas at San Antonio Department of Philosophy and Classics, USA Alan C. Tjeltveit, Muhlenberg College, USA Manuel Trachsel, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland; Clinical Ethics Unit, University Hospital of Basel and University Psychiatric Clinics Basel, Switzerland Jamie Carlin Watson, University of Arkansas for Medical Sciences, USA James L. Werth, Jr., Stone Mountain Health Services, USA Charlotte Wetterauer, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland; Clinical Ethics Unit, University Hospital Basel and University Psychiatric Clinics Basel, Switzerland Guy A.M. Widdershoven, Free University Amsterdam, The Netherlands

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lii   List of Contributors Refael Yonatan-­Leus, Department of Psychology, The Hebrew University of Jerusalem, Israel Heidi A. Zetzer, Department of Counseling, Clinical, and School Psychology at the Gevirtz Graduate School of Education, University of California, Santa Barbara, USA Ofer Zur, Zur Institute Inc., USA Tobias Zürcher, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland

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Section I

BAC KGROU N D A N D H ISTOR IC A L C ON T E X T

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chapter 1

W h y Ethics M at ter i n   Psychother a py Manuel Trachsel, Jens Gaab, Şerife Tekin, Nikola Biller-­A ndorno, and John Z. Sadler

Psychotherapy and Visions of the Good: Beyond Effectiveness Psychotherapy—the well-­ directed treatment of mental disorders by psychological ­methods—has established efficacy for an array of mental disorders and psychological problems (e.g., Wampold and Imel 2015). An important starting point for the launching of psychotherapy research on a grand scale was the verdict by Saul Rosenzweig that “a therapist who has an effective personality and who consistently adheres in his treatment to a system of concepts which he has mastered and which is in one significant way or another adapted to the problems of the sick personality, then it is of comparatively little consequence what particular method that therapist uses” (Rosenzweig 1936: 414–415). This so-­called Dodo bird verdict: “Everybody has won and all must have prizes” (see Wampold et al. 1997), still echoes in psychotherapy research. Over fifty years ago, Hans Eysenck contested the Dodo bird verdict through concluding that some forms of psychotherapy were not effective and could possibly be harmful (Eysenck 1952). Since then, a major aim of psychotherapy research has been to show its specific safety and effectiveness (Gerger et al. 2020). The more important the evidence-­based approach in healthcare and medicine became, the more necessary it became to adopt evidential criteria to psychotherapy outcome research in order to support psychotherapy as an empirically validated treatment (Beutler 1989; Blease et al. 2016). In addition to psychotherapy outcome research, other aspects of psychotherapy research became important in the last three decades; for example, differential indication, mode of action, patient effects, therapist effects, expediency, or efficiency (Lambert 2013). However, even though this work was needed and important, another important aspect has been neglected often in psychotherapy research and practice: ethics. Despite the release of codes of conduct by relevant professional associations and the codification of important ethical principles within the professional guidelines (e.g., American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct,

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4   Why Ethics Matter in Psychotherapy APA 2010), 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.

Ethical Challenges in Psychotherapy With its contemporary ties to healthcare, doctoring, and medical orthodoxies, psychotherapy has always been a heterodox and culturally diverse collection of approaches, schools, and practices. While psychotherapy has been associated (and associated itself) with mainstream medicine for many years, the field is also inhabited by other healing practices which are allied to, or share features of, mainstream medicine in degrees: from many, some, to none. This diversity and heterodoxy lead to all sorts of other diversities in the field—or perhaps, fields—as psychotherapy practices do not exhibit sharp boundaries from other healing practices (Frank and Frank 1993). Psychotherapies are ancient and modern, suspicious and accepting, medical and nonmedical, structured and spontaneous, philosophical and pragmatic, cognitive and emotional, storied and reductionistic, mysterious and ordinary, technical and poetic, to mention a few of the many possible dualities of the field. The name of the field, referring to the mind and healing, is a duality unto itself. These heterodoxies and other dualities undergird the many paradoxes of the psychotherapy world, which appear throughout these pages. We can mention a few of these paradoxes and appeal to the many more which lie within the pages of this collection. The matter of informed consent in clinical medicine has, for more than fifty years, been an accepted requirement for treatments (Faden and Beauchamp  1986). Yet, in psychotherapy, where informed consent surely belongs as well, its inclusion and implementation remains at issue (Trachsel et al. 2015). Clinical medicine implores clinicians to refocus on patient-­centered care (Epstein and Street  2011), yet psychotherapy relationships with patients are often entirely centered on the patient’s utterances and comportment, often becoming an issue with those selfsame patients who want their therapists to be “more real” and disclose more of themselves. Similarly, the current interest in shared decision making in clinical care may seem to be implemented obviously in psychotherapy, which is all about the therapist and patient/client(s) co-­constructing narratives of healing (see Koch and Cratsley, Chapter 4; Reiter-­Theil and Wetterauer, Chapter 18), yet therapists rarely negotiate the psychotherapy orientation, modality, and/or format with such clients, preferring to impose their own theoretical and format orientations on their patients (see Lampley and Sadler, Chapter 10; Sadler, Chapter 24). Psychotherapists often aspire to egalitarian power relations with patients,

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goals of the oxford handbook of psychotherapy ethics   5 yet the very nature of the therapy relationship is derived from an imbalance of power: one who suffers coming to another for assistance. The power imbalance is often wrestled with by patients and their therapists by alternative terminology for service-­seekers: patient (Latin patientor, one who suffers), client, service user, consumer, peer, even survivor. Other examples of these paradoxes are evident throughout this collection. An even larger set of challenges frames this Oxford Handbook of Psychotherapy Ethics. Mental health care in general, and psychotherapy most intimately, is presumably about helping people to get better and/or to live better lives. However, what counts as “better” lives is rarely considered in the field’s publications, and likely, even less commonly directly addressed in therapy relationships. Instead, the aims of therapy are typically symptom reduction or removal, or improving one’s interpersonal relationships, or perhaps aid in contending with a major life transition (divorce, death, disability, custody of children, for example). Some psychotherapies aspire to some variation on Maslow’s concept of “self­actualization” (Daniels 1982). Some therapies address ambitiously one’s goals or purposes in living, and this task brings us closer to ethics proper, as psychotherapy starts to address what might be called “visions of the good.” The bioethicist H. Tristram Engelhardt Jr., in a memorable essay “Psychotherapy as Meta-­Ethics” (Engelhardt 1973) linked psychotherapy explicitly to a discussion between therapist and patient about what “the good” is for the patient, and the patient’s particulars of the “the good,” and derivatively, how patients might secure “the good” for themselves. The shared process of agreeing on the “what and how” of the therapy at hand, but also on what this “what and how” in the end will result in, has also recently been linked to aspects of deliberate practice (Gaab et al. 2020) and the ethical obligations of therapists (Trachsel and Gaab 2016). Edmund Pellegrino’s account of “medical morality” describes the ethical core of medical caregiving as “helping, healing, caring, curing” (Pellegrino 1999); a fourfold of moral action that would seem to apply equally to most any brand of psychotherapy. As Miranda Fricker (2007) and Nancy Potter (2016) remind us, even the idea of gaining knowledge about a patient requires uptake, gaining knowledge with the patient—another ethical imperative. From this perspective, psychotherapy seems to share many affinities with philosophy, though the psychotherapy field has only occasionally embraced its overlap with philosophical inquiry. From this standpoint of psychotherapy as saturated with ethics and moralities, having an Oxford Handbook of Psychotherapy Ethics seems a necessity in a contemporary world where visions of the good seem up for grabs; subject to whomever shouts the loudest and the most often. The quiet exchanges behind (typically) closed doors, which consider what the good is for the patient, what it means, and how to secure it, seem more crucial than ever.

Goals of the Oxford Handbook of Psychotherapy Ethics Recognizing the diversity of the psychotherapy field, we set out to develop a reference textbook that would reflect the state of the field under the ethics lens. This proved to be challenging. We had some “models” of related texts to work from, notably the Oxford Handbook of Psychiatric Ethics (Sadler et al. 2015), but early on in our process we recognized the substantive differences offered by the psychotherapy field. Among these was the ­diversity

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6   Why Ethics Matter in Psychotherapy of theories, practical approaches, settings for care, assumed and explicit values, and the breadth of professionals offering these services. Commentators on the psychotherapy field often say the number of therapies number in the hundreds, so we recognized early on that some substantive choices had to be made. Even with these choices, we have produced a large and diverse volume. Some of our key limiting decisions were about what not to include. In large part, we decided against including “nonclinical” healing practices, from alternative medicine approaches, educational approaches like school and vocational counseling, to folk or nonmedical healing practices like acupuncture, traditional Chinese medicine, shamanic healing, and the like. While these practices may share many features with the psychotherapies proper, we thought they were too far away from what the public and professionals think of and identify as “psychotherapy.” Moreover, to the degree that Western countries regulate professional practices, we want to stick with healing practices that most laws would recognize as “psychotherapy.” That said, we were very open to exploring the diversity of psychotherapy practices, beyond theory and technique, and include a diversity of therapeutic settings and contexts of treatment. We were also agnostic about psychotherapists’ professional identities (psychologist, psychiatrist, social worker, licensed counselor, etc.) and hope this volume is of diverse professional interest to those practicing, learning about, and receiving, psychotherapy. Like all people, our authors and readers have intersectional identities, and we wanted to recognize this diversity in the contents and particulars of our chapters. Moreover, psychotherapy is embedded in our institutions and practices, so inclusion of research considerations, psychotherapy education and training, cultural considerations, religious perspectives, and related sociolegal contexts appear throughout our chapters. While limited to the English language, we wanted our contributors and audience to be as international as possible, as well. Like the now-­many editions in the remarkable Oxford Handbook series, we wanted to embrace the ethos for our chapters to be both state-­of-­the-­art resources on each of their topics, while also aiming to push the issues forward by exploring emerging ideas, research, practices, and, of course, ethical concerns. With these considerations in mind, we state the goals of the Oxford Handbook of Psychotherapy Ethics as (1) provide the most comprehensive reference textbook of psychotherapy ethics; (2) offer benchmark chapters as go-­to guides for a wide variety of practitioners, scholars, policymakers, and patient/clients; (3) offer English-­language discussions of international interest and relevance; (4) address conceptual, theoretical, philosophical, cultural, and religious perspectives while also addressing everyday practice concerns; (5) identify areas of ethical consensus and convention, while identifying unresolved issues as well as identifying new, problematic areas needing further analysis and research; and (6) promote creative, practical problem-­solving for the manifold ethical concerns faced by psychotherapists.

Organizational Features of the Oxford Handbook of Psychotherapy Ethics We are pleased to announce, as a premier organizational feature of the Oxford Handbook of Psychotherapy Ethics the offering of this reference text in two formats: as a standard printed

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Organizational Features   7 volume as well as the option of online purchasing of individual chapters on Oxford Handbooks Online (https://www.oxfordhandbooks.com/). This feature, now shared by the corpus of the Oxford Handbooks series, enables individual purchasers, such as students, to buy only what they need, without the requirement of buying the complete printed volume. In addition to the decisions the Editors had to make about what subject matter to include and not include, we also had to organize our 68 chapters into some practical order. In addition to a standard chapter/title/author Table of Contents in the front matter, we have also provided a Detailed Table of Contents which supplies the abstracts for each chapter. As users of reference books, we like a Detailed Table of Contents to help us determine the focus and more details about the chapter’s content than that permitted by a standard table of contents. Moreover, users in library or institutional settings can survey the whole reference text in a single sitting, aiding in determining what particular elements of the book are of most interest. Psychotherapy, because of its personal, interactional character, poses dual foci in providing introductory material. Section I, our Background and Historical Context lead-­off section, addresses these aspects from several vantage points: what moral and ethical “contents” exist in psychotherapy practices, how psychotherapy ethics fit into the larger context of professional ethics, and how the special interpersonal character of the healing encounter figures into the development of psychotherapy practice and ethics. Section II, Concepts and Theories for Psychotherapy Ethics provides a logical next step in the development of the book’s material. These chapters introduce technical and philosophical concepts and frameworks for psychotherapy ethics, as well as the corresponding or­gan­ i­za­tional schemata for psychotherapies themselves. These features of structural ideas, underlying intellectual traditions, and nomenclature provide a background for the more specific considerations of chapters to follow. For Section III, chapters that address ethical concerns shared by many, perhaps most, psychotherapy orientations and practices, provide detailed overviews of topics of prevailing interest in the field. Some of these chapters are familiar topics: informed consent, what and how much to disclose in psychotherapy informed consent, dual/multiple relationship ethics, privacy and confidentiality, business ethics, and others will be familiar to most therapists with even a passing interest in the ethics of the field, though this seeming familiarity will surprise readers as real controversies are contained therein. Other chapters in this section break new ground with novel, even perhaps uniquely first-­time discussion of ethics issues in psychotherapy. These chapters address topics such as the role and status of science in framing psychotherapy ethics; explorations of the question of imposing therapist values upon patients, considerations of psychotherapy “side effects” and treatment futility, the meaning of expertise in psychotherapy, and the puzzles surrounding the notion of placebo and nocebo in the context of understanding psychotherapeutic process. In keeping with the Oxford Handbook ethos, this section reflects vividly the demand for both the state-­of-­the-­art and the cutting-­edge of inquiry into psychotherapy ethics. Section IV addresses ethical issues in psychotherapies which are relatively specific to the particular theoretical framework, practice standards, and practical contexts of treatment. In addition to the mainstays of psychodynamic/psychoanalytic psychotherapy, cognitive­behavioral therapy, existential/humanistic therapy, and family/systems therapy, the section also features chapters on newer approaches such as mindfulness approaches, emotion­focused therapy, and the challenges of psychotherapy “integration.” The largest section by number of chapters, Section V explores ethics issues in particular populations of patients/clients and settings or contexts of care. Psychotherapy formats such

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8   Why Ethics Matter in Psychotherapy as family/couple and group therapy are considered, as well as specific populations like children and adolescents, elderly, and forensic populations. Regarding the latter, the differences of forensic settings matter, as we have separate chapters on therapy in prison settings with high-­risk offenders, as well as settings where outpatient therapy is court-­ordered. Topical concerns about racial, gender, language, and religious discrimination are considered in topical chapters and an “intersectionality” chapter, while emerging challenges associated with our digital era are considered: online therapy, therapy “apps,” and social media issues. Unique challenges related to special therapy modalities and additional unique populations are also offered. Section VI concludes the volume through considerations of training, research, and quality assurance. The ethical issues of psychotherapy training are broadly considered in multiple chapters in this section, from the character virtues required in providing care in a multicultural clinic, to professional codes of conduct, standards of conduct, and the hand­ling of misconduct. The cultural trappings of psychotherapy ethics are also explored, through chapters on film and literature. The last chapter of the volume deals with the ethical conduct of psychotherapy research. For the remainder of this introductory chapter, we next sketch out each of the Handbook’s sections in more detail, and their individual chapters therein.

Summary Reflections on the Sections of the Oxford Handbook of Psychotherapy Ethics Section I: Background and Historical Context For Section I, we wanted to provide a psychotherapy-­specific enough historical background, balancing cultural and ethical detail against a bird’s-­eye view survey of the development of psychotherapy ethics proper. We are convinced that the three chapters to follow accomplish this multifaceted task. In Chapter 2, “A Brief Moral History of Psychotherapy,” Alan Tjeltveit provides a study of the moral aspects of psychotherapy; both the development of moral/ethical awareness in the field, and the differentiation of the complex and numerous moral themes which has developed over its relatively short history. In the next chapter on “What Do Psychotherapists Need to Know about the History of Professional Ethics?” (Chapter 3), Carole Sinclair, in her respective historical perspective, approaches the ethical/moral development of psychotherapy from a different perspective, that of the social development of the “professional.” She summarizes the historical expectations of the professions, considers the appearance of ethics guidance as part of the reaction to public accusations of self-­serving “guild” interests, and concludes by examining the elements of professional ethics as they pertain to psychotherapy practices. In Chapter 4, “The History and Ethics of the Therapeutic Relationship”, Ulrich Koch and Kelso Cratsley take a third, equally complementary perspective through examining psychotherapy ethics from a history and ethics of the therapeutic relationship. They divide this

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summary reflections on the sections   9 territory into three aspects of the therapeutic relationship: the relationship as method, as skill, and as foundation. This framework usefully points to substantive differences in how different psychotherapy theories and practices frame and respond to ethics issues—motifs that reappear throughout the rest of the Oxford Handbook of Psychotherapy Ethics. Given the diversity and heterodoxy of psychotherapy theory and practice, we shouldn’t be surprised that a “moral history of psychotherapy” discussed by Tjeltveit in Chapter 2 offers very broad perspectives, punctuated by pools of historical moments, moral standpoints, and social contexts. Tjeltveit begins by exploring what “the moral” means in the psychotherapy context, connecting, most broadly, “the moral” to psychotherapy’s propensity to address what is good, or not good, in people’s lives. This reference to good/not good doesn’t refer to the client’s character, but to the character of the problems the client brings to the therapist. The moral character of such problems, in the process of therapy, may be revealed to harbor positive as well as negative values to the client, and the sorting out of these meanings often constitutes the process of the work, either explicitly or by implication. In addressing the crucial role of social context in ethically good psychotherapy, Tjeltveit emphasizes that what are today’s, or this community’s, ethical standards may not be the same as tomorrow’s. He links an aim of professional ethics guidance at the avoidance of imposing provincial values on clients, and notes that as social mores change, so do ethics guidelines. He notes, however, that social norms vary across communities in the cultural moment, requiring an awareness of the intersectionalities of the clients. So, ethics guidance has its own limits, and can be silent, even cruel to communities who hold different sets of values and norms. This concern with heterogeneity of our clients and their multiple cultural identities digs into the cultural and therapeutic conceptions of morality itself. Moral commitments can lead to interpersonal struggles, and when writ large, we can witness the corruption of morality into mass conflict and even war. Additionally, “helping” the other has increasingly provoked worry about helping as an imposition of power and control over the oppressed, provoking therapists to seek naïve reassurance in scientific objectivity in dodging value-­laden thinking and moral directedness. Tjeltveit highlights an apt message from Martin Luther King, that some personal distresses should never be accommodated or adapted to. The heterogeneity of clients/patients provokes Tjeltveit to consider the beginnings of “psychotherapy” as a field. Addressing the oft-­held belief that Freud’s psychoanalysis marked the beginning of psychotherapy, Tjeltveit describes the diverse communities, traditions, cultural approaches, and clinical and nonclinical practices which have a claim on contributing to the contemporary notion of psychotherapy. From these diverse origins and influences, Tjeltveit brings the discussion full circle to psychotherapy’s contemporary efforts to respond to diverse cultural mores, perception, and identities in ethically credible ways. In the introductory paragraphs of her contribution (Chapter 3), Sinclair argues that ethical psychotherapists should reflect multiple aspects of the regulatory moral mission of the professions: they should be able to follow the “rules” issued by their colleagues through formal ethics guidance, they should be conversant in ethics principles and values, they should be capable of basic analysis of ethics problems or dilemmas, and should cultivate a virtuous character suitable to the field’s demands. This, we think, is a salutary but a weighty order, as the breadth and depth of this Oxford Handbook of Psychotherapy Ethics attests through its bulk. Sinclair traces the prolegomena of contemporary ethics guidance from ancient times, often finding the fundamentals of contemporary clinical ethics to be

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10   Why Ethics Matter in Psychotherapy millennia-­old: maximizing benefit, reducing harm, practicing within the bounds of competence, the principle of confidentiality, the primacy of the patient’s interests, the importance of high moral character, and the guiding role of communities of practitioners, to mention a few. True “professional” ethics were much later phenomena as both clinicians and intellectuals articulated the social roles and expectations of clinical professionals in the nineteenth century. As Sinclair notes, a key “social” role was ethics rules, both to discourage self-­interested cronyism and guild-­building, but also to promote a higher, virtuous, burden of service to others within the clinical fields. Just as a crystallized, mature notion of “psychotherapy” was a late-­appearing feature of clinical therapies, so did the professional ethics codes for psychotherapy appear later in its history. (Indeed, as several chapters in this volume illustrate, professional ethics codes for some psychotherapy practices are still yet to be written and promulgated.) She concludes her chapter through examining the growth of psychotherapy-­ethics literature in more recent decades, noting the dual functions of enforcing a professional-­individual responsibility, but also respecting the connections and relationships which not only bind therapist and patient, but the centrality of connectedness to the contemporary vision of being human. Sinclair’s concluding focus on the importance of relationships provides a natural transition to Koch and Cratsley’s chapter (Chapter 4), which is centered upon the development of therapeutic relationships in psychotherapy’s history as well as the ethical implications of these formulations of the role of relationships in the field. In considering the psychotherapy relationship as “method,” the authors acknowledge that a caring relationship with a well­meaning, involved Other has manifested healing through many traditions. In describing the development of psychoanalysis and related therapies, the relationship itself becomes the space of care delivery as well as theoretical elaborations. The neutral therapeutic space of analysis and adjustment within the psychoanalytic dyad, however, was to be challenged and ultimately expanded with the post-­World War II realizations that many social conditions, as the Martin Luther King reference previously noted, couldn’t be accommodated or morally accepted, and a new social psychiatry began to interact with psychoanalytic psychiatry. Koch and Cratsley note that growing awareness of therapeutic abuses and power differences between therapists and patients in the mid-­twentieth century forward both shifted and exploded psychotherapy practices—shifted in the sense that different, less power­imbalanced collaborations, or “therapeutic alliances” were needed, and expanded in the sense that multiple ways of building alliances required new skills to be developed, tested, and refined. This shift and expansion they describe as through the development of new modalities of therapy, from Rogerian client-­centered therapy to cognitive-­behavior therapy and beyond. However, the focus on skills did not dissolve the problem of values: what are the endpoints for a “better” life? Moving on to the therapeutic relationship as “foundation,” the authors consider the late­twentieth century social trends towards greater empirical accountability in medicine broadly and psychotherapy particularly, leading to growing studies of psychotherapy efficacy, and greater demands on parsimony, efficiency, and economy, as healthcare payers increasingly demanded more for their money. For the authors, these social and economic conditions provoked increasing interest in not just efficacy studies, but in identifying scientifically the crucial, indispensable ingredients in effective psychotherapy—the “foundations.” The flagship trend marking this social interest was the common-­factors “movement” which sought and continues to seek the necessary and sufficient conditions for effective

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summary reflections on the sections   11 therapy, thereby challenging the loyalties of practitioners of the “brands” or “theoretical orientations” of psychotherapy (e.g., psychodynamic, cognitive-­behavioral, family systems, etc.). This debate continues to the present and in the pages of the Oxford Handbook of Psychotherapy Ethics.

Section II: Concepts and Theories for Psychotherapy Ethics Psychotherapy ethics is a highly diverse field, for various reasons: therapeutic approaches differ significantly, as well as the worldviews and theoretical commitments of providers, the role of different forms of psychotherapy in healthcare systems and the patient groups seeking help. This diversity is part of the fascination of exploring ethical issues in psychotherapy. At the same time, the heterogeneity of the field renders careful, scholarly reflections of the conceptual and theoretical bases of psychotherapy particularly important and demanding. This is what the section on “Concepts and Theories for Psychotherapy Ethics” has set out to offer. Autonomy is a core value in modern medicine. Patients increasingly wish to gauge the benefits and the risks, burden and cost of interventions themselves, rather than being steered through a healthcare system. This means providers are not only the experts delivering a diagnosis or a therapy but are expected to counsel patients about available options and coach them in order to being able to make informed decisions that correspond with their values, preferences, and priorities. Paul Biegler’s contribution on “Autonomy as a Goal of Psychotherapy” (Chapter 5) emphasizes the important role of psychotherapy in enhancing patients’ autonomy while pointing to some of the pitfalls in clinical practice including inadequate disclosure of information and the use of coercion. The flipside of autonomy is paternalism. A long-­standing debate in medical ethics asks what an appropriate role for paternalism might be. Concepts such as the therapeutic ­privilege—the provider decides what to tell the patient—seem to be outdated and clearly contradicting patient rights. Yet matters become more complicated as we move closer to clinical practice. In “Patient Protection and Paternalism in Psychotherapy” (Chapter 6), Marco Annoni critically investigates the complexities of paternalistic practices in psychotherapy with a focus on involuntary hospitalization to protect patients from self-­harm. The tension of protecting patients while respecting their autonomy puts high demands on the professional. It also invites reflections on the virtues and capacities that are required in order to make wise, well-­justified decisions that form the basis of client trust and a high-­quality therapeutic relationship. Building on Carl Rogers’s work, Jeffrey H. D. Cornelius-­White and Gillian Proctor set out to explore relevant therapist attitudes in their chapter on “Empathy, Honesty, and Integrity in the Therapist: A Person-­Centered Perspective” (Chapter 7). Beyond respecting autonomy, avoiding harm and promoting the well-­being of patients, justice considerations play an important role in bioethics, and psychotherapy ethics is certainly no exception in that regard. Access to treatment is a key issue for many patients and providers. Marta Herschkopf ’s and Rebecca Brendel’s chapter on “Fairness, Justice, and Economical Thinking in Psychotherapy” (Chapter 8) explores different theories of justice— Rawlsian, capabilities, utilitarian, and communitarian approaches—that bear on the challenge of fair resource allocation for psychotherapy and other (mental) health services. In “Ethics of Care Approaches in Psychotherapy” (Chapter 9), Anna Elsner and Vanessa Rampton draw the reader’s attention again to the relational aspects of patient and care

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12   Why Ethics Matter in Psychotherapy provider. Whereas a lot of theorizing around justice tries to abstract from the particular features of individual cases, context is key from an ethics of care perspective. Perceiving and responding to needs while not neglecting self-­care is a moral challenge that is not only in the forefront of ethics of care considerations but also shapes the everyday experience of therapists. The chapter shows how the ethics of care, with its reflections on attentiveness and empathetic concern and psychotherapy, with its long-­standing engagement with relationships and intersubjectivity, can mutually serve as a source of insight and inspiration. The following contribution spirals back to reflections on the concept of autonomy but involves a relational perspective. In their contribution, Susana Lampley and John Z. Sadler (Chapter 10) are concerned with “Legitimate and Illegitimate Imposition of Therapists’ Values on Patients.” In psychotherapy like in other fields of clinical practice the obvious consensus seems to be that care providers should not impose their values on their patients. However, a closer look reveals that imposing values may sometimes be hard to avoid and might, under certain conditions, in fact be ethically justifiable. Using a casuistic approach, the chapter sensitizes readers to the ambiguities in psychotherapeutic practice and outlines an approach that can help distinguish justified and unjustified value impositions. Another theoretical orientation of particular interest to psychotherapy is explored by Michael Laney and Adam Brenner in their chapter on “Virtue Ethics in Psychotherapy” (Chapter 11). The role of concepts such as empathy, attentiveness, and integrity has already been emphasized by other contributions to this volume. Virtue ethics provides an opportunity to focus at a still more general level on the attitudes and actions that characterize a good psychotherapist. As has become apparent, ethical issues of psychotherapy can be studied through many lenses, which are partly complementary and partly compete with each other. But how do psychotherapists and patients actually solve moral issues? This question is further explored in Chapter 12 by Eleanor Gilmore-­Szott and Thomas Cunningham called “How Do People Make Moral Medical Decisions?” A good grasp of how decision making is taking place and how it may fall short of what may be required based on theoretical deliberations is key to assuring that conceptual reflections in psychotherapy ethics have practical relevance and impact. Yet another lens is provided by Alexander Noyon and Thomas Heidenreich in their contribution on “Existential Philosophy and Psychotherapy Ethics” (Chapter 13). Introducing the reader to central concepts of existential philosophy—phenomenology, authenticity, paradoxes, isolation, and freedom vs. destiny—the chapter sets out to delineate the unique benefits an existentialist approach with its focus on individuality, the search for an authentic life and acceptance of paradoxes can bring to psychotherapy. The chapter on “Phenomenological-­Hermeneutic Resources for an Ethics of Psychother­ apeutic Care” (Chapter 14) by Giovanni Stanghellini, presents the reader with a further set of concepts that can enrich psychotherapeutic care: dialogue, attunement, recognition, and intimacy. The concepts are explained and examined with a view to their practical relevance for the patient–provider encounter. Rather than presenting simple instructions on how to behave morally, this approach invites psychotherapists to reflect on their practice in a more ample way. A concept that has been of central importance to philosophy but also to psychotherapy is free will. Adopting a compatibilist approach that integrates freedom of the will and determinism, in Chapter 15 entitled “Free Will, Responsibility, and Blame in Psychotherapy,”

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summary reflections on the sections   13 Tobias Zürcher outlines the ramifications for psychotherapeutic practice, in particular for the ascription of responsibility and the role of blame in the interaction between provider and patient. Finally, human dignity, the last concept to be discussed within this section, is explored by Roberto Andorno in his chapter on “Dignity in Psychotherapy Ethics” (Chapter 16). The concept of human dignity is mainly anchored in deontological theories and plays a pivotal role in Kantian ethics. According to a Kantian notion of human dignity, all humans have an infinite value, by virtue of belonging to the human species. The inviolability of human dignity and the duty of respect that follows may serve as an important reminder when dealing with patients who are severely compromised. Patient self-­determination, the right to privacy, and the clear rejection of exploitative interactions are among the central tenets that can be deduced from dignity-­based moral theory. The concepts and theories presented in Section II are not exhaustive but aim to unfold the wealth of perspectives and approaches that can explored as resources to address the multifaceted and frequently complex ethical challenges posed by psychotherapy.

Section III: Common Ethical Challenges in Psychotherapy The aim of Section III of the Handbook is to provide a collection of chapters dealing with topics often related to ethical challenges which pertain to all of the various approaches or formats of psychotherapy. These topics include informed consent, shared decision making, consensus on therapy goals, the therapeutic alliance, the evidence and science of talk-­based healing practices as well as patient information about clinical effectiveness, side effects, placebos, and nocebos in psychotherapy, privacy, confidentiality, dual and multiple relationships, therapist self-­disclosure, and the selection of modalities and formats. In “The Ethics of Informed Consent for Psychotherapy” (Chapter 17), Alastair McKean, Manuel Trachsel, and Paul E. Croarkin discuss informed consent as integral to the ethical practice of psychotherapy. Historically going back to the very beginnings of psychotherapy but still less established than in somatic medicine, informed consent is now increasingly acknowledged not only as a legal but also as an ethical prerequisite of psychotherapy. In their chapter, the authors argue for the ethical importance of informed consent by showing its summary relation to several principles of biomedical ethics: informed consent is an expression of respecting the patients’ autonomy and their right to self-­determination, it informs patients of potential benefits and harms that may arise in the treatment, and it provides a foundation for the formulation of joint treatment goals and the development of a strong therapeutic alliance. The authors further discuss the fact that despite its widely accepted importance, informed consent is both insufficiently and inconsistently implemented in psychotherapy for which one reason might be that many psychotherapists are not trained in traditional medical models of care, and thus, a medically based framework for informed consent may not be as familiar and appropriate for psychotherapy. However, this does not diminish the need for informed consent in psychotherapy but points to the necessity of adapting the informed consent process and content in order to meet specific challenges in psychotherapy and to facilitate implementation. The development of a therapeutic alliance and the importance of a consensus with regard to treatment goals mentioned as potential benefits of informed consent in Chapter 17 are

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14   Why Ethics Matter in Psychotherapy deepened and put in the context of shared decision making by Stella Reiter-­Theil and Charlotte Wetterauer in “Ethics of the Therapeutic Alliance, Shared Decision Making, and Consensus on Therapy Goals” (Chapter 18). The authors conclude that ethical questions around those three concepts often go unnoticed or remain implicit, and that explicitly discussing them—for example taking advantage of the still widely unknown format of Clinical Ethics Support (CES) services—may lead psychotherapists to acknowledging more complexity than expected. The following chapter picks “Evidence, Science, and Ethics in Talk-­Based Healing Practices” (Chapter 19) out as another general central theme of psychotherapy ethics. In this chapter, James Phillips and John Z. Sadler consider the role of knowledge and evidence in comparing and contrasting the ethics of nonclinical counseling (NCC) and mainstream mental healthcare as practiced by psychiatry, clinical psychology, and social work. The authors discuss three different NCC traditions which eschew diagnostic categorization and approach mental distress from different values, practices, and metaphysical standpoints— philosophical counseling, peer-­support services, and existential therapy. Framing their discussion by presenting six cases of ethically dubious conduct, the authors conclude that NCC practices are prone to errors of omission, e.g., not knowing what one does not know. While, according to the authors, mainstream mental health is also subject to these errors, the mainstream’s allegiance to evidence-­based practices leaves it prone to neglecting the crucial role of the clinician in dialogue with the patient. In the next chapter “Patient Information on Evidence and Clinical Effectiveness of Psychotherapy” (Chapter 20), Charlotte Blease, John M. Kelley, and Manuel Trachsel pursue one of the central themes of the previous chapter—scientific evidence—and focus on what information should be provided to patients about the evidence base supporting the clinical effectiveness of psychotherapy, e.g., whether patients should be provided with information on the relative importance of common factors versus specific factors as the causal agents of clinical improvement, or whether research on the relative efficacy of different forms of psychotherapy should be provided to patients. The authors 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. The following chapter, “Ethical Dimensions of Psychotherapy Side Effects” by Michael Linden (Chapter 21), broaches the issue of another general ethical question in psychotherapy: how to deal with psychotherapy side effects which are experienced by about 10 percent of psychotherapy patients? The author argues that because 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. Linden shows that this task requires value decisions and that there is a lack of generally accepted instruments and of guidelines on how to assess side effects. He concludes that psychotherapists should be aware of the possibility of side effects and adequately inform patients about this possibility. Two of the oldest but nevertheless not least important general ethical issues in psychotherapy are privacy and confidentiality. In their chapter on “Privacy and Confidentiality in Psychotherapy: Conceptual Background and Ethical Considerations in the Light of Clinical Challenges” (Chapter 22), Anke Maatz, Lena Schneller, and Paul Hoff situate privacy and confidentiality not only as central ethical and legal but also anthropological concepts for psychotherapy. In particular, the authors explore a unique significance that, it is argued,

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summary reflections on the sections   15 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. Potential ethical conflicts about privacy and confidentiality are then discussed by means of four case vignettes. The authors conclude their chapter by presenting some principles that can guide practitioners in responding to ethical conflicts about privacy and confidentiality in clinical practice. The chapter on “Dual and Multiple Relationships in Psychotherapy” (Chapter 23) by Kevin S. Doyle deals with a fundamental ethical obligation of all helping professions: maintaining appropriate boundaries with patients. Doyle shows that dual relationships or multiple relationships—i.e., holding more than one relationship with a past or current patient—can be ethically challenging at a minimum and highly unethical in certain circumstances. The author explores some of the common issues relating to dual relationships or multiple relationships and suggests how psychotherapists can frame the appropriate and the inappropriate. The chapter concludes by considerations on how professionals are able to balance the goal of avoiding inappropriate relationships with the goal of maintaining access to services in situations such as those posed by rural areas. A question which is crucial for every psychotherapist is the selection of a psychotherapy modality and format before formal treatment negotiation with a patient begins. This is a task inherently involving ethical and value considerations which John Z. Sadler discusses in his chapter “Ethics Considerations in Selecting Psychotherapy Modalities and Formats” (Chapter 24). The author 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. Thereby, Sadler suggests Karl Jaspers’s principles of clinical interpretation (hermeneutics) as a framework for the thinking process in making modality/format decisions. The author concludes that the interactions between the seven factors to consider in modality/format deliberations, clinical hermeneutics, and eight relevant clinician virtues he proposes combine to be a reasonable foundation for conscientious psychotherapy modality/format deliberations. In the next chapter on “Therapist Self-­Disclosure” (Chapter 25), Jeffrey E. Barnett illustrates different types of psychotherapist self-­disclosure—a widely-­used psychotherapeutic technique—and their potential value and benefits to clients and to the psychotherapy proc­ ess. The author then examines self-­disclosure as a boundary issue and addresses ethical issues relevant to its application. The chapter provides illustrative examples and suggests a decision-­making framework to assist psychotherapists in utilizing self-­disclosure with clients in an ethically appropriate and clinically effective way. The following chapter deals with concepts traditionally associated with somatic medicine and medical research: placebo and nocebo. However, in their chapter Jens Gaab, Cosima Locher, and Manuel Trachsel discuss “Placebo and Nocebo in Psychotherapy” (Chapter 26). Although there is empirical proof about psychotherapy as an effective intervention for many psychological problems and disorders, there is an ongoing debate about the mechanisms underlying these often overestimated effects, reaching back to the very origins of psychotherapy research. This “great psychotherapy debate” poses an ethical challenge for both psychotherapists and psychotherapy scholars, because even though patients can be provided with possible and expectable benefits, costs, and strains of a psychotherapy, the situation becomes more complex with regard to the specific mechanisms of change. In their

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16   Why Ethics Matter in Psychotherapy chapter, the authors discuss psychotherapy scholars’ strivings and troubles for specificity, touch the uncomfortable relationship with placebo and nocebo, and conclude with an ethical plea for transparency in psychotherapy and of psychotherapists. In most countries, psychotherapy is mainly practiced in private practice. Anna E. Brandon shows in her chapter “The Business of Psychotherapy in Private Practice” (Chapter 27) that this setting particularly requires navigating ethical professionalism alongside personal needs and values because psychotherapists are confronted with factors less relevant for professionals working in public institutions such as advertising, marketing, self-­promotion, and the setting/collecting of fees. The author discusses potentially resulting angst by challenging the altruistic values that likely influenced the choice of psychotherapy as a profession, and the particular challenges of self-­promotion and marketing via social media. A further focus of the chapter is the exchange of money which impacts the client–psychotherapist relationship and the resulting challenge of direct communication about fees to initiate. The next chapter by Joelle Robertson-­Preidler, Nikola Biller-­Andorno, and Tricia Johnson deals with another superordinated topic independent of the various approaches and formats of psychotherapy: the “Impact of Mental Health Care Funding and Reimbursement Systems on Access to Psychotherapy” (Chapter 28). The chapter’s focus is on distributive justice principles which can help guide health systems to fairly allocate scarce resources in healthcare systems in which priorities have to be set and trade-­offs navigated in how they choose to fund different services. The authors show that in most countries, mental health care and psychotherapy tend to be under-­prioritized despite the empirically proven effectiveness of psychotherapy for many mental disorders. The authors conclude that although distribution priorities and values may differ among countries, fair and transparent proc­esses involving all key stakeholders are vital for creating ethical funding systems that support appropriate access to psychotherapy. Another topic which has been discussed in medical ethics for decades but is still underexposed in psychotherapy ethics and only recently has a small body of work focused primarily on anorexia nervosa and schizophrenia is futility. In her chapter on “Psychotherapeutic Futility” (Chapter 29), Cynthia Geppert offers an exploratory investigation of the meaning of the concept of futility in the practice of psychotherapy. Her exploration starts with a tracing of the intellectual history of the concept and a review of attempts to develop definitions and typologies of futility. It continues with an outline of the fundamental ethical arguments debated in the medical futility literature with reference to anorexia nervosa. The author then examines the medical, philosophical, legal, and ethical critiques of the idea of futility and its use in medicine and finally applies the ethical principles and values inherent in the debate to psychotherapy. Related to the topic of the previous chapter, the following contribution on “The Moral Significance of Recovery” (Chapter 30) by Larry Davidson deals with the situation where a person loses the sense of self. This problem had been long associated with psychosis but the author stresses that preserving and helping to reconstruct the person’s sense of personhood becomes a primary objective, and ethical imperative, of the psychotherapeutic relationship. Davidson argues that 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. A particular approach of the chapter is that the author discusses the African concept of Ubuntu and argues that psychotherapy for psychosis should embody an appreciation of how persons only become persons

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summary reflections on the sections   17 through other people. The chapter concludes by describing 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. Another general ethical challenge in psychotherapy which pertains to almost all of its various approaches and formats, is the question of which ethical considerations can guide a therapist’s personal and professional use of social media. In her chapter on “Social Media Ethics for the Professional Psychotherapist” (Chapter 31), Kristi Pikiewicz explores the specific boundaries with regard to the use of social media and best practices for the patient– therapist relationship, along with privacy concerns in both directions, and the termination of this relationship. Pikiewicz concludes that personal competency of psychotherapists in the use of social media can serve both to avoid detrimental entanglements and to enhance progress toward therapeutic goals. In the next contribution on the “Relationship between Religion, Spirituality, and Psychotherapy: An Ethical Perspective” (Chapter 32), Thomas G. Plante starts with pointing out that spirituality and religion are typically important elements of most people’s lives which offer an overarching framework for making sense of the world, a strategy to cope with life’s stressors, and a community and a way to wrestle with life’s biggest questions regarding meaning, purpose, and suffering. The author points out that the codes of ethical conduct of many mental health professionals typically understand religion and spirituality as a multiculturalism issue. Plante shows that numerous resources are available to help professionals develop and maintain their skills in ethically minded clinical practice with spiritual and religious clients. In the last chapter of this section “Ethics and Expert Authority in the Patient– Psychotherapist Relationship” (Chapter 33), Laura Guidry-­Grimes and Jamie Carlin Watson broach the issue of a central statement by the consumer/survivor/ex-­patient movement that individuals diagnosed with mental health conditions are routinely doubted or dismissed when they make claims about their needs, values, and interests, and that many therapists take a parentalist stance toward their patients. The authors discuss the literature on so-­called patient experts, i.e., that some patients can acquire competence with their medical condition sufficient for sophisticated participation in management of their care and benefit from shared decision making. Guidry-­Grimes and Watson come to the conclusion that attitudes of distrust and protectionism by psychotherapists can lead to the moral failure of epistemic injustice harming both the patient and the therapeutic relationship, and they contend that the success of shared decision making relies largely on the therapist’s appreciation of the varying types and degrees of expertise and epistemic advantage involved in decision making.

Section IV: Ethical Issues within Specific Psychotherapy Modalities and Formats Although the topic at hand—psychotherapy—is generally understood as a single entity and even though there is little evidence for differential effects or mediators, psychotherapy has always been marked by distinct schools of thought. The consequential rivalry and dissent between proponents of different schools of psychotherapy—which may well be a constant in psychotherapy’s history and development—have been driven by philosophical and theoretical assumptions and considerations (or differences thereof), and more recently, the move

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18   Why Ethics Matter in Psychotherapy toward evidence-­based treatments has substantially added empirical, financial, and also societal dimensions to this debate. Data leads to funding (and vice versa) and to predominance in scientific and public recognition. This can be traced down to a strong increase in NIMH funding of randomized trials of specific treatments since the 1980s and the rise of so-­called Empirically Validated Therapies (APA Task Force on Promotion and Dissemination of Psychological Procedures 1995), which in retrospect has been seen as “a research program [that] was extremely discouraging, scientifically speaking [as] a focus on syndromes never seemed to lead to conclusive evidence on etiology, course, and response to treatment” (cited from Hofmann and Hayes 2019: 39) and which in the meantime showed a succession of increasingly modest denominations (i.e., Empirically Supported Treatments), down to the current “Psychological Treatments”1 and the turn toward equitable consideration of clinical expertise, patient characteristics, and empirical evidence for good outcome (APA Presidential Task Force on Evidence-­Based Practice 2006). Nevertheless, and in anticipation of the already-­proposed “decline of named therapies” and “of general schools” to come into effect (cited from Hofmann and Hayes 2019: 43), psychotherapy is divided into psychotherapies, of ever-­increasing number (Wikipedia currently lists 173 psychotherapies,2 and the more empirically founded APA Division 12 “Psychological Treatments” lists 86 psychotherapies3). This diversity might be seen as counter-­intuitive or even counter-­productive with regard to the outcome of psychotherapy research, but it might also be seen as a welcomed diversity in how psychological problems and disorders can be approached. Thus, this acknowledgment of diversity might not only stimulate a more inclusive understanding and approach in both research and clinical practice, but also maximize client and patient choice among effective alternative interventions. Section IV encompasses ethical considerations with regard to specific psychotherapy approaches, considering all major schools of thought, i.e., cognitive-­behavioral therapy (Chapter 34), psychoanalytic and psychodynamic psychotherapy (Chapter 35), systemic psychotherapy (Chapter 36), humanistic and experiential therapies (Chapters 37 and 38) as well as so-­called third-­wave therapies (Chapter 39). Each chapter adds different foci on different aspects. In the context of cognitive-­behavioral therapy, Sahanika Ratnayake and Christopher Poppe reason in “Ethical Issues in Cognitive-­Behavioral Therapy” (Chapter 34) that therapists are not fully equipped to evaluate failures of epistemic and practical rationality, and thus, run the risk of being unaware of being implicitly value laden in their work with clients. Furthermore, the authors address the caveats of informed consent in exposure-­based therapies, which for this approach often is seen as something which can be achieved in the process of therapy. Instead, Ratnayake and Poppe argue that patients need to be informed upfront and that the mismatch between first- and second-­order preferences, i.e., not to experience distress during exposure vs. the aim to live without phobic fears, should be tackled actively. The importance of ethics in the clinical process is also exemplified by Robert P. Drozek in his chapter “Ethical Processes in Psychoanalysis and Psychodynamic Psychotherapy” (Chapter 35). Here, psychoanalytical concepts and cornerstones of the analytical process are 1  https://div12.org/psychological-­treatments/ 2 https://en.wikipedia.org/wiki/List_of_psychotherapies 3  https://div12.org/psychological-­treatments/

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summary reflections on the sections   19 shown to be the focus of ethical considerations and how this focus has influenced the ­shaping of analytic and psychodynamic theory and practice. In Chapter 36 on “Ethical Issues in Systemic Psychotherapy,” Andreas Fryszer and Rainer Schwing exemplify the ethical codes in systemic therapy in the light of cultural, legal, and theoretical perspectives and provide an overview of ethical guidelines for the process and the practice of systemic psychotherapy. The possible “Ethical Issues in Existential-­Humanistic Psychotherapy” are then clearly outlined by Orah T. Krug and Troy Piwowarski in Chapter 37. With their perspective on a humanistic healing model—instead of a medical treatment model with a clear focus on diagnosis and treatment of symptoms—clinical practice not only is governed by ethical values, but also more challenging ethically as there are not predefined methods or techniques to be adhered to or followed. Thus, the authors describe four ethical principles upon which the clinical process is based. Turning to a more focused therapy—emotion-­focused, to be precise—Ueli Kramer and Robert Elliott show in “Ethical Considerations in Emotion-­Focused Therapy” (Chapter 38) how specific intervention principles are generally based on ethical obligations and how ethical conflicts, such as weighing possible benefits and risks and autonomy versus a structured therapy plan, are to be resumed in emotion-­focused therapy. Quite another problem is presented by Abigail Levin in Chapter 39 on “Ethical Considerations on Mindfulness-­Based Psychotherapeutic Interventions.” Here, mindfulness­based interventions, which have been adapted from Buddhist practices for the purpose of symptom relief, pose the problems of being appropriative from Buddhism as well as whether patients should be informed about its religious origins. To avoid this multiplicity of different perspectives from different schools of thought to become another example of the blind-­men-­and-­elephant parable, the last chapter on “Psychotherapy Integration as an Ethical Practice” by Martin grosse Holtforth, Juan Martin Gómez Penedo, Cosima Locher, Charlotte Blease, and Louis G. Castonguay (Chapter 40) defines four approaches for psychotherapy integration as well as postulates questions for the future of psychotherapy.

Section V: Ethical Challenges Involving Specific Settings and Populations One of the least controversial pillars of psychotherapy is that each person is complex and that their particular circumstances, such as race, gender, sexuality, socioeconomic status, language, place of origin, and cultural background play a crucial role in the kind of mental distress they experience and the response they develop. A skillful therapist grasps the uniqueness of their client and finds ways to enable and empower the individual to develop successful responses to their mental distress. The chapters in this section of the Handbook tackle a plethora of ethical issues emerging in diverse cultural settings. In “Identifying and Resolving Ethical Dilemmas in Group Psychotherapy” (Chapter 41), Virginia M. Brabender examines ethical issues in group psychotherapy, focusing specifically on therapist competence in tackling the group dynamics, confidentiality of each of the participants, evaluation of their progress, and the nature of dual relationships. The chapter

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20   Why Ethics Matter in Psychotherapy highlights that lack of knowledge and skills on the therapist’s part and various complex cognitive biases that the participants are subject to may serve as impediments to successful group psychotherapy. The author concludes with strategies to overcome these impediments. The next chapter, “Ethics in Couple and Family Psychotherapy” (Chapter 42) by Marcel Schaer and Célia Steinlin, underlines the complex dynamics of relationships and the interactions between family members during therapy sessions. The authors argue that the therapist must aim to maintain a balanced and trustful relationship with all individuals in the therapeutic context and do justice to their individual wishes and perspectives. Demonstrating that ethical guidelines developed by professional associations are not specific enough to address the ethical dilemmas that therapists encounter, the authors evaluate a number of scenarios using Beauchamp and Childress’s four principles of bioethics as a frame of reference. In “Ethical Challenges of Specific Settings and Populations: Psychotherapy with Children and Adolescents” (Chapter 43), Ashley S. Castro, Gerald P. Koocher, and Eric Peist focus on various ethical issues specific to providing psychotherapy for children and adolescents including competence, confidentiality, boundaries, use of specific therapeutic techniques, and attention to diversity. Emphasizing the shortcomings of traditional bioethical frameworks or risk management approaches, authors defend a relational approach in which therapists and clinicians pay attention to context, family dynamics, and culture. “Psychotherapy in Old Age: Ethical Issues” (Chapter 44) by Julian C. Hughes and Richard Cheston draws attention to challenges of psychotherapy for older clients who face aging related issues such as cognitive impairment and dementia. Arguing that utilitarianism, deontology, and virtue ethics have shortfalls in developing ethical guidelines, the authors call for more nuanced frameworks such as those emphasize narrative, communication, meaning making, and care. In “Ethical Considerations of Court-­ Ordered Outpatient Therapy” (Chapter 45), Josh E. Becker, Audrey Cecil, and Michael C. Gottlieb focus on the ethical challenges of providing court-­ordered psychotherapy to treat adolescents and adults for mental illnesses, substance use, and sex offenses. Because the clients do not voluntarily choose psychotherapy, this circumstance creates a number of ethical dilemmas regarding informed consent, potential loyalty conflicts, violations of confidentiality, and the risk of therapeutic ruptures that clinicians typically do not encounter on daily basis. Continuing with a similar theme in “Ethical Issues in the Psychotherapy of High Risk Offenders” (Chapter 46), Gwen Adshead discusses the ethical dilemmas that emerge in the psychotherapy of offenders who caused serious harm to others and who may be at risk of doing so again. Adshead examines the activities these offenders are expected to take part in that purportedly reduce the risk of harm and improve mental health. Exploring the ethical issues raised by the assumption that these activities will yield such benefits, the chapter concludes with a discussion of (a) autonomy and coercion, (b) welfare and outcomes, (c) justice, and (d) disclosure of risk and confidentiality. In “Beyond the Office Walls: Ethical Challenges of Home Treatment, and Other Out-­of­Office Therapies” (Chapter 47) Ofer Zur and Manuel Trachsel focus on the intricacies of psychotherapy occurring in out-­of-­office settings such as through home visits, outdoor or adventure therapy, and clinical interventions such as in vivo desensitization in the treatment of phobias. Examining ethical issues related to confidentiality, time, location, flexibility, complexity, unpredictability, and safety considerations, the authors provide suggestions for maintaining standards of care.

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summary reflections on the sections   21 The next chapter, “Common Ethical Issues Associated with Psychotherapy in Rural Areas” (Chapter 48) by Alysia Hoover-­Thompson, Brandon C. Bogle, and James L. Werth, Jr., highlights ethical issues related to providing psychotherapy in rural areas, with a specific focus on professional competence, confidentiality, and the presence of multiple relationships within these communities. The chapter reviews typical complications that arise by using sample dilemmas and providing solutions. In “Ethical Aspects of Online Psychotherapy” (Chapter 49) Julia Stoll and Manuel Trachsel examine the fast-­growing option to deliver mental health care online. By providing an overview of the different terminologies and definitions of online psychotherapy they juxtapose arguments in favor of online psychotherapy, e.g., increased access to care, improvement of treatment, anonymity, and cost effectiveness against those critical, e.g., impairment of treatment, confidentiality issues, issues with informed consent, patient identification, legal issues, and additional required skills. Continuing with the theme of the use of online technologies in psychotherapy, in the next chapter on “The Ethics of Artificial Intelligence in Psychotherapy” (Chapter 50) Tania Manriquez, Nikola Biller-­Andorno, and Manuel Trachsel evaluate the ethical issues involved in the use of artificial intelligence (AI) in psychotherapy. Specifically, the authors focus on the use of chatbots and AI tools as supplements to psychotherapy delivered by persons, concluding with an optimistic note that AI tools may help to establish caring relationships between therapist and patient, and thereby contribute to the therapeutic process. The next chapter turns the focus to the ethical issues surrounding the psychotherapy of patients who are themselves psychotherapists. In “Unique Ethical Dilemmas in Psychotherapy of Other Psychotherapists: Description, Considerations, and Ways of Coping” (Chapter 51), Gaby Shefler, Shai Lederman, and Refael Yonatan-­Leus argue that because the therapist serves both the role of a therapist and a colleague, a number of complex issues arise in the relationship between patient-­therapists and therapists. Therapists’ duty to care for the patient-­therapists and their duty to report patient-­therapists’ professional impairment and ethical violations may give rise to serious ethical burdens. The authors conclude that the therapist’s primary ethical duty is to the patient first and that reporting should only be considered a last resort. The chapter “Ethics of Psychotherapeutic Interventions in Palliative Care” (Chapter 52) by Mathieu Bernard, Sonia Krenz, and Ralf J. Jox looks at the ethical issues surrounding psychotherapy in palliative care. It focuses on the fundamental principles of bioethics, i.e., beneficence, nonmaleficence, respect for autonomy, and justice to evaluate ethical issues in the context of palliative psychotherapy. In “Ethical Psychotherapeutic Management of Patients with Medically Unexplained Symptoms: The Risk of Misdiagnosis and Harm” (Chapter 53), Diane O’Leary and Keith Geraghty examine the potential ethical risks involved in psychotherapeutic treatment of patients with medically unexplained symptoms (MUS). Starting with the ambiguities surrounding the notion of MUS, the authors argue that psychotherapists have a moral obligation to not confuse diagnostic uncertainty with psychological diagnosis of unexplained symptoms. The next chapter, “Psychotherapy in a Multicultural Society” (Chapter 54) by Jan Ilhan Kizilhan, focuses on the ethical issues surrounding the psychotherapeutic treatment of immigrants from family-­oriented societies by drawing attention to various generational and cultural conflicts, language barriers, and the different ways of understanding and coping with mental distress.

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22   Why Ethics Matter in Psychotherapy Following with the theme of cultural and language related conflicts, the next chapter, “Conducting Psychotherapy Through a Foreign Language Interpreter” (Chapter 55) by H. Russell Searight, draws attention to increased demand for foreign language interpreters in mental health settings where the addition of an interpreter to the therapist–patient dyad raises a number of ethical issues. Searight argues that psychotherapists must not assume that interpreters’ linguistic fluency extends to meeting the unique demands of mental health settings and must consider the relative risks and benefits of interpreter mediated psychotherapy. In “Ethical Issues in Working with LGBTQ+ Clients” (Chapter 56), Sheila Addison and Whit Ryan examine the complex interplay of ethical and clinical considerations in psychotherapy, research, and supervision with sexual and gender minority clients. With a survey of the ethical codes and “best practices” documents from mental health organizations throughout the Anglophone world, the authors explore topics such as clinical competence, nonmaleficence, non-­discrimination, confidentiality, and supervision through a feminist, queer lens. In “Intersectionality and Psychotherapy with an Eye to Clinical and Professional Ethics” (Chapter 57), Suryia Nayak highlights the importance of adopting intersectionality as a framework for psychotherapy in order to explicitly address the mutually constitutive relationship between social contexts of inequality and mental health. Nayak concludes this important analysis by arguing that the ethical contribution of intersectionality to psychotherapeutic approaches is the insistence that there is nothing neutral about the psychosocial experience of oppression. In “Ethics of Animal-­Assisted Psychotherapy” (Chapter 58), Karin Hediger, Herwig Grimm, and Andreas Aigner focus on the ethical issues surrounding our responsibilities toward therapy animals in the context of animal-­assisted psychotherapy. They argue for an ethical framework that emphasizes relation-­based reasoning in the therapeutic context. The section concludes with “Ethical Issues of Mindfulness-­Based Interventions from a Public Health Perspective” (Chapter 59) by Andreas  T.  Schmidt and Lovro Savić. The authors evaluate the common criticisms that mindfulness-­based interventions (MBIs) received and argue that contemporary MBIs should remain normatively thin, because it makes them more suitable for population-­level contexts.

Section VI: Ethics of Psychotherapy Education, Training, Quality Assurance, and Research The last section of the Oxford Handbook of Psychotherapy Ethics, “Ethics of Psychotherapy Education, Training, Quality Assurance, and Research,” is devoted to ethical questions which arise in the context of psychotherapy education and training such as criteria for selecting candidates for psychotherapy training (e.g., demands made on the prerequisites or character virtues of future psychotherapists, Chapter 60), teaching the standards of professional competence (Chapter 61), professional conduct and handling misconduct (Chapter 64), or teaching psychotherapists how to care for themselves and what to do if self-­care fails (Chapter 62). This final section further contains more conceptual contributions on the metaethics of psychotherapy codes of ethics and conduct (Chapter 63) and on dealing with

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summary reflections on the sections   23 moral dilemmas in psychotherapy by means of clinical ethics support services (Chapter 65). Before completing the book by a chapter dedicated to psychotherapy research ethics (Chapter 68), two chapters pertaining to the area of the medical humanities are presented which are especially well suited as resources for teaching: psychotherapy ethics in film (Chapter 66) and in twentieth-­century literature (Chapter 67). Opening this last section of the Oxford Handbook of Psychotherapy Ethics with a chapter on “Virtue Ethics and the Multicultural Clinic” (Chapter 60), Jennifer Radden and Jerome Kroll show how to apply a character-­focused, virtue ethics framework to psychotherapeutic practice by introducing some distinctive demands made on the character of those who undertake psychotherapy with immigrant populations using various case examples from institutions where Southeast Asian and East African patients are treated. In the next chapter, “Toward an Evidence-­Based Standard of Professional Competence” (Chapter 61), Scott D. Miller, Joshua Madsen, and Mark Hubble discuss the reality that psychotherapists are ethically bound to provide services within the boundaries of their competence traditionally delimited by their education, training, and supervised experience. The authors propose that effectiveness become the foundation of any formulation and assessment of competence which should be measured by routine outcome monitoring and compared to international norms. Miller, Madsen, and Hubble hold that psychotherapists must act on the data provided by routine outcome monitoring in order to be ethical which corresponds to Feedback Informed Treatment. The next chapter by Andrés Consoli, Heidi A. Zetzer, and Himadhari Sharma is dedicated to the “Ethical Importance of Psychotherapists’ Self-­Care and When It Fails” (Chapter 62). The authors focus on the fact that psychotherapy can be as rewarding as challenging. One side of the coin is that psychotherapists feel inspired by their work at times and experience their clients as a source of encouragement, even admiration in their abilities to overcome their difficulties; the other side of the coin is that psychotherapists get demoralized, and that clients can be experienced as source of stress and discouragement. Consoli, Zetzer, and Sharma conclude that in light of the sizable range of emotions psychotherapists will experience in their daily practice, they need to exhibit a certain ability to proactively engage in self-­care while striving toward congruence. In his conceptual chapter on “The Metaethics of Psychotherapy Codes of Ethics and Conduct” (Chapter 63), Paul Snelling broaches the issue of whether the codes of ethics and conduct and associated guidance they operate under are sufficiently detailed to guide practice. He shows that those codes must be evaluated alongside an understanding of the role of the organizations that write and publish them. The chapter details the regulatory framework in the UK, where about forty codes of ethics and/or conduct relating to the various professions of psychotherapy exist. Snelling concludes that the codes’ regulatory role in establishing minimum practice is difficult to assess, and he questions their role in guiding practice by using disclosure of confidential information as an example. In their chapter on “Professional Conduct and Handling Misconduct in Psychotherapy: Ethical Practice between Boundaries, Relationships, and Reality” (Chapter 64), Irina Franke and Anita Riecher-­Rössler likewise introduce their chapter holding that codes of conduct are necessary due to the special nature of the professional relationship in psychotherapy to, on the one hand, protect the patient, and on the other hand, allow therapeutic flexibility. The main part of the chapter, however, focuses on transgressions of professional conduct as events when psychotherapists go beyond their professional boundaries to satisfy their own personal

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24   Why Ethics Matter in Psychotherapy needs. The authors discuss misconduct in its various faces and facets. They emphasize that although sexual misconduct is the most drastic form of boundary violation, this should not detract attention from other various forms of misconduct, especially because they often precede the more severe boundary violations. Thereby, their analysis yields that any form of misconduct is profoundly connected with the person of the therapist. In the final sections of their chapter, Franke and Riecher-­Rössler discuss options for prevention and intervention, and suggest options for improving training of future psychotherapists. In the next chapter, Guy A. M. Widdershoven and Andrea M. Ruissen delve into the field of moral dilemmas from a conceptual and clinical perspective. Building on the notion of moral dilemma, making use of the work of the philosopher Martha Nussbaum, their chapter “Dealing with Moral Dilemmas in Psychotherapy: The Relevance of Moral Case Deliberation” (Chapter 65) addresses the nature of moral issues in psychotherapy, and the way in which psychotherapists can be supported in dealing with them. Particularly, the authors introduce Moral Case Deliberation (MCD) as an approach of clinical ethics support service guided by a facilitator who applies a deliberation method such as the Dilemma Method. The method is illustrated by a case vignette with a psychotherapy patient requesting euthanasia. The following chapter, “Psychotherapy Ethics in Film” by Tobias Eichinger (Chapter 66), picks out cinematic depictions of psychotherapy and psychotherapists as a central theme which have been popular since the beginning of film history. Although most of these portrayals are not realistic or commendable, but rather obey the laws of film narration, entertainment, and pleasure of spectatorship, Eichinger convincingly points out that regarding psychotherapy ethics, the quartet of stereotypical images of the crazy (“dippy”), the bad (“evil”), the good (“wonderful”), and the sexually suggestive (“horny”) psychotherapist refers to the ethical requirements of the profession and constitutes an index of ethical misconduct. This makes the chapter particularly suitable for teaching. The next chapter is a fraternal twin of the preceding in the sense that it broaches the issue of the medical humanities for psychotherapy ethics. In her chapter “Psychotherapy Ethics in Twentieth-­Century Literature” (Chapter 67), Anna Magdalena Elsner carves out central topics of psychotherapy ethics such as confidentiality, boundaries in the therapeutic relationship and informed consent, prominently figuring in a range of twentieth-­century literary texts that portray psychotherapy. Focusing on examples that either illustrate professionalism and the absence of ethical challenges in psychotherapy, or take up ethical reservations, Elsner proposes that selected literary depictions of psychotherapy can play a key role in sensitizing psychotherapists to the complex make-­up of ethical dilemmas as well as illustrating their cultural and historical contexts. The last chapter of the section, and at the same time the last chapter the Oxford Handbook of Psychotherapy Ethics, is devoted to the wide and complex field of “Ethical Issues in Psychotherapy Research” (Chapter 68). The authors Violette Corre, Poornima Bhola, and Manuel Trachsel hold that psychotherapy research is so important from an ethical perspective because psychotherapists treat vulnerable persons in the context of a particular patient– therapist relationship in which the most serious and sensitive topics of human existence are talked about. Often, the central moral conflict in conducting psychotherapy research is to align the ethical prerequisites of practicing psychotherapy with the particular methodological requirements for meaningful studies. The authors discuss the following topics in the light of current guidelines and a narrative review of the literature: study designs, the process

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conclusion: the future of psychotherapy ethics   25 of informed consent to research, confidentiality, different cultural paradigms, internet-­based research, and the role of research ethics committees.

Conclusion: The Future of Psychotherapy Ethics Examining the Oxford Handbook of Psychotherapy Ethics as a whole poses a daunting challenge regarding foreseeing the future of psychotherapy ethics. Soothsaying is always a risky business. As noted in the first sections of this chapter, the psychotherapy field is diverse in theory, practices, values, traditions, and the cultures and regions in which the field is embedded. Placed into the Handbook’s international setting, this diversity is compounded. We would like to organize our musings on the future of the field into five areas: (1) Psychotherapy as treatment modality and as professional identity; (2) the ethical fates of psychotherapy craft and psychotherapy science; (3) intersectional psychotherapy ethics; (4) ethics and automated psychotherapy; and (5) the future of psychotherapy ethics research. For each of these subtopics, we would like to be both descriptive and prescriptive; describe what is happening in the domain and also recommend some directions within the domain.

Psychotherapy as Treatment Modality and Professional Identity An implicit distinction runs throughout the Oxford Handbook of Psychotherapy Ethics: that between “psychotherapy” as a treatment modality and “psychotherapy” as a part of, or even the whole of, a practitioner’s professional identity. This motif runs through the “historical” chapters for the Handbook, Chapters 2, 3, and 4. As treatment modality, psychotherapy figures into a diverse range of professional ­identities—psychologist, social worker, psychiatrist, professional counselor, etc. However, even describing psychotherapy as a “treatment modality” does some injustice to some psychotherapy traditions, especially ones which eschew medicalization or the “clinical model” centered around addressing impairments or psychopathology. For these nonclinical practices, perhaps “helping practice for mental distress” is more fair and neutral, albeit unwieldy. The weight of emphasis on various goals may vary by practice tradition (relief from symptoms, improving psychosocial functioning, expanding autonomy, and/or promoting the flourishing of the individual and/or group) but all likely have intentional or accidental impact on all of these goals. Chapters 6, 17, 19, 20, 30, 32, 33, 37, 51, and 61 address myriad variations of these concerns. As a component of, or even complete description of professional identity, psychotherapy or “psychotherapist” carries a separate set of implications. For a conventional mental health professional (psychiatrist, social worker, psychologist) psychotherapy may be one of many professional activities, and the “psychotherapist” identity depicts the professional’s investment of time and effort in the field, as well as a social identity so that others know what the

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26   Why Ethics Matter in Psychotherapy professional does. If I am a professional psychologist who happens to do psychotherapy in my practice, I’m still subject to the professional, legal, and ethical obligations defined by my larger professional identity as a psychologist, and likewise for the other mental health professions. As a “psychotherapist” in my complete vocational identity, I may not be bound, or may not feel bound, by conventions, ethics, and laws tied to the mental health professions. The label of “psychotherapist” may be subject to legal and ethical regulation in different countries and jurisdictions, but many high-­to-­middle income countries have little to no regulations for presenting oneself as a psychotherapist. In some cases, anyone can “hang the shingle” as a psychotherapist with no training or moral-­legal regulation whatsoever. Chapters 8, 10, 17, 19, 49, 50, and 61 consider variations on these themes. This brings us to the future of psychotherapy ethics, for the helping practitioner and the professional mental health practitioner, for one’s work identity and as the practice an individual performs. We commend the continued prominence of psychotherapy ethics in the mental health professions in the form of ongoing continuing education, ethics guidelines, ethics committee deliberations and advice, and related professional ethics institutions. Their ethical ambition is to protect the patient/client from exploitation of vulnerabilities, assure practice competence, and identify and respond to emerging ethics challenges. Their embedding in a community of practitioners provides a buffering framework when these ethical ambitions fail or pursue misguided goals. We suspect that professional ethical guidance in the future will differentiate in response to a more complicated world; this expanding complexity raises the question of a need for more psychotherapy ethics scholars, experts, or consultants to sort through and evaluate the changing psychotherapy ethics landscape. However, no set of ethical or regulatory guidelines from professional associations will address every ethical challenge posed by the field. Our devotion to substantive ethics theory in the Oxford Handbook of Psychotherapy Ethics remains needed now and in the future. Ethics and regulation are considered in several chapters: 8, 19, 31, 49, 50, 61, 63, and 64. The future is not so clear for the psychotherapy helping-­practitioner outside the mental health professional network. We are confident, however, that the need to protect vulnerable people from exploitative relationships falls into this realm as well, and many of the traditional ethics mechanisms to address this apply equally to helping practitioners: informed consent, conflict of interest concerns, accountability to competence of practice, respect for persons (see Chapters 6, 7, 9, 10, 17, 18, 19, 20, and 51). How to assure these ethical goals are preserved in the non- or para-­professional setting is an open question, and we can only applaud the steps taken by many helping-­practitioners outside of the mental health system to assure these ethical goals are met; for example, existential therapists, philosophical counselors, and peer advocates (see Chapter 19). We hope these efforts will continue and become even more robust and widespread.

The Ethical Fates of Psychotherapy Craft and Psychotherapy Science A second distinction in psychotherapy relevant to the future of psychotherapy ethics concerns psychotherapy as a craft and psychotherapy as a practice grounded in scientific research. We typically think of craft as a set of refined and targeted skills passed on to new practitioners

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conclusion: the future of psychotherapy ethics   27 through apprenticeships with skilled, typically older, practitioners. We think of the practices of cabinetmakers, glassblowers, and chefs as craftwork. While a certain amount of scientific knowledge augments one’s craft, or even is required by one’s craft, we don’t think of glassblowing and cookery as scientifically based practices as we do with clinical practices like psychotherapy or psychopharmacology. Instead, craft is to science as wisdom is to knowledge; both craft and wisdom build upon science and knowledge, but craft and wisdom are achieved only by hard and extensive experience gained over time. We would like to see the future of psychotherapy craft/science move into closer, more interactive, relationships. These relationships are explored in various ways in Chapters 17, 19, 20, 24, 33, 61, and 63. Scientific appraisals of craft skills would be likely to advance both the promulgation of such skills by seasoned psychotherapists, as well as the refinement of such skills through scientific testing of craft activities like psychotherapy supervision, making interventions like clarifications and interpretations, and the like. Conversely, we have seen the limits of scientific psychotherapy and evidence-­based practice when selection criteria and controlled populations limit the generalizability of clinical trial results to a rarefied group of patients (Chapter 19). Extensive scientific knowledge of psychotherapy is unlikely to substitute for the craft of intervening with unique individuals. Improving both craft and science serves the ethical ends of increasing competent practice, reducing risk of treatment failure or dropout, and producing more prepared, competent new practitioners. A merger and equal recognition of the role of craft and science will likely contribute to clarifying ongoing ethical ambiguities like the role, timing, and sequencing of informed consent, or matching psychotherapy modality to patient characteristics.

Intersectional Psychotherapy Ethics Nayak (Chapter 57) identifies two arms of intersectionality: the idea that people have multiple identities (in family, by race, by work, by politics, and more) that are linked to complex vectors of power in the larger society. Hence “intersectional psychotherapy ethics” might be framed as the study of psychotherapy ethics from the vantage points of interacting identities and power relations. This seems to us to be a vanguard concept for the future. Consider the issue of cross-­cultural validity for a particular psychotherapy, such as cognitive behavioral therapy (CBT) (see also Chapter  54). What unique ethical demands in therapy are posed by the recent Somali immigrant traumatized by civil war in her native country? Are our CBT practices and empirical knowledge even valid for such individuals? The old saw states that “ethics are local,” but in our multicultural, transnational society what counts as locality is often, perhaps usually, in question. Intersectional psychotherapy ethics pushes matters of social justice for psychotherapy practice to the forefront. Can psychotherapy practice, limited to wealthy natives in high-­income countries, be ethically justified? What can the field do to reduce its economic elitism and even, institutional racism? Consider the tradition of the therapist–patient dyad. Does this tradition make sense in the context of immigrant patients needing cultural orientation while maintaining connections to their ethnic communities? We have only scratched the surface of the considerations posed by intersectional psychotherapy ethics, and hope our work serves to promote this inquiry for the future.

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28   Why Ethics Matter in Psychotherapy

Ethics and Automated Psychotherapy In several chapters of the Oxford Handbook of Psychotherapy Ethics, we have seen the development of computer-­assisted psychotherapy, whether in the form of online psychotherapy delivered by people, to automated online therapy, to psychotherapy apps and chatbots. Ethical issues in this environment have been sketched out only recently, as we see in Chapters 27, 31, 49, and 50. The next ten years, and further ahead, will be formative as the new challenges of digital psychotherapy are addressed, and the expansion of digital psychotherapy will pose important considerations to resolve. Privacy in ordinary life is now under an “existential” threat, in that our online profiles are assembled into images for the public sphere, and surveillance for security purposes raises the possibility that no one can be anonymous (see also Chapter  22). One’s very DNA has become a unique identifier for each individual. How much erosion of privacy and confidentiality will be acceptable in the brave new world? Concerns about consent to treatment and responsibility for treatment also abound. Does a commercial psychotherapy app carry the same burden of responsibility that a living therapist does? Similarly, we wonder about the moral obligation of the makers of digital psychotherapy products to ensure that those products are safe and effective. Who will police such obligations? These concerns and more await us.

The Future of Psychotherapy Ethics Research The previous four sections all point to the future of psychotherapy ethics research. In contrast to psychopharmacology clinical research, which has huge amounts of funding and advocacy from pharmaceutical companies, psychotherapy has been long-­stymied by the lack of a comparable associated commercial industry to develop, support, and promulgate it. Coupled with the labor-­intensive and expensive task of clinical research on psychotherapy, the field has had difficulty developing a comparable evidence base to psychopharmacology. However, this could well change in the digital psychotherapy era, where online and app-­based psychotherapy could be both cheap and widely available, while also having the industry wealth of the software and social media companies to promulgate and protect the legal interests of their products. This, of course, raises the question about the ethics of being treated by a machine, and ultimately, whether the human psychotherapist will become a relic of economic non-­competitiveness. For “human” research in psychotherapy, an onus could well develop where people would have to demonstrate their superiority to automated therapy—and at considerable financial disadvantage. This is a grim picture for the viability of human-­delivered psychotherapy, and the details of the ethics are yet to appear in the literature. One wonders about the role of professional associations in addressing these issues. At the same time, the promise of digital psychotherapy also offers the laudatory promise of increased and low-­cost access to care. How these risks and benefits play out in the future is unclear, but will likely involve both professional, commercial, and political aspects. We have seen that many questions remain to be considered in this relatively novel field of psychotherapy ethics. A key conclusion from the Oxford Handbook of Psychotherapy Ethics is this: psychotherapy poses ethics challenges comparable to those of other branches of clinical care, but is unique in its scope of offering narrative-­based, ethical reflection as the

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conclusion: the future of psychotherapy ethics   29 center of its moral practice. Now and in the future, psychotherapy will be regulated by ethics, but also negotiate morally significant values as part and parcel of its everyday work (Engelhardt 1973).

References APA (2010). Ethical Principles of Psychologists and Code of Conduct. Washington, DC: American Psychological Association. APA Presidential Task Force on Evidence-Based Practice (2006). “Evidence-Based Practice in Psychology.” American Psychologist 61: 271–285. APA Task Force on Promotion and Dissemination of Psychological Procedures (1995). “Training in and Dissemination of Empirically-Validated Psychological Treatments.” The Clinical Psychologist 48: 3–23. Barnett, J. E. (2019). “The Ethical Practice of Psychotherapy: Clearly Within Our Reach.” Psychotherapy 56: 431–440. Beutler, L.  E. (1989). “Differential Treatment Selection: The Role of Diagnosis in Psychotherapy.” Psychotherapy: Theory, Research, Practice, Training 26: 271–281. Blease, C. R., Lilienfeld, S. O., and Kelley, J. M. (2016). “Evidence-Based Practice and Psychological Treatments: The Imperatives of Informed Consent.” Frontiers in Psychology 7: 1170. Curtis, D. A. and Kelley, L. J. (2020). “Ethics of Psychotherapist Deception.” Ethics & Behavior 30: 601–616. Daniels, M. (1982). “The Development of the Concept of Self-Actualization in the Writings of Abraham Maslow.” Current Psychological Reviews 2: 61–75. Engelhardt, H. T., Jr. (1973). “Psychotherapy as Meta-Ethics.” Psychiatry 36: 440–445. Epstein, R. M. and Street, R. L., Jr. (2011). “The Values and Value of Patient-Centered Care.” Annals of Family Medicine 9: 100–103. Eysenck, H. J. (1952). “The Effects of Psychotherapy: An Evaluation.” Journal of Consulting Psychology 16: 319–324. Faden, R. and Beauchamp, T. L. (1986). A History of Informed Consent. New York: Oxford University Press. Frank, J. D. and Frank, J. B. (1993). Persuasion and Healing: A Comparative Study of Psychotherapy. Baltimore: Johns Hopkins University Press. Fricker, M. (2007). Epistemic Injustice: Power and the Ethics of Knowing. Oxford: Oxford University Press. Gaab, J., Annoni, M., Blease, C., Gerger, H., and Locher, C. (2020). “The Good Treatment: A Biopsychosocioethical Proposition.” European Journal of Person Centered Healthcare 8: 201–206. Gerger, H., Frey Nascimento, A., Locher, C., Gaab, J., and Trachsel, M. (2020). “What Are the Key Characteristics of a ‘Good’ Psychotherapy? Calling for Ethical Patient Involvement.” Frontiers in Psychiatry 11: 406. Hofmann, S. G. and Hayes, S. C. (2019). “The Future of Intervention Science: Process-Based Therapy.” Clinical Psychological Science 7: 37–50. Knapp, S.  J. and VandeCreek, L.  D. (2006). Practical Ethics for Psychologists: A Positive Approach. Washington, DC: American Psychological Association. Koocher, G. P. and Keith-Spiegel, P. (2016). Ethics in Psychology and the Mental Health Professions: Standards and Cases (4th ed.). Oxford: Oxford University Press. Lambert, M. J. (2013). Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (6th ed.). Hoboken, NJ: Wiley. Pellegrino, E. D. (1999). “The Goals and Ends of Medicine: How Are They to Be Defined?” In The Goals of Medicine: The Forgotten Issues in Health Care Reform (ed. M. J. Hanson and D. Callahan, pp. 55–68). Washington, DC: Georgetown University Press.

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30   Why Ethics Matter in Psychotherapy Pope, K. S. and Vasquez, M. J. T. (1991). Ethics in Psychotherapy and Counseling: A Practical Guide. New York: Wiley. Potter, N. N. (2016). The Virtue of Defiance and Psychiatric Engagement. Oxford: Oxford University Press. Rosenzweig, S. (1936). “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” American Journal of Orthopsychiatry 6: 412–415. Sadler, J. Z., Van Staden, C. W., and Fulford K. W. M. (eds.) (2015). The Oxford Handbook of Psychiatric Ethics. Oxford: Oxford University Press. Trachsel, M. and Gaab, J. (2016). “Disclosure of Incidental Constituents of Psychotherapy as a Moral Obligation for Psychiatrists and Psychotherapists.” Journal of Medical Ethics 42: 493–495. Trachsel, M., grosse Holtforth, M., Biller-Andorno, N., and Appelbaum, P.  S. (2015). “Informed ­Consent for Psychotherapy: Still Not Routine.” The Lancet Psychiatry 2: 775–777. Wampold, B. E. and Imel, Z. E. (2015). The Great Psychotherapy Debate (2nd ed.). London: Routledge. Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., and Ahn, H. N. (1997). “A MetaAnalysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, ‘All Must Have Prizes’.” Psychological Bulletin 122: 203–215. Welfel, E. R. (1998). Ethics in Counseling & Psychotherapy: Standards, Research, and Emerging Issues. Boston: Cengage Learning.

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chapter 2

A Br ief Mor a l History of Psychother a py Alan C. Tjeltveit

Introduction Understanding the history of the ethical dimensions of psychotherapy requires zooming out from the classic image of psychotherapy—a psychotherapist in an office working with a person to resolve their psychological problems. A broader perspective cuts across time and cultures and makes possible a deeper understanding of how the moral qualities of the practices, techniques, theories, institutions, professions, and meanings of psychotherapy have developed. Because our cultures, especially their moral dimensions, profoundly shape our assumptions in ways of which we are often unaware, and because psychotherapy may be understood as the product of objective medical and psychological science, or relationships that enable authentic persons to emerge when freed from oppressive societal moralities, the ethical dimensions of psychotherapy are more often implicit than explicit, so generalizations are difficult to make. Nevertheless, considerable scholarly work has addressed how the moral dimensions of therapy have developed historically (Browning and Cooper 2004; Cushman 1995; Doherty 1995; Richardson et al. 1999; Tjeltveit 1999; Woolfolk 2015). Another difficulty in making generalizations about therapy’s moral qualities arises because those qualities vary by individual client and therapist, by community, by therapeutic tradition, and by historical era. This brief history thus has to do with the interrelationships of multiple histories—of psychotherapies, of ethics/morality, of several professions and their professional ethics, and of cultures. Different histories will emerge from different emphases. Perhaps, however, to paraphrase Kluckhohn et al. (1953), the moral history of each moment in psychotherapy, each person’s psychotherapy, each set of therapeutic practices, each general approach to psychotherapy, and each culture is like all others, like some others, and like no others. Accordingly, taking into account both historical continuities and differences produces the best understanding of therapy’s moral dimensions. A brief history necessarily focuses more on continuities and generalities than specifics. Much historical richness will thus not be covered. One caveat: Although there is considerable overlap between psychotherapy and counseling, I will focus on psychotherapy by psychiatrists,

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32   A Brief Moral History of Psychotherapy clinical and counseling psychologists, and social workers; the related moral histories of counselors (addictions, marriage, guidance, etc.) are not directly addressed.

The Moral Dimensions of Psychotherapy “Moral” is used in a variety of ways. In this chapter, I mean moral in its broadest sense, as what is (or is regarded as) good, right, obligatory, and/or virtuous, that is, the topics moral philosophers address. Moral in this sense is a broadly normative term, contrasting with “descriptive.” To complicate matters, moral is also used in a more restrictive sense, referring to universal obligations, to what everyone should do. Notions of goodness and virtue are moral in the broader sense, but not in the narrower sense. These distinctions are important because most of the moral dimensions of psychotherapy I am discussing are moral only in the broader sense. I will talk about normative dimensions of the problems people bring to therapy (for example, most say accusatory hallucinations and identity confusion are not good; we do not, however, say such persons are immoral). I will also discuss the goals of psychotherapy (the good state toward which therapy aims), therapy outcomes (considered evaluatively), and an ethical evaluation of the means by which problems are addressed in therapy (e.g., good or not-­so-­good techniques and relationship qualities, plus therapist obligations to clients). There is, of course, no unanimity in the moral realm. We address what is considered to be moral; disagreement exists about moral realism, the view that, as Sayre-­McCord (2011: 1) put it, “at least some moral claims actually are true.” Clients, however, generally think that something is not good in their lives, so they seek help; diagnoses are based on values, on judgments that certain problematic (not good) states exist (Sadler  2002,  2005). Psychotherapists and clients agree that the goals toward which therapy aims are good. They also generally concur that there are some wrong ways for therapists to work with clients (e.g., exploiting them). In what follows, however, I will make no assumptions about whether moral assertions are really true.

Moral Concomitants of Changing Sociocultural Contexts Because psychotherapy always exists within a sociocultural context, and because what is good, right, and/or virtuous depends, in part, on that context, understanding the moral history of psychotherapy requires examining the relationships of sociocultural contexts to those moral dimensions. Ethical issues arising from therapy conducted with involuntarily committed persons differ from those arising in private practice, which differ from those in settings where government agencies or managed care organizations dictate therapy duration and the problems for which therapy may be sought. Context shapes assessment of problems, determining goals, and selecting techniques/relationship qualities.

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Moral Challenges to Certain Forms of Morality   33 Moral failures in psychotherapy have resulted from mishandling its contexts. Wendt et al. (2015a: 338), for instance, point out that the multicultural counseling movement “developed in response to the recognition that ‘mainstream’ interventions had long failed to adequately address the mental health needs of culturally diverse individuals.” Failure to address the contexts of racism, sexism, and other forms of bias has had a deleterious effect on psychotherapy; a growing recognition of those contextual realities is slowly changing psychotherapy. Those who have developed both national and universal codes of professional ethics have recognized the importance of culture. The framers of the Universal Declaration of Ethical Principles for Psychologists, Gauthier et al. (2010: 195) reported, sought deliberately to create a “culture-­sensitive” approach to professional ethics, one that recognizes, for instance, that “cultural differences exist regarding appropriate professional boundaries, multiple relationships, and conflicts of interest.” Korkut (2010: 289), for instance, described the process that produced an ethics code that deliberately “reflects the value system” of Turkey and “matches the needs of relevant professionals.” The moral history of psychotherapy thus involves the development of key ethical ideas in relationship to cultural context. As cultures change, professional ethical standards change, as do client and therapist goals. For example, cultural rejection of paternalism contributed to a greater emphasis in professional ethics on respect for therapy patients and on informed consent. The reverse is also the case: Psychotherapeutic ideas and practices change cultures, with consequent moral results. For example, psychotherapists focused on the costs to clients (especially women) of excessively serving others, which led in some cases to cultures characterized by more persons concerned solely with themselves, but more often to a healthier (good) balance of self-­care and other-­care.

Moral Challenges to Certain Forms and Understandings of Morality Psychotherapists and others have raised searching questions about morality. Some have claimed that psychotherapy addresses something very different than morality: mental health. Others have noted that Western civilization has been racked by battles over various moral claims, battles that often turned to war. To avoid such battles, many have turned from morality to the objectivity of science, the good will of the case worker, and the wisdom of medicine. Psychotherapists saw clients as sick, not bad, as victims of oppressive societal rules, not morally flawed. This avoided the judgmentalism and shame that negatively affect mental health. Some medical leaders, noted Burnham (1988: 182), “embodied the cutting edge of the movement to secularize society: they represented, in their own eyes, science, and as such they wanted to advise everyone how to live according to the findings of science.” To succeed at that task, “they sensed that they had to replace the usual dispenser of advice and guidance, the clergy” (Burnham 1988: 182). Another critical challenge sees moral claims as masked attempts to exercise power and control over others and retain privileged status. Nietzsche’s famous critique of morality, along with that of neo-­Nietzschean postmodernists and critical theorists, challenged dominant

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34   A Brief Moral History of Psychotherapy moral claims. The radical rethinking found in Foucault’s (2006) History of Madness has received particular attention. The moral dimensions of psychotherapists’ claims to diagnose accurately and to benefit others are seen as duplicitous, with mental illness understood to be a social construction, not real, and psychotherapists’ underlying motivation seen to be controlling others and imposing on them a moral (or amoral) vision. Such views have, however, been amply criticized. The merit of these critical claims that morality harms people is spotlighting significant problems that have historically resulted from certain forms of moral reflection and practice. They helped understand the moral history of psychotherapy and changed that history. Obtaining relevant, reliable scientific knowledge that pertains to therapy, tying therapy to the field of medicine, and connecting client problems to social structures have all enriched therapy, producing positive consequences. The problem with these criticisms of morality is twofold: First, because therapists’ moral convictions are seen as harmful or duplicitous, those convictions—including the inescapably ethical content of their concepts of problematic forms of life (e.g., psychopathology), of the good life, of the obligations psychotherapists have to clients, and of the ethical character of therapist techniques and relationships—have often not even been acknowledged, and thus have not been easily discussed, critiqued, and improved. Accordingly, psychotherapists, in the main, have not been in the forefront of critical evaluations of psychotherapy’s de facto moral influence on individuals and societies. For example, from the observation that being judgmental harms clients, some therapists have sought to be completely objective and accepting, holding no moral views; however, because it is impossible to function as a professional psychotherapist without some moral convictions, therapists’ moral cognitions were not eliminated, but merely pushed out of conscious awareness, preventing careful reflection about them. The second problem is that clients whose moral lives were askew sometimes became convinced that morality per se was their problem; they then turned away from moral stances that were deeply connected with their communities, values, and identities, although those stances could have been recast in healthy forms. For example, persons with a strong cultural identification with a collectivist culture and its values have been alienated from their culture (and their selves) by a strong therapist emphasis on the primacy of the individual and related values. In contrast to those in whom therapy created moral alienation, some drew on moral sources in ways permitting psychotherapy, and their lives, to flourish.

The Historical Origins of Moral Ideals/Practices Moral psychologists have stressed moral judgments (Kohlberg 1984), the power of situations (Zimbardo 2008), the importance of intuition and emotion (Haidt 2012), the importance of social group (tribal) memberships (Greene 2013), and other psychological phenomena. A broader set of influences has also shaped the moral character of psychotherapies. Peterson (1998: 37) noted that “professional ministrations” are “inherently and unavoidably moral actions,” adding that the “principled foundations” of professionals’ work could

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Psychotherapies’ Moral Dimensions: Some Historical Trajectories   35 “obviously” not be found in science. They were to be found “just as obviously, in a moral philosophy of some kind.” Psychotherapists have drawn on analytic philosophy, continental philosophy, or both. Schimmel (1997) noted the well-­developed understandings of human problems found in Classical Greek and Roman, Jewish, and Christian traditions, with sophisticated assessments and interventions. Eggerth and Flynn (2010: 231) pointed to “Ayurvedic medicine from India and traditional Chinese medicine,” with their “ancient roots and rich, well-­articulated systems within which to conceptualize illness and wellness.” Buddhist (Epstein 1995) and Muslim (Shah 2005) ethical perspectives also informed psychotherapy, as did many non-­religious and non-­philosophical sources. Life experience also contributed to ideas about the moral nature of human problems, goals, and problem­resolution strategies. Indeed, a key document in clinical psychology’s history (Committee on Training in Clinical Psychology 1947: 541) contended that the clinical psychologist . . . should have had experiences . . . involving close relations with both ordinary and unusual persons in field, factory, institution, or laboratory. In addition to direct contact with people of various kinds he should have had the indirect acquaintance with people that comes from immersion in great literature, because of the . . . insights into human nature that they give.

Finally, experiences with families, friends, and neighbors have also served as historical sources of psychotherapy’s moral dimensions, both facilitating and distorting moral perceptions.

Psychotherapies’ Moral Dimensions: Some Historical Trajectories Divergent stories about psychotherapy’s origins have been told; each has implications for the moral dimensions of therapy’s history. Given the existence of what Shamdasani (2005: 15) called psychotherapies’ “competing historical genealogies,” and the diversity of psychotherapeutic theories, practices, and cultures, attempting to write a single, unified moral history of psychotherapy risks omitting many of psychotherapies’ moral complexities. I will instead describe several historical trajectories involving therapy’s moral character.

Competing Genealogies Freud, many contend, created psychotherapy; the intersection of Freud and morality (e.g., Rieff 1979) is accordingly central to therapy’s moral history. Challengers assert that “Freudian apologists rescripted the history of psychotherapy as if it began and ended with Freud” (Shamdasani 2005: 13). Alternative histories (Cautin 2011; Ehrenwald 1976; Ellenberger 1970; Frank and Frank 1991; Jackson 1999; Schofield 1986) discuss crucial developments that predated Freud, including the moral treatment of those in eighteenth- and nineteenth-­century asylums (Bockoven  1963; Charland  2011) and various forms of what might be called

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36   A Brief Moral History of Psychotherapy proto-­psychotherapy: Religious leaders (whether priest, rabbi, imam, or guru), wise men and wise women, and physicians all met with troubled individuals and helped them address their problems, at times with considerable sophistication. Physicians, Hathaway (1958: 259) asserted, were “reputed” “from the culture” “to have great psychological wisdom in what used to be called the philosophy of living.” “The physician could be trusted,” Hathaway (1958: 259) continued, “with the most private revelations and was the only person, except family, before whom the opposite sex could appear undressed with propriety and to whom one would bring psychological and physical excreta.” The continuity across various forms of psychological interventions—ancient and modern—was stressed by Jackson (1999), in his book’s subtitle: A History of Psychological Healing. Those stressing the continuity between proto-­psychotherapies and psychotherapies nevertheless maintained, Shamdasani (2005: 15) observed, that psychotherapy was new and “superior.” The term “psychotherapy” first appeared in the French literature in 1872 (Shamdasani 2005) and “increasingly became perceived as a distinct entity in its own right” with the term providing “an appearance of novelty and innovation” and “a scientific aura” (Shamdasani 2005: 1, 13). Inspired in part by those French developments, a variety of forms of pre-­Freudian psychotherapy arose in the United States in the late nineteenth century, many in conjunction with the Boston School of abnormal psychology or psychotherapy (Hale 1971; Taylor 2000). Associated with Morton Prince, James Jackson Putnam, and philosopher-­psychologist­physician William James, this eclectic set of psychotherapies included, Hale (1971) documented, the concepts of trauma, the subconscious, and association, plus changing habits, re-­education, relationships, and inculcating “‘healthy’ hopeful attitudes,” and “the power of thoughts and feelings” (Hale 1971: 148, 124) especially in contrast to contemporary psychiatry’s strictly somatic understanding of the cause and treatment of mental disorders. Prince (1909, as cited in Caplan  1998: 103) emphasized the quality of the relationship with the person seeking treatment, adding that the physician “is to teach the patient how to help himself.” In 1907, Putnam “hired social workers who acted as psychotherapists” (Hale  1971: 140). Collaboration between clergy and physicians occurred in the development of a widely popularized form of psychotherapy that was part of the Emmanuel Movement, which began in 1906 and to which Putnam lent his support (Caplan 1998; Gifford 1998). As part of a multimodal intervention, this form of psychotherapy involved a comfortable Morris chair, suggestion, bibliotherapy, and relaxation training, “taught,” Gage (1909, as cited in Caplan 1998: 123) noted, “by rhythmic breathing and by visual imagery.” Freud’s famous 1909 visit to the United States thus occurred at a time when non-­Freudian psychotherapy had been rapidly expanding, not when Americans knew nothing about psychotherapy. Sociocultural contexts created a readiness for psychotherapy (Caplan 1998; Cushman  1995; Hale  1971). Those developments were morally relevant because expertise concerning life problems changed from religious and other moral authorities to psychotherapists. Cultural understandings of the nature of the problems (bad states) for which help was sought also changed. Another story of psychotherapy’s origins focuses on the founding role of Lightner Witmer, an experimental psychologist who, in 1896, created clinical psychology as an application of the new scientific psychology. The problem with this interpretation of psychotherapy’s origins, however, is that the “clinical problems” seen in his clinical practice were mostly educational and behavioral problems exhibited by children, rather than the kind of

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Professions and Professional Ethics/Moral Principles and Qualities   37 problems most psychotherapists now address. Moreover, Witmer’s psychologists were more school psychologists than psychotherapists. In fact, Taylor (2000: 1029) noted that Witmer “clearly detested and actually knew very little about” psychotherapy. Furthermore, many of Witmer’s interventions did not come from the labs and scientific findings of experimental psychology, but from other sources. School teachers were used in therapeutic roles, noted Levine and Levine (1970), with therapeutic innovations often coming from outside professional mental health fields. For example, Witmer’s (1907: 58) intervention with a boy with chronic bad spelling involved a referral to an oculist and “almost daily instruction by Miss Maguire,” who for six months gave him “a persistent course of instruction in rapid reading,” which was largely successful. Levine and Levine (1970: 5) also noted that the therapeutic work in one case was conducted, with Witmer’s “knowledge and encouragement, by a housemaid.” Suffice it to say that the role of such women, and of working-­class wisdom and skill, has received insufficient attention in standard histories of psychotherapy. By the 1950s, the clinical psychology stream joined with the streams of psychiatry, social work, and pastoral counseling to form the new generalized professional identity of psychotherapist (Burnham  1988). Certain clinical psychologists, however, inspired by the Witmerian ideal of science-­based practice and medicine’s evidence-­based practice movement, began to assert that psychotherapy should only use empirically supported techniques. As McFall (1996: 9) put it, “Scientific clinical psychology is the only legitimate and acceptable form of clinical psychology.” Strong moral claims have often been associated with this position: Psychologists promised to base practice on science; only science can determine treatment effectiveness and psychotherapists should only use such treatments; it is wrong to use treatments known scientifically to harm clients (Lilienfeld 2007); and it is unjust to use scarce resources to pay for unvalidated psychotherapeutic techniques. A final alternative story about psychotherapy tells how powerful elites have harmed vulnerable persons seeking help. Despite psychotherapists’ pretensions, psychotherapy at first ignored human rights (Grob  2015), and continues to maintain an unjust status quo and bolster the power of societal elites. Psychotherapists mollified the distress of individuals without addressing the real underlying problem: unjust societal structures, poverty, sexism, racism, white supremacy, ethnocentrism, privilege, and so forth. A long history of inequities in understanding and treating women and members of disempowered racial, ethnic, sexual identity, and other groups has been documented (Chesler  1974; Guthrie  2004; Thomas and Sillen  1972). ­Anti-­psychiatry critiques (Laing  1969; Szasz  1961) have also challenged psychotherapists, raising fundamental ethical questions about the legitimacy of traditional psychotherapy, including its diagnoses, treatments, and honored role in society. These critiques view therapy, or most therapy, as a historical development warranting negative moral evaluation. Other stories, of course, view psychotherapy, or most therapy, as essentially good.

Professions and Professional Ethics/ Moral Principles and Qualities The moral history of psychotherapy is tied to changes in professions and professional ethics, with the latter prohibiting certain behaviors and explicating the ethical principles and

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38   A Brief Moral History of Psychotherapy standards that professional psychotherapists profess. Indeed, integral to being a professional is to live in accord with the profession’s ethical ideals; those ideals emerged as the psychotherapy professions developed. Medical ethics are, of course, ancient, with the notion of a code of ethics being of relatively late origin. The American Medical Association only adopted its first code in 1847 (Baker 1995), the American Psychological Association in 1953, the National Association of Social Workers (2018) in 1960, and the American Psychiatric Association’s (2013b) The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry in 1973. By the time those professions adopted those codes, psychotherapy was well established. Pope (2016: 51) distinguishes between professional ethics, which “protect the public against abuse of professional power, expertise, and practice, and hold members accountable to values beyond self-­interest,” and guild ethics, which “place members’ interests above public interest, edge away from accountability, and tend to masquerade as professional ethics.” Starr (1982) and others have suggested, however, that professional ethics codes have been at least as focused on etiquette and protection of professions as on others’ welfare. Gauthier et al. (2010) noted that an ethics code should be clearly tied to the purpose of an organization, whether that be protecting the public, serving its members, or both. An acknowledgment of the necessary balance between self-­care and other-­care appeared in the newly revised World Medical Association’s Declaration of Geneva: It added, “I WILL ATTEND TO my own health, well-­being, and abilities in order to provide care of the highest standard” (Parsa­Parsi 2017: 1971), while retaining “THE HEALTH AND WELL-­BEING OF MY PATIENT will be my first consideration” (Parsa-­Parsi 2017: 1971). Ethical challenges for psychotherapists have arisen when the best interests of the client or of society clash with therapists’ best interests. The relationship between a psychotherapist’s own ethical ideals and qualities and professional codes and expectations has therefore received careful attention (e.g., Handelsman et al. 2005). In order to avoid ethical problems and aim for ethical excellence, ethics educators have increasingly focused on the use of ethical decision-­making guides (e.g., Canadian Psychological Association 2017), on virtues, on the crucial role of emotion and intuition, and on the importance of consultation (Kitchener and Anderson  2011; Knapp et al.  2015; Pope and Vasquez  2016; Tjeltveit and Gottlieb 2010). These broader understandings of professional ethics were not replacements for clear professional ethical standards, but intended to equip psychotherapists with the knowledge, skills, and character necessary to practice optimally. In some regards, the ethically acceptable range of psychotherapist behaviors has narrowed. For instance, under current standards of professional ethics, Sigmund Freud could not ethically psychoanalyze his daughter Anna. Using a concept, boundaries, emphasized by family therapists (e.g., Minuchin  1974), extensive discussion of multiple relationships occurred, resulting in very restrictive rules on self-­disclosure and therapist contact with clients outside sessions. In response, Gutheil and Gabbard (1993) crafted a distinction between boundary crossings (inevitable and ethically neutral) and problematic boundary violations. This, along with decision-­making models (e.g., Gottlieb 1993), permitted more nuanced, ethically adequate approaches to multiple relationships and boundaries. Beneficence and non-­maleficence may appear to be straightforward ethical principles. Peterson (1998: 29) noted, “if we are not effective, we had better close the shop.” However, judgments about the meaning of help and harm vary across time and culture and are complex (Tjeltveit 2006). Helping women submit to controlling husbands may once have been

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The Problems Psychotherapy Addresses   39 viewed as a good outcome, but many would now think it harmful. Judgments about harm also lie behind efforts to exclude “quacks.” Whether excluding a form of therapy is viewed as a good or bad outcome hinges in part on the evaluator’s moral framework. Peterson’s (1998) contention takes on particular weight in light of empirical findings that racist and discriminatory practices are effectively present in psychotherapy professions. Judgments about beneficence and non-­maleficence in psychotherapy are generally made with regard to individual clients, on the assumption that society will benefit when individuals receive the therapeutic help they need. However, as I will discuss below, historical evidence suggests that certain forms of helping individuals may harm societies. This has led to sharp moral criticisms of therapy, and to some alterations of it. Justice is another ethical principle that has grown in importance. As Behnke and Bullock (2010) note, however, the ways in which justice and fairness are perceived are not always clear. Indeed, Haidt (2012) has identified multiple understanding of fairness that often get conflated. Furthermore, Gauthier et al. (2010: 182) note that “whether issues of social justice can be incorporated in a code of ethics varies a great deal internationally.” Ethical ideals addressing respect have also become more prominent. The updated World Medical Association’s Declaration of Geneva includes an addition: “I will respect the autonomy and dignity of my patient” (Parsa-­Parsi 2017: 1971). Principle 4.1 of the International Federation of Social Workers’ (2012) Statement of Ethical Principles similarly states “Social work is based on respect for the inherent worth and dignity of all people,” including “Respecting the right to self-­determination.” The Universal Declaration of Ethical Principles for Psychologists includes Principle 1: “Respect for the dignity of persons and peoples” (Gauthier et al. 2010: 194). Tension among various formulations of this principle has existed, however. Psychologists rarely affirm “self-­determination” or “respect for autonomy” (Beauchamp and Childress  2013: 101), perhaps because Skinner (1971), based on his understanding of science, argued that we need to move “beyond freedom and dignity.” Affirming respect has meant that psychotherapists have become more likely to include clients in decisions regarding treatment through an ongoing process of informed consent and to reject the paternalism that Grob (2015) notes was widespread prior to World War II. Finally, some have developed a revitalized understanding of virtues to best capture the professional ethical character of psychotherapists (Fowers  2005; Meara et al.  1996). The relatively stable positive characteristics of persons are emphasized, with Waring (2016) focusing, not just on therapist virtues, but also on the development of virtues in psychotherapy clients. That is, the moral history of an individual’s psychotherapy can be understood in terms of the kind of person he or she becomes.

The Problems Psychotherapy Addresses Psychotherapy exists because people have problems for which they seek assistance (or for which family members, friends, employers, or governmental entities think they need help). Those problems are moral problems, in the broad sense of the term, because problems are some kind of not-­good, disvalued, negatively-­inflected state. The moral history of

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40   A Brief Moral History of Psychotherapy psychotherapy is thus tied to the problems for which therapy is sought. The literature documenting the role of values in diagnosis is voluminous (e.g., Loughlin 2014; Miller 2015; Sadler 2002, 2005). Particularly worthy of note is that the framers of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association 2013a) largely ignored the scholarship, evidence, and arguments urging that careful attention be paid to the moral dimensions of diagnosis, focusing instead almost solely on scientific evidence and ignoring how changing moral ideals produce nosological changes. A morally relevant trend in diagnosis, reflecting societal changes and professions mirroring societal norms, concerns disorders involving sexuality. Most famously, homosexuality was removed as a disorder (Bayer 1987), and paraphilias (no longer considered bad) are no longer disorders. Some critics have focused on the harms produced by diagnosis: stigma, self-­fulfilling prophecies, helplessness (if the diagnosis has a poor prognosis), and a kind of depersonalization that leads mental health professionals to see the diagnostic category and lose sight of the person seeking help. Moral defenses of diagnosis are a routine feature of abnormal psychology or psychopathology texts (e.g., Oltmanns and Emery 2015) and the DSM (American Psychiatric Association  2013a), with advocates contending that good diagnosis produces good effects, since it directs treatment, helps clients understand themselves, reduces the sense of ­isolation experienced by persons with problems, facilitates communication, and helps researchers. Linking the moral history of psychotherapy to mental illness is unduly limiting, however, since many people not meeting any diagnostic criteria seek psychotherapy. Kessler et al. (2005: 2515) reported that only around half of those receiving treatment “met diagnostic criteria for a mental disorder.” In discussing the history of psychiatry, Burnham (1988: 183) noted, “the role of the psychiatrist in American society became distinctive: instead of being called upon to cure illnesses, he or she came to function as a person who could solve problems, usually personal problems but sometimes social problems.”

Goals/Outcomes Any time psychotherapy goals are set—whether by patient, therapist, family member, or others—moral ideals are in play. Mental health is a good end, as is feeling less sad or confused. When recognized as ethical matters, and tied to societal debates about the nature of good lives and human fulfillment, fruitful dialogue with moral philosophy and deeper reflection on goals is possible (Tjeltveit 1999, 2006). Moral ideals are present not just in goals, but in therapy outcomes. A positive outcome occurs when some good goal is reached; a negative or adverse outcome occurs when either therapy’s good aims are not reached or negative outcomes occur. Although evaluations about benefit and harm have generally focused on individuals, the moral effects of psychotherapy on a group, community, or society level have increasingly been emphasized (Wendt et al. 2015a). Many Western psychologists, Fowers et al. (2015: 387) assert, have failed “to recognize that there is a very large and important set of goods that can never be pursued or attained individually because these goods are only attainable through

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Self and Society   41 concerted, collective action. . . . Shared goods are ubiquitous and deeply valued, including friendship, social harmony, democracy, and justice.” Unfortunately, not all that is shared is good. “The most important element of harm in therapy,” asserted Sue (2015: 365), “is cultural oppression.” Adverse outcomes and potentially harmful therapies have received increasing attention. Lilienfeld (2007) identified several potentially harmful therapies for individuals: By staying aware of “unsafe psychological interventions, practicing clinicians can aspire to the laudable goals of the Hippocratic Oath and thereby fulfill their solemn mandate to do no harm” (Lilienfeld  2007: 66). Wendt et al. (2015a: 344) pointed out, however, that determining whether harm has occurred is a “multidimensional, historically contingent” matter that is “open to interpretation by multiple parties with fluctuating levels of power.”

Psychotherapeutic Techniques and Relationships The means by which, or the relationships through which, clients work to address their problems have also been evaluated ethically in changing ways. Techniques that are ineffective or harm clients have been viewed as not good; effective techniques, especially if quicker and less expensive, have been viewed as good. Empirical research on effectiveness is clearly relevant here, concerning both treatments (Nathan and Gorman  2015) and relationship qualities (Norcross 2011). In general, far more research attention has been paid to questions of effectiveness for individuals than for society. Questions have also been raised about therapists’ influence on client moral values. Have psychotherapists exerted their power in ways that go beyond what clients want? Have they inadvertently or otherwise pressured clients to work—not within their own moral f­ rameworks— but within their therapist’s moral framework (Meehl 1981)? Empirical evidence suggests that therapists have sometimes converted clients to their values (Kelly 1990), which has given rise to attempts to reduce inappropriate influence.

Self and Society The interplay of self and psychotherapy, and of society, self, and psychotherapy, is an important theme in the moral history of psychotherapy. Psychotherapy’s initial promise was to help society by helping individuals. However, differing concepts of self and of psychotherapy have affected cultures in ways that have invited deep criticism. Lasch’s (1979) The Culture of Narcissism and Wallach and Wallach’s (1983) Psychology’s Sanction for Selfishness painted a portrait of psychotherapy patients as selfish narcissists, shaped by anti-­ moral psychotherapists masquerading as scientists. To the question—“Has psychotherapy been good for society?”—they and other critics emphatically answered, “No!” Careful analyses have moderated the selfish narcissist critique and examined how problematic forms of psychotherapy resulted from psychotherapists absorbing and amplifying

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42   A Brief Moral History of Psychotherapy cultural themes (Cushman 1995). Wendt et al. (2015b: 397) suggest that the sole focus of therapists on clients (as opposed to also addressing relationships and societal well-­being) stems, in part, from “the market-­driven nature of mental health services in the United States,” but more fundamentally from “a Western tendency to abstract individuals away from context.” The Western focus on individuals (as opposed to groups to which persons belong) has also been implicated. To respond to the claim that psychotherapy produces clients concerned about themselves but not others, some have fleshed out the concept of self-­care and distinguished it from selfishness. Others have focused on developing goals that focus on the client in his or her relationships with others, enlarging therapy’s focus to include community, friendship, and political engagement. Multicultural counseling and multicultural competence developed to address psychotherapy’s historical failure to be sufficiently tailored to different cultural backgrounds. Critics have asserted that expecting Western ethics to be used with non-­Western peoples represented a profoundly problematic cultural colonialism (Eggerth and Flynn  2010). Wendt et al. (2015a: 350) have argued that “radically cultural-­divergent healing approaches that may be more likely to be used by ethnoracial minorities than non-­Latino Whites,” for example, Mestizo spiritually and Qigong healing, have been problematically suppressed. Sue (2015) notes that some therapist behaviors that have been perceived to be prohibited, such as self-­disclosure and accepting gifts from clients, are precisely what would have led many African American clients to regard a therapist as credible. In response to these concerns, many psychotherapists now strive to tailor their approaches to a wide range of non-­dominant cultures. Psychotherapists have sometimes uncritically accepted cultural norms, unduly influencing clients in ethical directions dictated by a society. This becomes problematic when those norms produce injustice, harm, or fail to optimally benefit those with whom psychologists work. The psychotherapeutic ideal of adjusting to society has been used conservatively to pathologize those out of step with their culture. However, this imposition of cultural values has been challenged, for instance, in Martin Luther King’s (1968) address to the American Psychological Association: There are some things in our society, some things in our world to which we should never be adjusted. There are some things concerning which we must always be maladjusted if we are to be people of good will. We must never adjust ourselves to racial discrimination and racial segregation. We must never adjust ourselves to religious bigotry. We must never adjust ourselves to economic conditions that take necessities from the many to give luxuries to the few. We must never adjust ourselves to the madness of militarism, and the self-­defeating effects of physical violence.  (King 1968: 10–11)

Therapists have yielded to social norms in other arenas. For example, most psychotherapists can no longer make the sweeping promises of confidentiality they once made, as cultural changes have led to a range of laws requiring therapists to divulge certain categories of information, like child abuse and serious threats against others. Government entities and insurance companies expect, and receive, access to client records, with the focus sometimes appearing to be, not client well-­being, but saving money. Societal ideals thus shape and restrict psychotherapy ideals.

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Conclusion   43

Conclusion The moral history of psychotherapy emerges from the tension-­filled intersections of the moral ideas, practices, and personal qualities of clients and their families and communities, the moral ideas, practices, and personal qualities of psychotherapists and their families and communities, the moral qualities of psychotherapy concepts, theories, and techniques, and the moral dimensions of psychotherapy’s cultural contexts. Careful attention to professional ethics and increasing sophistication has not been matched by attention to the underlying moral ideas often implicit in psychotherapy and to the broader consequences of psychotherapy’s focus on individuals. Understanding the history of psychotherapy’s ethical character can, however, yield important benefits.

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44   A Brief Moral History of Psychotherapy Doherty, W. J. (1995). Soul Searching: Why Psychotherapy Must Promote Moral Responsibility. New York: Basic Books/HarperCollins. Eggerth, D.  E. and Flynn, M.  A. (2010). “When the Third World Comes to the First: Ethical ­Considerations When Working with Hispanic Immigrants.” Ethics & Behavior 20: 229–242. Ehrenwald, J. (ed.) (1976). The History of Psychotherapy: From Healing Magic to Encounter. New York: Aronson. Ellenberger, H.  F. (1970). The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. New York: Basic Books. Epstein, M. (1995). Thoughts without a Thinker: Psychotherapy from a Buddhist Perspective. New York: Basic Books. Foucault, M. (2006). History of Madness (ed. J. Khalfa; trans. J. Murphy and J. Khalfa). New York: Routledge. Fowers, B. J. (2005). Virtue and Psychology: Pursuing Excellence in Ordinary Practices. Washington, DC: American Psychological Association. Fowers, B. J., Anderson, A. R., Lefevor, G. T., and Lang, S. (2015). “Beyond Harms: Exploring the Individual and Shared Goods of Psychotherapy.” The Counseling Psychologist 43: 380–392. Frank, J. D. and Frank, J. B. (1991). Persuasion and Healing: A Comparative Study of Psychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press. Gauthier, J., Pettifor, J., and Ferrero, A. (2010). “The Universal Declaration of Ethical Principles for Psychologists: A Culture-Sensitive Model for Creating and Reviewing a Code of Ethics.” Ethics & Behavior 20: 179–196. Gifford, S. (1998). The Emmanuel Movement: The Origins of Group Treatment and the Assault on Lay Psychotherapy. Cambridge, MA: Harvard University Press. Gottlieb, M.  C. (1993). “Avoiding Exploitive Dual Relationships: A Decision-Making Model.” ­Psychotherapy: Theory, Research, Practice, Training 30: 41–48. Greene, J. (2013). Moral Tribes: Emotion, Reason, and the Gap between Us and Them. New York: ­Penguin. Grob, G. N. (2015). “A Moral/Ethical History of American Psychiatry.” In The Oxford Handbook of Psychiatric Ethics (ed. J. Z. Sadler, W. W. Van Staden, and K. M. Fulford, pp. 637–653). New York: Oxford University Press. Gutheil, T. G. and Gabbard, G. O. (1993). “The Concept of Boundaries in Clinical Practice: Theoretical and Risk-Management Dimensions.” American Journal of Psychiatry 150: 188–196. Guthrie, R. V. (2004). Even the Rat Was White: A Historical View of Psychology (2nd ed.). Boston, MA: Allyn & Bacon. Haidt, J. (2012). The Righteous Mind: Why Good People are Divided by Politics and Religion. New York: Pantheon. Hale, J. (1971). Freud and the Americans. New York: Oxford University Press. Handelsman, M.  M., Gottlieb, M.  C., and Knapp, S. (2005). “Acculturation as a Framework for Training Ethical Psychologists.” Professional Psychology: Research and Practice 36: 59–65. Hathaway, S. R. (1958). “A Study of Human Behavior: The Clinical Psychologist.” American Psychologist 13: 257–265. International Federation of Social Workers (2012). Statement of Ethical Principles. Rheinfelden, ­Switz­er­land: Author. Jackson, S. W. (1999). Care of the Psyche: A History of Psychological Healing. New Haven, CT: Yale University Press. Kelly, T. A. (1990). “The Role of Values in Psychotherapy: A Critical Review of Process and Outcome Effects.” Clinical Psychology Review 10: 171–186. Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., E. E. Walters, Wang, P., Wells, K. B., and Zaslavsky, A. M. (2005). “US Prevalence and Treatment of Mental Disorders: 1990–2003.” The New England Journal of Medicine 352: 2515–2523. King, M. L., Jr. (1968). “The Role of the Behavioral Scientist in the Civil Rights Movement.” Journal of Social Issues 24: 1–12.

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Conclusion   45 Kitchener, K. S. and Anderson, S. K. (2011). Foundations of Ethical Practice, Research, and Teaching in Psychology and Counseling (2nd ed.). New York: Routledge. Kluckhohn, C., Murray, H. A., and Schneider, D. M. (eds.) (1953). Personality in Nature, Society, and Culture (rev. ed.). New York: Knopf. Knapp, S.  J., Gottlieb, M.  C., and Handelsman, M.  M. (2015). Ethical Dilemmas in Psychotherapy: Positive Approaches to Decision Making. Washington, DC: American Psychological Association. Kohlberg, L. (1984). The Psychology of Moral Development: The Nature and Validity of Moral Stages. San Francisco, CA: Harper & Row. Korkut, Y. (2010). “Developing a National Code of Ethics in Psychology in Turkey: Balancing International Ethical Systems Guides with a Nation’s Unique Culture.” Ethics & Behavior 20: 288–296. Laing, R. D. (1969). Self and Others (2nd ed.). London: Tavistock. Lasch, C. (1979). The Culture of Narcissism: American Life in an Age of Diminishing Expectations. New York: Warner. Levine, M. and Levine, A. (1970). A Social History of Helping Services: Clinic, Court, School, and ­Community. New York: Appleton-Century-Crofts. Lilienfeld, S. O. (2007). “Psychological Treatments That Cause Harm.” Perspectives on Psychological Science 2: 53–70. Loughlin, M. (ed.) (2014). Debates in Values-Based Medicine: Arguments For and Against. Cambridge: Cambridge University Press. McFall, R.  M. (1996). “Making Psychology Incorruptible.” Applied and Preventive Psychology 5: 9–15. Meara, N. M., Schmidt, L. D., and Day, J. D. (1996). “Principles and Virtues: A Foundation for Ethical Decisions, Policies, and Character.” The Counseling Psychologist 24: 4–77. Meehl, P. E. (1981). “Ethical Criticism in Value Clarification: Correcting Cognitive Errors Within the Client’s—Not the Therapist’s—Framework.” Rational Living 16: 3–9. Miller, R. B. (2015). Not so Abnormal Psychology: A Pragmatic View of Mental Illness. Washington, DC: American Psychological Association. Minuchin, S. (1974). Families and Family Therapy. Cambridge, MA: Harvard University Press. Nathan, P. E. and Gorman, J. M. (eds.) (2015). A Guide to Treatments That Work (4th ed.). New York: Oxford University Press. National Association of Social Workers (2018). History of the NASW Code of Ethics. Washington, DC: Author. Norcross, J.  D. (ed.) (2011). Psychotherapy Relationships That Work: Evidence-Based Responsiveness (2nd ed.). New York: Oxford University Press. Oltmanns, T. F. and Emery, R. E. (2015). Abnormal Psychology (8th ed.). Boston, MA: Pearson. Parsa-Parsi, R. W. (2017). “The Revised Declaration of Geneva: A Modern-Day Physician’s Pledge.” JAMA 318: 1971–1972. Peterson, D. R. (1998). “The Professional Psychologist as a Moral Agent.” In Creativity and Moral Vision in Psychology: Narratives on Identity and Commitment in a Postmodern Age (ed. L. T. Hoshmand, pp. 29–49). Thousand Oaks, CA: Sage. Pope, K. S. (2016). “The Code Not Taken: The Path from Guild Ethics to Torture and Our Continuing Choices.” Canadian Psychology/Psychologie Canadienne 57: 51–59. Pope, K. S. and Vasquez, M. J. T. (2016). Ethics in Psychotherapy and Counseling: A Practical Guide (5th ed.). Hoboken, NJ: Wiley. Richardson, F.  C., Fowers, B.  J., and Guignon, C.  B. (1999). Re-envisioning Psychology: Moral ­Dimensions of Theory and Practice. San Francisco, CA: Jossey-Bass. Rieff, P. (1979). Freud: The Mind of the Moralist (3rd ed.). Chicago, IL: University of Chicago Press. Sadler, J.  Z. (ed.) (2002). Descriptions and Prescriptions: Values, Mental Disorders, and the DSMs. ­Baltimore, MD: Johns Hopkins University Press. Sadler, J. Z. (2005). Values and Psychiatric Diagnosis. Oxford: Oxford University Press. Sayre-McCord, G. (2011). “Moral Realism.” In The Stanford Encyclopedia of Philosophy (ed. E. N. Zalta, pp. 1–25). Retrieved from http://plato.stanford.edu/archives/sum2011/entries/moral-realism/

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46   A Brief Moral History of Psychotherapy Schimmel, S. (1997). The Seven Deadly Sins: Jewish, Christian, and Classical Reflections on Human Nature. New York: Oxford University Press. Schofield, W. (1986). Psychotherapy: The Purchase of Friendship (rev. ed.). New Brunswick, NJ: Transaction. Shah, A. (2005). “Psychotherapy in Vacuum or Reality: Secular or Islamic Psychotherapy with Muslim Clients.” Pakistan Journal of Social and Clinical Psychology 3: 3–20. Shamdasani, S. (2005). “‘Psychotherapy’: The Invention of a Word.” History of the Human Sciences 18: 1–22. Skinner, B. F. (1971). Beyond Freedom and Dignity. New York: Knopf. Starr, P. (1982). The Social Transformation of American Medicine. New York: Harper. Sue, D.  W. (2015). “Therapeutic Harm and Cultural Oppression.” The Counseling Psychologist 43: 359–369. Szasz, T. (1961). The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Hoeber-Harper. Taylor, E. (2000). “Psychotherapeutics and the Problematic Origins of Clinical Psychology in Amer­ica.” American Psychologist 55: 1029–1033. Thomas, A. and Sillen, S. (1972). Racism and Psychiatry. New York: Brunner/Mazel. Tjeltveit, A. C. (1999). Ethics and Values in Psychotherapy. London: Routledge. Tjeltveit, A. C. (2006). “To What Ends? Psychotherapy Goals and Outcomes, the Good Life, and the Principle of Beneficence.” Psychotherapy: Theory, Research, Practice, Training 43: 186–200. Tjeltveit, A.  C. and Gottlieb, M.  C. (2010). “Avoiding the Road to Ethical Hell: Overcoming ­Vulnerabilities and Developing Resilience.” Psychotherapy: Theory, Research, Practice, Training 47: 98–110. Wallach, M.  A. and Wallach, L. (1983). Psychology’s Sanction for Selfishness: The Error of Egoism in Theory and Therapy. San Francisco, CA: W. H. Freeman. Waring, D.  R. (2016). The Healing Virtues: Character Ethics in Psychotherapy. New York: Oxford University Press. Wendt, D. C., Gone, J. P., and Nagata, D. K. (2015a). “Potentially Harmful Therapy and Multicultural Counseling: Bridging Two Disciplinary Discourses.” The Counseling Psychologist 43: 334–358. Wendt, D. C., Gone, J. P., and Nagata, D. K. (2015b). “Potentially Harmful Therapy and Multicultural Counseling: Extending the Conversation.” The Counseling Psychologist 43: 393–403. Witmer, L. (1907). “A Case of Chronic Bad Spelling: Amnesia Visualis Verbalis, due to Arrest of Post-Natal Development.” The Psychological Clinic 1: 53–64. Woolfolk, R. L. (2015). The Value of Psychotherapy: The Talking Cure in an Age of Clinical Science. New York: Guilford Press. Zimbardo, P.  G. (2008). The Lucifer Effect: Understanding How Good People Turn Evil. New York: Random House.

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Chapter 3

W h at Do Psychother a pists N eed to K now a bou t Ethics? Lessons from the History of Professiona l Ethics Carole Sinclair

Introduction History cannot give us a program for the future, but it can give us a fuller ­understanding of ourselves, and of our common humanity, so that we can better face the future. —Robert Penn Warren, 1961

What does it take to be ethical as a psychotherapist? Some would say it takes knowledge of, and adherence to, the behavioral rules that can be found in our professions’ codes of conduct and codes of ethics. Others would say it involves understanding the ethical values and principles that underlie the rules, and the ability to apply those values and principles to situations that are not specifically covered by the rules or to situations in which the rules conflict. Still others would say being an ethical psychotherapist is the ability to apply particular moral theories (e.g., deontology, teleology, virtue ethics, relational ethics) when faced with an ethical dilemma that requires ethical analysis and choosing the best course of action. Some would say ethical practice is a matter of moral character—and that if one does not have moral character, it is impossible to be truly ethical as a practitioner. The primary position of this chapter is that it takes all the above to be an ethical psychotherapist. Rather than treating them as separate entities (or as competing explanatory

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48   What Do Psychotherapists Need to Know about Ethics? c­ oncepts), the emphasis will be on how they need to be viewed and treated as an integrated whole in order to maximize our efforts to be ethical. This position will be demonstrated through an exploration of the history of professional ethics, based on the belief that to understand ethics and meaningfully integrate its many components into our professional lives, it is important to understand the history of its development. The history will be explored through three separate time periods: (i) early history (eighteenth century bce to seventeenth century ce); (ii) the transitional eighteenth and nineteenth centuries ce; and (iii) modern times (twentieth and twenty-­first centuries ce). The first two time periods will be explored under four sub-­headings: ethical values and codes; the concept of “profession”; expectations of moral character; and the influence of moral theory. The third section, which explores the twentieth and twenty-­first centuries ce, also will address each of these topics, but not under the same sub-­headings. Rather the topics will be presented as parts of an integrated historical narrative.

Early History of Professional Ethics (Eighteenth Century bce to Seventeenth Century ce) Ethical Values and Codes For all professions, a sense of ethical responsibility, and the need to articulate that responsibility, has a long history (Sinclair 1993, 2012; Sinclair et al. 1996). From ancient times to the present, people around the world have struggled to identify the ethical responsibilities of professionals and define right and wrong professional behavior. The history of this struggle has been shaped by the evolution of society and its various structures, cultures, beliefs, values, and expectations. On the one hand, history shows how the ethics of professions have varied in their expression over time and across world locations and cultures; however, on the other hand, it also shows the deep roots of many of the ethical values and principles espoused by today’s professions. As medicine is the profession with the longest documented history, it provides us with the best information about those roots. One of the earliest and most complete examples of a set of laws that includes laws for occupational groups, including physicians, can be found in the Code of Hammurabi. This code comprises a set of 282 laws, along with fines and punishments, covering such matters as contracts, divorce, slander, trade, as well as the behavior of various occupational groups (e.g., builders, merchants, physicians). Hammurabi was the king of Babylon in the ­eight­eenth century bce. The code, although apparently available and cited off and on throughout ­several centuries, was rediscovered carved on a black stone at the beginning of the twentieth century ce. This stone currently resides in the Louvre. Nine of the 282 laws relate to physicians, many of which set specific fees depending on the social status or value of the patient (e.g., freeman, woman, slave). An example of a punishment for physicians is that the physician’s hands were to be cut off if a patient died after surgery, unless the patient was a slave, in which case replacement or reimbursement of the

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early history of professional ethics  49 slave would be sufficient. Both the laws and the punishments can be seen to reflect the ­culture and values of the times, including the existence of what we today would see as very harsh punishments (sometimes characterized by the expression “an eye for an eye, and a tooth for a tooth”). In addition, they reflect an apparent absence of belief in the equal worth and dignity of all human beings, regardless of social status. In fairness to the Code of Hammurabi, however, it is important to mention that it also was the first set of laws that included the concept of presumption of innocence until proven guilty. The Code of Hammurabi was written by lawmakers and is a good example of early s­ ocietal concern about the behavior of occupational groups. However, it tells us little about  the underlying sense of ethical responsibility or values of the physicians of the day. For this, we must turn to documents produced by physicians themselves (for copies, see Adelaide Centre 2013; Reich 1995). Such documents include: the Ayurvedic Instruction (India, circa sixth century bce); the Hippocratic Oath (Greece, fourth century bce); the Ayurvedic Oath of Initiation (India, circa 100 ce); the Hebrew Oath of Asaph (Middle East, unknown country, circa 600 ce); Haly Abbas’ Advice to a Physician (Persia, circa 950 ce); the Daily Jewish Prayer of a Physician (Egypt, circa 150 ce); the Seventeen Rules of Enjuin (Japan, circa 1500 ce); and the Five Commandments and Ten Requirements (China, 1617 ce). None of these documents was entitled a “code”; rather they were called an “oath,” “instruction,” “rules,” “requirements,” and, in one case, a “prayer.” However, they all fit the basic definition of a moral code, namely something that provides “a system of principles or rules” to be followed. Although probably preceded by the Ayurvedic Instruction (an early version of the Ayurvedic Oath of Initiation) by about two centuries, the Hippocratic Oath is the most widely recognized early example of a code of ethics for a profession (e.g., Dolgoff et al.  2012; Fowler, n.d.). Written about 400 bce, it is believed to have been part of a rite of induction into a particular guild-­like community of Greek physicians. Unlike other guild oaths of the day, which tended to address only a member’s responsibility to one’s “craft,” teachers, and other members, the Hippocratic Oath also addressed specific responsibilities to those served. In addition to reflecting the culture and beliefs of the times, one of the striking features of the Hippocratic Oath is how closely it reflects many of the major ethical values or principles that can be found in today’s codes of ethics—not just for physicians, but for many other professions as well. Using the English translation of the Hippocratic Oath by Edelstein (1943: 56), the following five examples help to illustrate this. The first example of a major ethical value that has survived through these many centuries is concern for being of benefit and avoiding harm. In fact, the main ethical message of the Hippocratic Oath often is summarized as the responsibility to “try to be of benefit, but at least do no harm.” Although this statement does not appear in the Oath itself, it does appear in the larger “Hippocratic Corpus” (of which the Oath was a part). Rather, the Oath itself states: “I will apply . . . measures for the benefit of the sick according to my ability and judgment. I will keep them from harm.” The ethical expectation that members will avoid harm and try to be of benefit is an expectation that can be found in almost all of today’s ethics codes for professions. A second example is the importance of staying within the limits of one’s competence: “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.” Most current professional codes of ethics contain such an expectation.

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50   What Do Psychotherapists Need to Know about Ethics? A third example of a major ethical value that has survived to the present day relates to confidentiality, about which the Oath states: “What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.” Once again, most of today’s codes of ethics for professionals include expectations of respect for privacy and confidentiality. A fourth example relates to the responsibility to ensure that the best interests and well-being of the patient are not compromised by other interests. This is expressed in the Hippocratic Oath as, “Whatever houses I might visit, I will come for the benefit of the sick, remaining free of . . . all mischief, and in particular of sexual relations with both male and female persons, be they free or slaves.” Many similar admonitions can be found in modern codes of ethics, often under the general heading of avoidance of conflicts of interest (e.g., personal, social, financial, or business interests that compete with the best interests of ­clients or patients). The fifth example of a major ethical value that has survived to the present day does not involve members of the public, and was found in other ancient guild oaths, namely the belief that, as members of a professional community, professionals have responsibilities to that community and to fellow members. Related to this, the Hippocratic Oath states: “To hold the one who taught me this art equally precious to me as my parents and live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee or covenant.” The specific responsibilities may sound odd to us today, and would not be the precise way we would conceptualize our responsibilities to our professional community; however, within almost every current profession’s code of ethics, statements can be found regarding members’ responsibilities to their professional community. The Hippocratic Oath was translated into many languages over the centuries, with wording adapted to different cultures and religions. It served as a major foundation of medical ethics off and on through many centuries, and is well-­known and often cited even today. In addition to providing examples like the above from the Hippocratic Oath, Sinclair (2012) reviews many of the other ethics documents cited above from around the world and over the centuries, and provides examples of statements relating to the five values noted above. She also provides examples of statements relating to other current values, such as: belief in the worth and dignity of all human beings; honesty and truthfulness; fairness and justice; concern for the well-­being of society; contributing to knowledge; and the importance of adequate training. As noted above, the documents range from oaths taken by new physicians to sets of instructions for physicians to, in one case, a physician’s prayer. They are dated from the sixth century bce to the seventeenth century ce, and come from such places as India, Persia, Egypt, Japan, and China. The conclusion reached from the review states: The overview provided in this chapter has allowed us to see that there has been considerable similarity in ethical values since ancient times. Although the vehicles used to articulate them in a way that can guide professionals have varied widely—from laws, to oaths, to prayers, to formal codification—it is evident that the ethical principles and values we espouse . . . in today’s world were not “invented” by us; rather, they have deep roots to the past and reflect our common humanity.  (Sinclair 2012: 17)

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early history of professional ethics  51

The Concept of “Profession” The concept of profession was not well-­developed in ancient times. In fact, members of occupations that we today would consider one of the three original “learned professions” (theology, law, medicine) were not always clearly differentiated in the centuries prior to the time of Hippocrates. Egyptian papyri of the sixteenth century bce refer to the “priestphysician,” who sometimes also seemed to be involved in the codification of law. It is only over time that the three professions became more differentiated. However, “they were trusted, admired members of society, viewed as ‘ministering’ to the needs of the people. In turn, they believed themselves to be chosen in some way by their gods and goddesses to perform public service in accordance with what they could determine were the wishes and directives of these supernatural beings” (Sinclair 1993: 170). As we will see in the sections on the later two historical periods, though, the social status afforded, and often sought by, professions sometimes would prove problematic.

Expectations of Moral Character One of the biggest differences between pre-eighteenth-­century ce and later ethics documents is the amount of emphasis placed on moral character. The pre-eighteenth-­century ce ethics documents listed above are replete with references to character (see Table  3.1 for examples). Later ethics documents, especially during the twentieth century ce, rarely mentioned character. However, as we will see and discuss when covering the third historical period, concern about the role of moral character has re-­entered current ethical discourse, particularly in the last two decades.

Table 3.1  Examples of moral character expectations in pre-­eighteenth century ce ethics documents Positive characteristics (To strive for)

Negative characteristics (To be surmounted)

Benevolence Compassion Diligence Generosity Gentleness Gratefulness Holiness Humility Kindness Love for humanity Mercifulness Pity for the poor Purity

Arrogance Association with criminals Boastfulness/conceit Drunkenness Envy/covetousness/jealousy Lustfulness Mocking others Thirst for admiration Thirst for profit Thirst for renown Undue extravagance Vindictiveness

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52   What Do Psychotherapists Need to Know about Ethics?

Influence of Moral Theory The emphasis on moral character in the early documents is not surprising, as the philosophy of the earliest moral theorists (e.g., Confucius [sixth century bce], Plato [fifth century bce], Aristotle [fourth century bce], and Mencius [fourth century bce] relied heavily on the concept of virtue. Although the details of each early theorist’s philosophy varied, virtues generally were seen as dispositions (traits, qualities, habits) of feeling, thinking, and behavior that were deemed to lead to moral goodness. Confucius and Mencius emphasized the virtues of compassion and humaneness. Plato and Aristotle emphasized such virtues as courage, moderation, good temper, and fairness and justice. All four believed that human beings have a moral responsibility to cultivate such virtues in themselves. In Table 3.1, evidence of the influence of their thinking on the ethics documents reviewed is readily apparent. This approach to being ethical is associated with what we now call virtue ethics.

The History of Professional Ethics during the Transitional Eighteenth and Nineteenth Centuries ce Ethical Values and Codes Two major documents were developed in the eighteenth and nineteenth centuries ce, namely A Physician’s Ethical Duties (Persia, 1770 ce) (see Adelaide Centre 2013; Reich 1995), and the Medical Code of Ethics of the American Medical Association (1847). Although the two documents are from different parts of the world, and strikingly dissimilar in structure and detail, they reflect the same range of ethical values found in the ethics documents from earlier times (Sinclair 2012). A Physician’s Ethical Duties is similar in structure and length (one to two pages) to the earlier ethics documents reviewed in the early historical period. The Medical Code of Ethics of the American Medical Association, however, is substantially longer (fourteen pages), and took on a more complex structure—dividing its statements, guidelines, and rules into three separate chapters: (i) “Of the Duties of Physicians to their Patients, and of the Obligations of Patients to their Physicians”; (ii) “Of the Duties of Physicians to Each Other, and to the Profession at Large”; and (iii) “Of the Duties of the Profession to the Public, and of the Obligations of the Public to the Profession.” Each chapter is then sub-­divided into two sections reflecting the two components of its title. Each section contains a series of related behavioral prescriptions related to the particular component. For example, under the ­second component of the first chapter (i.e., “Obligations of Patients to their Physicians”), the following statement appears: The first duty of a patient is, to select as his medical adviser one who has received a regular professional education. In no trade or occupation, do mankind rely on the skill of an untaught artist; and in medicine, confessedly the most difficult and intricate of the sciences, the world ought not to suppose that knowledge is intuitive.  (AMA 1847: 95)

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Professional Ethics in the 18TH AND 19TH CENTURIES  53 The Medical Code of Ethics of the American Medical Association, which had been h ­ eavily based on the Thomas Percival’s book Medical Ethics (published in the United Kingdom in 1803), added two new directions to the history of professional ethics. Both directions were to have a long-­term impact into the next century. The first was to move away from articulation of values primarily only through an oath or other rite of induction, and add a much more codified and detailed document, often officially entitled a “code of ethics.” The second change in direction was to include in such a code not just a physician’s responsibility to patients, the public, and the professional community (similar to the Hippocratic Oath and the other early ethics documents), but also to include the obligations of patients and the public to physicians (e.g., see above quote). As we will see in the next historical period to be covered, this second direction was to prove problematic and was not changed until 1957.

The Concept of “Profession” By the eighteenth and nineteenth centuries ce, the original three “learned professions” were well differentiated, and several occupational groups other than theology, law, and medicine began to identify themselves as professions. This included dentistry, nursing, psychology, social work, and veterinary medicine, as well as the disciplines of architecture and engineering. The concept of a profession was understood as an occupation that required specialized knowledge and skills, long and intense preparation, commitment to continued study, and commitment to the rendering of service to members of the public (Flexner 1915; Gidney and Millar  1994; Sinclair  1993). By the end of the nineteenth century ce, members of these groups all had begun to organize themselves into communities that developed their field of knowledge, established educational programs, and promoted recognition by the public of their status as separate professions. Universities and other institutions of higher learning began to offer related training programs. As we will see in the third historical section of this chapter, however, formal attention to ethics by the new professions came more slowly.

Expectations of Moral Character A Physician’s Ethical Duties (Persia, 1770 ce) is very similar to earlier ethics documents in its exhortations about the importance of moral character. In addition to mentioning several of the positive characteristics listed in Table  3.1, the document adds such characteristics as civility, good humor, politeness, and contentedness. Similarly, in addition to mentioning many of the negative characteristics listed in Table 3.1, it adds conceit, greediness, and pride (of one’s station in life). The Medical Code of Ethics of the American Medical Association (1847 ce) is quite different in the way it treats moral character. Although the introduction lauds the ethics of the Hippocratic Oath, including mention of several of the character traits that are part of the Hippocratic tradition, there is a strong emphasis throughout the document on what physicians are owed by patients and the public due to the claim that physicians can be assumed to have these character traits. For instance: Being required to expose his health and life for the benefit of the community, he has a just claim, in return, on all its members, collectively and individually, for aid to carry out his

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54   What Do Psychotherapists Need to Know about Ethics? measures, and for all possible tenderness and regard to prevent needlessly harassing calls on his services and unnecessary exhaustion of his benevolent sympathies.  (AMA 1847: 84)

As we will see in the next historical period to be covered, this tone influenced some of the ethics codes of the twentieth century ce and, as noted above, was to prove problematic.

Influence of Moral Theory In addition to virtue ethics, one can find elements of other major moral theories (e.g., deontology, utilitarianism [a form of teleological moral theory], and relational ethics) in the writings of the ancient moral philosophers. However, it was not until the eighteenth century ce, during what is variously called the “Age of Reason” or the “Enlightenment,” that two of these other moral theories began to be fully developed, namely deontology and utilitarianism. Both rely on the concept of using principles to determine whether an action is right or wrong. In deontology (largely credited to Immanuel Kant, 1724–1804 ce), the principles are related to duties and rights, and are considered morally obligatory (the “moral imperative”), regardless of their consequences. In utilitarianism (largely credited to Jeremy Bentham, 1748–1832, and John Stuart Mill, 1806–1873), the morality of an action is based primarily on the action’s outcome or consequences with regard to happiness or well-­being. There is little evidence of either of these two theories having an impact on A Physician’s Ethical Duties (Persia, 1770 ce). Some influence, however, can be seen in the Medical Code of Ethics of the American Medical Association, with a repeated mention of “duties” and “rights” (albeit primarily the rights of physicians) and a single reference to the concept of “moral principles.” The influence of the moral theories was much greater on twentieth and twenty-­first century ce professional ethics, and will be explored further in the historical narrative presented in next section.

A Brief History of Modern Professional Ethics (Twentieth and Twenty-­F irst Centuries ce) Attention to the Ethics of Psychotherapy The origins of modern psychotherapy are often traced to the publication of Studies on Hysteria in 1895, by Josef Breuer and Sigmund Freud. First called “the talking cure,” the treatment method described in this work was later dubbed “psychoanalysis” by Freud. Brought forward to the twentieth century ce, approaches to psychotherapy grew rapidly. Table 3.2 contains the results of an October 2018 search of PsycINFO for literature that is indexed as or contains the terms “professional ethics” or “psychotherapy,” individually or in combination. (The search for “psychotherapy” also included the related terms of

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Table 3.2  Number of publications on psychotherapy and professional ethics, individually and in combination, appearing in PsycINFO, per time period Time period

Psychotherapy

Psychotherapy + professional ethics

Professional ethics

1800–1899 1900–1919 1920–1939 1940–1959 1960–1979 1980–1999 2000–2018

22 757 5,386 20,586 46,558 123,007 246,361

0 1 0 31 273 2,327 3,536

11 16 25 210 1,481 8,366 21,410

“psychoanalysis,” “counseling,” or “counselling.”) PsycINFO is a database of abstracts of the behavioral and social science literature. Although a product of the American Psychological Association, it is interdisciplinary in nature and provides abstracts from a wide variety of disciplines. The results reported in the first column of Table 3.2 indicate that the number of publications regarding psychotherapy (and its above related terms, hereinafter referred to ­collectively as “psychotherapy”) began appearing in the late nineteenth century ce (twenty-­two publications from 1883 to 1899). It increased exponentially in the first decade of the twentieth century ce, and continued to do so over the next five decades (over 26,000 publications from 1900 to 1960). The rapid increase then slowed somewhat, but still doubled and tripled over the following decades, yielding almost 250,000 publications from 2000 to 2018. On the other hand, as shown in the second column of Table 3.2, the number of publications that contained both “psychotherapy” and “professional ethics” followed a strikingly different pattern. There was not a single publication that contained both terms during the nineteenth century ce. Furthermore, over the first four decades of the twentieth century ce, a time when psychotherapy was developing rapidly, there was a total of only one publication containing both terms. It was not until the next two decades (1940 to 1959) that publications with both terms began appearing regularly. At first, the number was quite small (less than two a year) until the two decades beginning in 1960, when the number of publications increased by 700 percent (to about 14 per year, on average). The average number of publications per year where both terms appeared continued to increase substantially decade over decade, with an average count since 2000 of 176 per year. What explains the above pattern of very slow attention to the ethics of psychotherapy in the first few decades of the twentieth century ce, despite the rapid growth of psychotherapy? Interestingly, comparing the results in the second and third columns of Table  3.2 ­indicates that the pattern for attention to the ethics of psychotherapy is not limited to psychotherapy; rather, it is very similar to the pattern for professional ethics as a whole, about which significant attention did not appear until the fifth decade. Sinclair (1993, 2012, 2017) and Sinclair et al. (1996) propose two main reasons for this pattern; one related to events during World War II, and one related to concerns about the concept of “profession.” The first played itself out from 1940 to 1959; the second began during the late 1960s, lasting through to the 1980s.

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56   What Do Psychotherapists Need to Know about Ethics?

The Influence of World War II By 1940, none of the newer professions of the late nineteenth and early twentieth centuries ce (e.g., dentistry, nursing, psychology, and social work) had developed formal codes of ethics. In addition, although the few publications on ethics indicated very similar values and concerns as those addressed in the ethics documents of the earliest historical period (e.g., confidentiality, avoiding conflicts of interest), there was little attention to the need for ethics codes or guidelines, or to a profession’s responsibility to society to protect the public from incompetent or unethical conduct. Rather, ethics seemed to be treated as a personal matter, with an apparent assumption that members of any profession would be persons of high moral character who would know what was right or wrong, and behave accordingly (Sinclair 2017). The aftermath of World War II brought a major change to this perception, when the world became aware of the highly harmful research conducted by physicians on concentration camp inmates (e.g., Lifton 2017 [1986]). The research studies often resulted in long-­ term harm and even death, and the research participants had had no choice about whether they participated. The research was carried out despite physicians having sworn the Hippocratic Oath. In defending themselves during the Nuremberg trials, their justification for these acts was that the concentration camp victims were not patients; therefore, such codes as the Hippocratic Oath did not apply. They also argued that the experiments were a “contribution to knowledge” and could benefit society. They further defended their actions by pointing out that similar experiments had been conducted in other parts of the world. (Note: The other experiments cited in their defense invariably had been carried out with vulnerable persons—prisoners, unknowing hospital patients, persons who had been enslaved, or ­persons with developmental disabilities.) The fact that these events occurred served as a wake-­up call to the world. One immediate response was the Nuremberg Code of Ethics in Medical Research, which addressed the scientific component of a discipline, and included such principles as: (i) the need for informed consent; (ii) the responsibility to balance risks and benefits; and (iii) the unacceptability of doing harm to an individual for the purpose of benefiting society. However, the events also served as a wake-­up call to professions, raising consciousness about the importance of having codes of ethics that clearly state the discipline’s ideals and ethical principles, and that articulate behavioral expectations and rules, as well as the importance of paying much more attention to the need for ethics education of members and the monitoring of, and accountability for, professional behavior. Professional ethics was no longer seen as just a personal matter, but rather the responsibility of the profession as a whole. The responsibility of professionals to those they served and to society in general, became a much discussed matter, and the newer professions began to develop ethics codes for their members at a rapid rate. By the late 1970s, Levy (1974) found eighty-­nine human service occupational groups in the United States with a code of ethics.1 1 This pattern has continued to the present day. By 1990, the Office of Scientific Freedom and Responsibility of the American Association for the Advancement of Science (AAAS) reported that they had collected 153 codes of ethics. Of these, twelve were from countries outside the United States, and eight were codes of international associations (Sinclair 1993: 178). Today, it would be difficult to find a discipline or a region of the world that does not have a code of ethics to which it refers. In addition to

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Concerns Related to the Concept of “Profession” A parallel development after World War II, however, was increasing concern about “the professionalization of society” (Freidson  1986). The twentieth century ce was seeing a ­burgeoning number of occupations identifying themselves as professions, and asking to be recognized as such by society. This led to considerable discussion in the sociological and professional literature. By the 1980s, there was growing agreement (Jennings et al. 1987; Kultgen  1988; Newton  1988; Rychlak  1984; Sinclair  1993; Sinclair et al.  1987; Weissman 1984) that an occupation should be recognized as a profession only if it had the following characteristics: 1. Members individually and/or collectively render service to members of the public and to society. 2. Members possess a high degree of generalized and systematic knowledge and skill, requiring long and intense education, extended practice, and continuing education. 3. Members develop and promote a code of ethics, and function in accordance with this code. 4. Members function as a community that: (a) controls entry requirements; (b) trains new members; (c) socializes new members into the attitudes, values, and accepted practices of the community; (d) regulates and monitors the professional activities of members; and (e) develops its field of knowledge and skill. 5. Members are accountable, willing to subject their activities to scrutiny both from within their own community and from society at large. Two distinct views of professionalization emerged. Kultgen (1988) called the first view the “functionalist perspective.” Those who took this view “approve of what they see” (Kultgen 1988: 7), and emphasized the societally beneficial characteristics of professions. Those who took the second view, called the “conflict perspective,” saw professionalization as primarily a class struggle involving the domination of some groups by others, and considered the development of ethics codes and other professionalization structures as “window dressing.” To support their view, they pointed to the frequent inclusion in recently developed ethics codes of statements that were oriented primarily to professional self-­protection and status, rather than to the responsibility for ethical behavior and concern about the well-being of members of the public. Many in this camp proposed that the development of new professions should be discouraged; some that it should be eliminated. (For discussions of this perspective, see Gross 1978, 1984; Illich et al. 1977; Larson 1977.) The discourse regarding these two perspectives raised awareness within the professions of the pros and cons of professionalization. In turn, this led to professions becoming more conscious when developing national codes, several international codes and ethical frameworks for codes have been developed (e.g., International Association of Applied Psychology’s Universal Declaration of Ethical Principles for Psychologists, 2008; International Association of Marriage and Family Counselors Code of Ethics, 2017; International Federation of Social Workers’ Global Social Work Statement of Ethical Principles, 2018; and World Medical Association’s International Code of Medical Ethics, 2006). In some of this work, particular attention was given to ensuring that non-­Western and Indigenous values and world views are reflected, not just those of the Western world (e.g., Gauthier and Pettifor 2012; Prentice et al. 2017).

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58   What Do Psychotherapists Need to Know about Ethics? or revising their codes of ethics and other professionalization structures, taking care to avoid “slipping into trade unionism” (American Psychological Association  1964: 170) or being guided primarily by self-­interest (e.g., Zemlick 1980) rather than by the motivation to protect the public and promote the highest standards of ethical behavior. As summarized by Sinclair: Kultgen (1988) proposes a rapprochement between the functionalist and conflict perspectives. He postulates that the increased rate of professionalization is a natural and logical result of the progress of scientific and technological knowledge, and that a division of labor, roles and expertise is essential to today’s complex society. Through the assignment of particular responsibilities to specialized experts, he believes that professionals serve the welfare of clients, employers and society as a whole . . . in order to avoid a destructive impact on society, all professions, or occupations aspiring to be professions, must become true “moral communities,” that is, groups of persons who have a genuine commitment to a clear and socially responsible ethic, show evidence of effectively socializing and regulating their members in the context of this ethic, and are actively accountable to the public for their activities. (Sinclair 1993: 174)

Other Influences The intense dialogue regarding “the professionalization of society” raised consciousness in the professions about the importance of ethics codes being ethics documents that guide and promote high ethical standards, rather than just vehicles of professionalization. There was increasing recognition of the importance of ethics in a world that seemed to be becoming ever more complex. The remainder of this section will briefly outline the journey of psychotherapy ethics from 1960 to the present, weaving components such as moral theory and moral character into the overall narrative, rather than treating them separately as done in the previous two sections. Tracing this journey is a somewhat daunting task, insofar as the PsycINFO search indicated that there was a total of 6,136 publications on psychotherapy ethics from 1960 to 2018 (see column three of Table 3.2). It would be difficult indeed to cover all the changes and influences in a way that does even small justice to the journey. However, to provide a framework for an overview, another PsycINFO search was carried out. This second search looked for specific topics within the 6,136 publications. Twenty topics were chosen, which can be broken down into three categories. The first category included topics related to moral theory (e.g., deontological and utilitarian ethics, virtue ethics, relational ethics). The second category included topics related to four ethical principles commonly found in professional ethics: (i) respect for dignity and rights (e.g., consent/autonomy, confidentiality, justice/ fairness, culture, diversity, culture, and sex/gender); (ii) beneficence/non-­maleficence (e.g., competence, self-­knowledge, benefit/harm, and effectiveness); (iii) integrity (e.g., multiple relationships; power); and (iv) responsibility to society (e.g., codes/guidelines, social responsibility, and licensing). The third category related to ethical reasoning and decision making, and ethics education. For each topic, several related words or phrases were included in the search. For instance, the search for justice/fairness included the words “justice” and “fairness,” but also included “social justice” and “discrimination”; the search for consent

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Table 3.3  Number of publications on specific topics related to psychotherapy and professional ethics combined, appearing in PsycINFO, per modern time period, listed in order of rank 1960–1979

1980–1999

2000–2018

Confidentiality (50) Codes/guidelines (39) Consent/autonomy (29) Benefit/harm (28) Sex/gender (20) Effectiveness (18) Competence (14) Power (14) Licensing (13) Social responsibility (6) Ethics education (1) Virtue ethics/character (1) Self-­knowledge (1)

Codes/guidelines (541) Confidentiality (495) Consent/autonomy (343) Benefit/harm (237) Ethical reasoning (231) Competence (179) Multiple rel’ps (174) Effectiveness (149) Licensing (141) Ethical principles (136) Culture (121) Power (92) Justice/fairness (73) Ethics education (52) Self-­knowledge (38) Diversity (37) Sex/gender (21) Social responsibility (21) Relational ethics (18) Virtue ethics/character (8)

Codes/guidelines (991) Consent/autonomy (517) Confidentiality (576) Competence (501) Ethical reasoning (496) Multiple rel’ps (469) Culture (438) Benefit/harm (430) Effectiveness (300) Ethical principles (234) Licensing (204) Justice/fairness (172) Power (140) Diversity (129) Self-­knowledge (86) Ethics education (75) Virtue ethics/character (37) Sex/gender (37) Social responsibility (37) Relational ethics (30)

included “autonomy” and “self-­determination”; the search for self-­knowledge included “self-­awareness,” “self-­care,” and “self-­regulation”; and the search for multiple relationships included “dual relationships” and “boundaries.” The results of this PsycINFO search can be found in Table  3.3, divided into three blocks of time consisting of approximately twenty years each. One of the first observations that can be made readily from Table 3.3 is that attention to ethics codes and guidelines was consistently very high throughout the three time periods. Publications on this topic centered on such issues as the purposes, development, application, content, and format for ethics codes, as well as the need for and development of supplementary ethical guidelines for specific areas of activity (e.g., Hare-­ Mustin et al. 1979; Herlihy and Corey 1997; McAuliffe et al. 2012). The next most frequently occurring topics on the ranked lists in Table 3.3 are very similar to the topics found in the majority of professional ethics documents throughout history, namely confidentiality, consent, and benefit/harm. The large increase in publications on confidentiality seems to have been partly in response to an increase in work with special populations (e.g., children, adolescents, older adults), as well as to an increase in the number of forms of service (e.g., group therapy, couples therapy, family therapy). (See, for instance, Hendrix 1991; Hines and Hare-­Mustin 1978; Jenkins 2010.) However, further influence can be seen from legal cases (e.g., Tarasoff), growing interactions with the courts, and the development of privacy laws (e.g., Bersoff 1976; Kachigian and Felthous 2004; Wulsin et al. 1983). Publications on consent also were influenced by work with special populations and growth

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60   What Do Psychotherapists Need to Know about Ethics? in types of service; however, in addition, they show the influence of concept of informed consent as first introduced in the Nuremberg Code of Ethics in Medical Research (e.g., Handelsman et al. 1986; Noll 1976; Saks and Golshan 2013). Although lower in rank, publications on topics related to beneficence and non-maleficence (e.g., benefit/harm, competence, effectiveness, self-­knowledge) also show a consistent presence across the three time periods, and the publications themselves increase in the complexity of the ethical analysis of the issues (e.g., Bongar 1992; Pompeo and Levitt 2014; Stevens et al. 1979). Although consistently low in rank, the same can be said of publications on the topic of social responsibility, partly influenced by the sociological discussion of the 1970s and Kultgen’s concept of moral community and a contract with society (e.g., Bernet 1995; Bersoff 1976; Gobodo-­Madikizela 2009). Moving from topics that appear frequently and consistently across the three periods of time, of interest also is the observation that several topics are missing from the list for the first twenty-­year time period (1960–1979). These include: culture, diversity, fairness/justice, multiple relationships, ethical reasoning, ethical principles, and relational ethics. The importance of culture, diversity, and fairness/justice seems to have been influenced pri­ma­ rily by the growing multicultural nature of our societies and by globalization, especially since 1990. Once it appeared, “diversity” grew from being defined primarily as differences in sex/gender, age, socioeconomic status, etc., to a definition that also included differences in culture, language, religion, and worldviews. Over time, non-­discrimination, self-awareness, and striving to meet the ideal of respect for equal worth and dignity of all human beings became more of a challenge. This led to considerable ethical discourse in the literature (e.g., Hurley and Gerstein 2013; Pedersen 2008; Vasquez and Eldridge 1994). The fact that the topic of multiple relationships does not appear in the list for the first twenty-­year period is also notable. Interestingly, attention to power and power imbalances existed during this earlier time period and had entered the ethical discourse on sexual harassment and sexual intimacies with clients and students. However, it did not lead to much awareness of the ethical issues surrounding multiple relationships until the 1980s’ rising awareness of the importance of avoiding conflicts of interest and of the ethical responsibility to put the client’s best interests first when there are such conflicts (e.g., Gutheil and Gabbard 1998; Lerman and Rigby 1990; Peternelj-­Taylor and Yonge 2003; Simon and Williams 1999; Zur 2017). As a final observation, and perhaps the most important to the development of professional ethics over the past few decades, is the fact that topics such as ethical principles, ethical reasoning, and relational ethics seemed to explode onto the scene in the 1980s, and have had a significant impact on professional ethics since then. The sociological discussion and misgivings, which arose primarily during the 1970s and are outlined earlier in this chapter, seem to have been taken very seriously by the professions. This resulted in a return to paying attention to the relevance of moral theory. However, the emphasis has changed from seeing one moral theory as superior to others for guiding professional behavior, to viewing all moral theory as relevant and helpful. As just one example of this, the emphasis on ethical principles (both deontological and utilitarian) has changed the focus of many ethics codes. In addition, the twentieth century ce development of relational ethics (derived from feminist ethics) also has been very influential. It has helped change the concept that ethics is primarily the concern and preserve of independent rational individuals, to the concept that it primarily reflects and is drawn from our human interdependence and

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Conclusion   61 c­ onnectedness (relationships). Combined with continued and growing attention to moral character and virtue ethics, being ethical is no longer seen as just knowing and following the rules or behavioral prescriptions of a professional code, but as a commitment to “doing the right thing,” and being able to detect ethical issues and problems. It also includes having the ability to understand and apply ethical values and principles to situations not covered by rules or where rules conflict, think through the consequences, and choose an ethical course of action. (See e.g., Cottone and Tarvydas 2016; Gabriel and Casemore 2009; Kitchener 1984; Pope and Vasquez 2016; Rave and Larsen 1995; Vasquez 1996).

Conclusion In conclusion, what does the history of professional ethics teach us about being ethical as psychotherapists today? First, it teaches us that professional ethics was not “invented” by us; rather it reflects our common humanity and connectedness to those who have preceded us. It has its roots in ancient times, and many of the ethical values we espouse today are fairly universal, insofar as they go back thousands of years and can be found in early ethics documents from around the world. Second, it tells us that ethical values, codes, moral character, the concept of “profession,” and moral theory all have played important roles in the efforts of professionals to determine what is right and wrong ethical behavior. In addition, it teaches us that being ethical is not a matter of only being of good character, or only having a professional identity, or only knowing and understanding the ethical rules of one’s profession, or only having the ability to apply ethical principles and moral theory to problematic situations. Rather, it requires all of these. However, the history of professional ethics also provides us with lessons about what can go wrong, and how much harm can be done, when professionals do not act as members of a moral community that has a genuine commitment to a clear and socially responsible ethic, but instead gets caught in striving for goals (e.g., “territory,” status, and recognition) that do not support the best interests of those served. It teaches us that, in order to maximize our efforts to be ethical, it is important to: have ethics codes that clearly state a profession’s ideals and ethical principles, not just its rules; engage in continuous improvement of our ethical knowledge, ethical reasoning, and ethical decision making; and be involved in ongoing development and strengthening of our moral character.

References Adelaide Centre for Bioethics and Culture (2013). “Bioethics Resources.” Retrieved from http://www. bioethics.org.au/Resources.html American Medical Association (1847). Code of Ethics of the American Medical Association. Retrieved from https://collections.nlm.nih.gov/catalog/nlm:nlmuid-63310430R-bk American Psychological Association Committee on Scientific and Professional Ethics and Conduct, Ad hoc Committee on Ethical Practices in Industrial Psychology (1964). “Ethical Practices in Industrial Psychology: A Review of One Committee’s Deliberation.” American Psychologist 19: 174–182. Bernet, W. (1995). “Running Scared: Therapists’ Excessive Concerns about Following Rules.” Bulletin of the American Academy of Psychiatry and the Law 23: 367–374.

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62   What Do Psychotherapists Need to Know about Ethics? Bersoff, D. N. (1976). “Therapists as Protectors and Policemen: New Roles as a Result of Tarasoff?” Professional Psychology 7: 267–273. Bongar, B. (1992). “The Ethical Issue of Competence in Working with the Suicidal Patient.” Ethics and Behavior 2: 75–89. Cottone, R. R. and Tarvydas, V. (2016). Ethics and Decision Making in Counseling and Psychotherapy (4th ed.). New York: Springer. Dolgoff, R., Harrington, D., and Loewenberg, F. M. (2012). Ethical Decisions for Social Work Practice (9th ed.). Belmont, CA: Brooks/Cole. Edelstein, L. (1943). The Hippocratic Oath: Text, Translation, and Interpretation. Baltimore, MD: Johns Hopkins University Press. Translation retrieved from https://hslmcmaster.libguides.com/c. php?g=306726&p=2044095 Flexner, A. (1915). “Is Social Work a Profession?” Social Work History Project. Retrieved from https:// socialwelfare.library.vcu.edu/social-work/is-social-work-a-profession-1915/ Fowler, S. M. (n.d.). Introduction: Reflecting on the Eye of Ethics Series. [Website of the Society for Intercultural Education, Training and Research.] Retrieved from https://www.sietarusa.org/page-1416481 Freidson, E. (1986). Professional Powers: A Study of the Institutionalization of Formal Knowledge. ­Chicago, IL: University of Chicago Press. Gabriel, L. and Casemore, R. (eds.) (2009). Relational Ethics in Practice: Narratives from Counselling and Psychotherapy. New York: Routledge. Gauthier, J. and Pettifor, J.  L. (2012). “The Tale of Two Universal Declarations: Ethics and Human Rights.” In The Oxford Handbook of International Psychological Ethics (ed. M. M. Leach, M. J. Stevens, G. Lindsay, A. Ferrero, and Y. Korkut, pp. 113–133). Oxford: Oxford University Press. Gidney, R. D. and Millar, W. P. J. (1994). Professional Gentlemen: The Professions in Nineteenth-Century Ontario. Toronto, ON: University of Toronto Press. Gobodo-Madikizela, P. (2009). “Exploring the Ethical Principle of Social Responsibility and Other Ethical Issues in the Context of the Mental Health Professionals' Response to Xenophobic Violence in Cape Town.” Psychoanalytic Psychotherapy in South Africa 17: 73–95. Gross, S. J. (1978). “The Myth of Professional Licensing.” American Psychologist 11: 1009–1016. Gross, S.  J. (1984). Of Foxes and Hen Houses: Licensing and the Health Professions. Westport, CT: Quorum Books. Gutheil, T. G. and Gabbard, G. O. (1998). “Misuses and Misunderstandings of Boundary Theory in Clinical and Regulatory Settings.” The American Journal of Psychiatry 155: 409–414. Handelsman, M. M., Kemper, M. B., Kesson-Craig, P., McLain, J., and Johnsrud, C. (1986). “Use, Content, and Readability of Written Informed Consent Forms for Treatment.” Professional Psychology: Research and Practice 17: 514–518. Hare-Mustin, R. T., Marecek, J., Kaplan, A. G., and Liss-Levinson, N. (1979). “Rights of Clients, Responsibilities of Therapists.” American Psychologist 34: 3–16. Hendrix, D. H. (1991). “Ethics and intrafamily confidentiality in counseling with children.” Journal of Mental Health Counseling 13: 323–333. Herlihy, B. and Corey, G. (1997). “Codes of Ethics as Catalysts for Improving Practice.” In The Hatherleigh Guide to Ethics in Therapy (pp. 37–56). New York: Hatherleigh Press. Hines, P.  M. and Hare-Mustin, R.  T. (1978). “Ethical Concerns in Family Therapy.” Professional Psychology 9: 165–171. Hurley, E. J. and Gerstein, L. H. (2013). “The Multiculturally and Internationally Competent Mental Health Professional.” In Internationalizing Multiculturalism: Expanding Professional Competencies in a Globalized World (ed. R. L. Rowman, pp. 227–254). Washington, DC: American Psychological Association. Illich, I., Zola, I. K., McNight, J., Caplan, J., and Shaiken, H. (1977). Disabling Professions. London: Marian Boyers. International Association of Applied Psychology (2008). Universal Declaration of Ethical Principles for Psychologists. Retrieved from http://www.iupsys.net/about/governance/universal-declarationof-ethical-principles-for-psychologists.html

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Conclusion   63 International Association of Marriage and Family Counselors (2017). IAMFT Code of Ethics. ­Retrieved from http://www.iamfconline.org/public/IAMFC-Ethical-Code-Final.pdf International Federation of Social Workers (2018). Global Social Work Statement of Ethical ­Principles. Retrieved from https://www.iassw-aiets.org/2018/04/18/global-social-work-statementof-ethical-principles-iassw/ Jenkins, P. (2010). “Having Confidence in Therapeutic Work with Young People: Constraints and Challenges to Confidentiality.” British Journal of Guidance and Counselling 38: 263–274. Jennings, B., Callahan, D., and Wolf, S.  M. (1987). “The Professions: Public Interest and Common Good.” Hastings Center Report: Special Supplement 17 (February): 3–10. Kachigian, C. and Felthous, A. R. (2004). “Court Responses to Tarasoff Statutes.” Academy of Psychiatry and the Law 32: 263–273. Kitchener, K. S. (1984). “Intuition, Critical Evaluation and Ethical Principles: The Foundation for Ethical Decisions in Counseling Psychology.” The Counseling Psychologist 12: 43–55. Kultgen, J. (1988). Ethics and Professionalism. Philadelphia, PA: University of Pennsylvania Press. Larson, M. S. (1977). The Rise of Professionalism. Berkeley, CA: University of California Press. Lerman, H. and Rigby, D.  N. (1990). “Boundary Violations: Misuse of the Power of the Therapist.” In Feminist Ethics in Psychotherapy (ed. H.  Lerman and N.  Porter, pp. 51–59). New York: Springer. Levy, C. S. (1974). “On development of a code of ethics.” Social Work 53: 207–216. Lifton, R. J. (2017 [1986]). The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York: Basic Books. McAuliffe, D., Sauvage, D., and Morrisey, S. (2012). “Integrity Provisions in Response to Practitioner Sexual Boundary Violations in Australia: A Comparative Analysis.” Psychiatry, Psychology and Law 19: 45–59. Newton, L. H. (1988). “Lawgiving for Professional Life: Reflections on the Place of the Professional Code.” In Professional Ideals (ed. A. Flores, pp. 47–56). Belmont, CA: Wadsworth. Noll, J. O. (1976). “The Psychotherapist and Informed Consent.” The American Journal of Psychiatry 133: 1451–1453. Pedersen, P. B. (2008). “Ethics, Competence, and Professional Issues in Cross-Cultural Counseling.” In Counseling across Cultures (ed. P. B. Pedersen, J. G. Draguns, W. J. Lonner, and J. E. Trimble, pp. 5–20). Thousand Oaks, CA: Sage Publications. Percival, T. (1803). Medical Ethics (Reprint). South Yarra, Australia: Leopold Publishing. Retrieved from www.leopoldclassiclibrary.com Peternelj-Taylor, C. A. and Yonge, O. (2003). “Exploring Boundaries in the Nurse–Client Relationship: Professional Role and Responsibilities.” Perspectives in Psychiatric Care 39: 55–66. Pompeo, A. M. and Levitt, D. H. (2014). “A Path of Counsellor Self-Awareness.” Counseling and Values 59: 80–94. Pope, K. S. and Vasquez, M. J. T. (2016). Ethics in Psychotherapy and Counseling: A Practical Guide (5th ed.). Hoboken, NJ: Wiley. Prentice, J., Dobson, K. S., and Gauthier, J. (2017). “Ethics from a Global Perspective.” In International Perspectives on Psychotherapy (ed. S. G. Hofmann, pp. 241–257). New York: Springer International. Rave, E. J. and Larsen, C. C. (eds.) (1995). Ethical Decision Making in Therapy: Feminist Perspectives. New York: Guilford Press. Reich, W. T. (ed.) (1995). Encyclopedia of Bioethics (Vol. 5, rev. ed.). New York: Macmillan. Rychlak, J. F. (1984). “Newtonianism and the Professional Responsibility of Psychologists: Who Speaks for Humanity?” Professional Psychology: Research and Practice 15: 82–95. Saks, E. R. and Golshan, S. (2013). Psychoanalytic Interventions. Informed Consent to Psychoanalysis: The Law, the Theory, and the Data. New York: Fordham University Press. Simon, R. I. and Williams, I. C. (1999). “Maintaining Treatment Boundaries in Small Communities and Rural Areas.” Psychiatric Services 50: 1440–1446. Sinclair, C. (1993). “Codes of Ethics and Standards of Practice.” In Professional Psychology in Canada (ed. K. S. Dobson and D. J. G. Dobson, pp. 167–199). Toronto, ON: Hogrefe and Huber.

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64   What Do Psychotherapists Need to Know about Ethics? Sinclair, C. (2012). “Ethical Principles, Values, and Codes for Psychologists: An Historical Journey.” In International Handbook of Psychological Ethics (ed. M. Leach, M. Stevens, G. Lindsay, A. Ferrero, and Y. Korkut, pp. 3–18). New York: Oxford University Press. Sinclair, C. (2017). “Ethics in Psychology: Recalling the Past, Acknowledging the Present, and Looking to the Future.” Canadian Psychology 58: 20–29. Sinclair, C., Poizner, S., Gilmour-Barrett, K., and Randall, D. (1987). “The Development of a Code of Ethics for Canadian Psychologists.” Canadian Psychology 28: 1–8. Sinclair, C., Simon, N. P., and Pettifor, J. L. (1996). “The History of Ethical Codes and Licensure.” In Professional Conduct and Discipline in Psychology (ed. L. J. Bass, S. T. DeMers, J. R. P. Ogloff, C. Peterson, J. L. Pettifor, R. P. Reaves, T. Rétfalvi, N. P. Simon, C. Sinclair, and R. M. Tipton, pp. 1–15). Washington, DC: American Psychological Association, and Peachtree City, GA: Association of State and Provincial Psychology Boards. Stevens, J., Yock, T., and Perlman, B. (1979). “Comparing Master’s Clinical Training with Professional Responsibilities in Community Health Centers.” Professional Psychology 10: 20–27. Vasquez, M. J. T. (1996). “Will Virtue Ethics Improve Ethical Conduct in Multicultural Settings and Interactions?” The Counseling Psychologist 24: 98–104. Vasquez, M.  J.  T. and Eldridge, N.  S. (1994). “Bringing Ethics Alive: Training Practitioners about ­Gender, Ethnicity, and Sexual Orientation Issues.” Women and Therapy 15: 1–16. Weissman, H. N. (1984). “Professional Standards from the Perspective of the Sociology of Professions.” Professional Psychology: Research and Practice 15: 471–472. World Medical Association (2006). International Code of Medical Ethics. Retrieved from https://www. wma.net/policies-post/wma-international-code-of-medical-ethics/ Wulsin, L. R., Bursztajn, H., and Gutheil, T. G. (1983). “Unexpected Clinical Features of the Tarasoff Decision: The Therapeutic Alliance and the ‘Duty to Warn’.” The American Journal of Psychiatry 140: 601–603. Zemlick, M. J. (1980). “Ethical Standards: Cosmetics for the Face of the Profession of Psychology.” Psychotherapy: Theory, Research, and Practice 17: 448–453. Zur, O. (ed.) (2017). Multiple Relationships in Psychotherapy and Counseling: Unavoidable, Common, and Mandatory Dual Relationships in Therapy. New York: Routledge.

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chapter 4

The History a n d Ethics of th e Ther a peu tic R el ationship Ulrich Koch and Kelso Cratsley

“Psychological therapies can be defined as interventions that utilize language and relationships to explore mental experience with the aim of improving mental health and reducing psychological distress.”  (Adshead 2015: 1250)

Introduction This chapter reviews past and present debates surrounding the ethics of the therapeutic relationship. We take a broad historical approach, tracing the shifting fortunes of the ­therapeutic relationship while drawing out relevant ethical implications. Such an approach of course reminds us that treatments emphasizing the relational dynamics of the clinical encounter have always been ethically contentious (Tjelveit, this volume). Throughout the history of psychiatry and psychotherapy, practitioners have frequently raised ethical concerns about specific treatment methods and, particularly in the last three decades of the twentieth century, about the potential risks of relational practices. Notable examples include longstanding concerns in the psychoanalytic tradition regarding analytic neutrality (Leider  1983), and ongoing debates over boundary violations in various traditions (Gabbard 2009). A historical perspective allows for the identification of such continuities and discontinuities, with each psychotherapeutic tradition associated with distinctive ethical challenges. It is also consistent with recognition that the ever-changing social and moral landscape has often prompted re-evaluation and reform of clinical practice. Therapeutic relationships are never forged in a sociocultural vacuum; social forces shape clinical practice, and moral concerns surrounding the therapeutic relationship have changed over time.

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66   History and Ethics of the Therapeutic Relationship In the following, we distinguish between three different ways of conceptualizing the t­ herapeutic relationship and its ethical implications, situated in historical context. We begin with a focus on the idea, perhaps best represented by the psychoanalytic tradition, that the clinical encounter itself constitutes the medium, and often the primary means, of psychotherapy (“Relationship as method”). Here the ethical questions have to do with the challenge of curtailing dependence on the psychoanalyst that such treatments may engender, as well as related concerns about boundary violations. Next, we turn to the recent proliferation of treatments that rely upon a more collaborative relationship to support the transmission of cognitive, emotional, and social skills—seen most clearly in cognitive behavioral approaches (“Relationship as skill”). The ethical tensions here largely concern the possibility of endorsing implicit values that may not coincide with those of the individuals undergoing treatment, alongside questions regarding the special demands relational practices make of clinicians. In the third section, we discuss issues arising from the turn towards evidence-based treatment, particularly the growing body of research suggesting that relationships are a foundational component of psychotherapy and psychiatric interventions of all types (“Relationship as foundation”). This shift has wide implications, concerning the quality of the available evidence and the ethics of influence in clinical interactions. The final section describes several newly emerging challenges and offers brief critical commentary.

Relationship as Method Physicians have long recognized the importance of establishing an emotional connection or rapport with patients. Prior to the major therapeutic advances of the twentieth century, bedside medicine had traditionally relied on the doctor–patient relationship as a source of comfort and a means to build trust and ensure treatment adherence (Shorter 1992). By the end of the nineteenth century, more targeted interpersonal interventions such as hypnosis had found adherents among several heterodox physicians prone to clinical experimentation, among them the Viennese neurologist Sigmund Freud (Ellenberger 1970; Shamdasani 2003). Although, the founder of psychoanalysis would soon distance his own practice from those of his colleagues who employed suggestive techniques (Freud 1919). Psychoanalytic treatment, in its purest form, aims to provide patients insight into the workings of their unconscious. Yet intellectual insights, arrived at through interpretations, are hardly the sole ingredient of a successful psychoanalysis. To make sense of what he ­conceived to be obstacles in the treatment process, Freud (1905) repurposed the term “Übertragung” or transference to describe the emergence of impulses and phantasies that seemed to be directed towards the psychoanalyst but instead originated in the patient’s past (Makari 1992). It should be noted, though, that Freud’s notion of transference was but one attempt to conceptualize a particular relational aspect of the clinical encounter; other authors would devise their own conceptual tools to describe varying aspects of the therapeutic relationship.1 Later, Freud (1910,  1912) introduced the complementary notion of countertransference, the psychoanalyst’s unconscious response to the patient’s affective 1  A dynamic similar to transference was given the name “parataxis” by the American psychiatrist and psychoanalyst Harry Stack Sullivan (1954).

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relationship as method   67 reaction, and distinguished between positive transferences, such as erotic phantasies or feelings of admiration, and negative transferences, as in anger and other forms of aggression. Early discussions of transference and countertransference likely served as warnings to fellow psychoanalysts regarding the persistent dangers of emotional entanglements and sexual transgressions, which, to some degree, accounted for the way Freud portrayed transference dynamics in his writings (Cremerius 1984). Transference, whether positive or negative, was understood to be a manifestation of a patient’s defenses during psychoanalysis. By drawing on the notion of transference, then, the analytic relationship itself could become the object of interpretations and analyzed. Psychoanalysts no longer only operated through the clinical encounter; Freud set an influential precedent for working “on and with the therapeutic relationship” (Boothe and Grimmer 2004).

Negotiating Neutrality In the United States, which would quickly become the intellectual center of psychoanalysis with the influx of European analysts during the 1930s and 1940s, a rigid, so-called “orthodox” style of doing analysis was taught at the elite training institutions (Hale 1995). The stereotypical psychoanalyst of the postwar years remained aloof and taciturn during analysis, displaying few if any signs of emotion. Whatever the historical accuracy of this depiction and the actual reach of such practices, orthodox Freudians at least conceived of the psychoanalytic situation as akin to an experiment that demanded the neutral, objective stance of an uninvolved observer (Koch 2017). The therapeutic stance that would later be described as one of “neutrality” had only been discussed briefly by Freud (1914), who recommended that analysts should approach their patients’ complaints with impartiality. In subsequent decades, neutrality became conceived of as a technical precondition of psychoanalysis, ensuring both the procedure’s clinical effectiveness as well as the scientific validity of its findings. It was only in the last third of the twentieth century that discussions of neutrality regularly included warnings that psychoanalysts should refrain from imposing their values on their patients (e.g., Hoffer 1985). The “classical” conception of the analytic relationship was never left unchallenged. A broadening of psychoanalysis’ client base during the interwar years had been a ferment for technical innovation. One important countercurrent was shaped by the work of two of Freud’s contemporaries and former collaborators, Otto Rank and Sándor Ferenczi. In The Development of Psychoanalysis from 1924, they suggested that the patient’s experience of the  analytic situation was key to recovery, rather than intellectual insight (Ferenczi and Rank 1925 [1924]). In the United States, psychoanalytically trained psychiatrists and social workers shifted the focus of their respective practices to patients’ current emotional struggles and interpersonal relationships. The psychoanalytic treatment of children, pioneered by prominent figures such as Anna Freud and Melanie Klein (in the United Kingdom) and lesser known ones such as Jessie Taft (in the United States), also called for technical modifications and prompted theorizing that would eventually transform the psychotherapeutic treatment of adults (Hughes 2019). Broadly speaking, these countercurrents assigned the therapist a more active role, and reductionist interpretations of the therapeutic relationship, according to which transference phenomena were always rooted in the patient’s past, gave way to more elastic views, often

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68   History and Ethics of the Therapeutic Relationship informed by the social-scientific study of human relations. In the 1940s, for instance, Franz Alexander proposed that successful analyses entailed a “corrective emotional experience” (Alexander 1946, 1950). He and his colleagues argued that long-term analyses were often unnecessary and protracted, fostering dependence on the analyst rather than promoting self-reliance (Alexander and French 1946). Defenders of the “classical” method such as Kurt Eissler countered that short-term therapy could never lead to true independence, since the latter required a transformation of character which the superficial methods were unlikely to achieve (Eissler 1950). Dependence, then, was conceived of quite differently by orthodox Freudians and those adopting more flexible techniques. Defenders of the classical method maintained that psychoanalysis provided the means to free neurotics from the restraints imposed on them by unconscious conflicts. On this view, independence was not a given, not a state, but rather a goal an individual strived towards. Reformers, on the other hand, acknowledged that patients gave up some of their independence by undergoing psychoanalytic treatment and that therapies involving intense transferences, sustained over long periods of time, came with considerable risks.2 Given that a classic psychoanalysis involves an intense meeting schedule and an emotional reliving of childhood, then, worries about iatrogenic dependency were never far off. Neither were concerns about the pitfalls of becoming involved with or sexually exploiting patients, even as the profession failed to effectively address the persistent issue of boundary violations. Undergirding the orthodox notion of mastery over and independence from internal conflicts was a teleological view of human development, which the historian Eli Zaretsky (2015) called the “maturity ethic” of psychoanalysis. “Maturity, according to Freud,” wrote the cultural critic Philipp Rieff in defense of what he termed the “analytic attitude,” “lay in the trained capacity to keep the negotiations [between culture and instinct] from breaking down” (Rieff 2006 [1966]: 24). In practice, though, it was left to the clinician to determine when this developmental goal had been reached. A technical understanding of neutrality, in other words, was easily reconciled with—and could even serve as justification of—paternalistic attitudes that upheld rigid postwar social norms. Indeed, the social and cultural rifts of the  late 1960s were about to expose the assumptions upon which the psychotherapeutic practices of the postwar years had rested. Once seemingly innocuous notions such as social and emotional adjustment, which had been espoused across various disciplines, now became suspect and seen as potentially oppressive. The sanity of the social order to which an individual had to adjust, critics charged, was itself never questioned (Staub 2011).3

Abandoning Neutrality Social transformations and political upheavals not only called into question the societal values ingrained in assessments of psychological functioning, they also challenged clinicians’ 2  Surveying the psychoanalytic scene at mid-century, their concerns appear at least somewhat justified: the average length of psychoanalyses had increased from months to years since the pioneering days of Freud (cf. Glover 1955). 3  Rieff (2006 [1966]) had taken the opposing, conservative view; namely, that “the gospel of freer impulse,” allegedly preached by proponents of the various therapeutic schools that had begun swarming the therapeutic marketplace in the 1960s, would tug at the strings of communal “faith” holding a culture together.

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Relationship as Skill   69 professional authority and social role as experts. Politicized mental health workers and patient groups problematized the social conditions held responsible for mental health problems as well as the questionable role the psychiatric profession played in identifying and treating the socially “deviant.” In light of the erupting political fault lines, maintaining moral neutrality was simply no longer an option for a growing number of politically engaged clinicians (Richert 2019). Aside from psychiatric institutions, a recurring focus of reformers’ efforts was the therapeutic relationship. Cases of sexual transgressions and other boundary violations had long been treated in a cavalier manner; some therapists had even suggested that having sex with a patient could be therapeutic in certain instances (Kim and Rutherford 2015). By the early 1970s, sexual abuses of the therapeutic relationship were denounced from within the profession, particularly by feminist psychotherapists, and exposed to the wider public in the popular press. Legislative changes also lowered the bar for medical malpractice suits, which further exposed accounts of abuse. Building on the influential work of Phyllis Chesler (1997 [1972]) feminist psychotherapists advocated an “egalitarian” view of the client–therapist relationship that considered the client “as his or her own expert” (Rader and Gilbert  2005: 427). The radical psychiatrist Claude Steiner had grown skeptical of the dyadic therapeutic relationship altogether, which he deemed an “elitist, outmoded, as well as nonproductive form of psychiatric help” (Steiner 1981: 725; quoted in Richert 2019: 53). Only through group therapy, he suggested, could one escape the power asymmetries that plagued traditional therapeutic relationships and extend support to a greater number of individuals. Despite obvious differences to the psychoanalytic methods, then, these radical proposals still employed the therapeutic relationship as a method to instigate personal or, as was the case with radical psychiatry, broader societal change. It must be noted that the various moral concerns stirred by psychotherapeutic practices during this period were often discussed under the rubric of politics or raised against the backdrop of ongoing social and cultural transformations (e.g. the so-called “psycho-boom” of the 1960s and 1970s; Tändler  2016); only gradually did the mental health professions begin to address them by developing applicable ethical standards. The American Psychiatric Association, for instance, declared sexual relations with patients unethical in 1973, and the American Psychological Association followed suit only in 1977 (Kim and Rutherford 2015). Ethical codes of conduct, in short, began taking aim at the most egregious boundary violations. As such they sought to protect patients from sexual and monetary exploitation—now widely rejected forms of malpractice.

Relationship as Skill In a liberal pluralistic society, paternalistic attitudes and abusive therapeutic relationships are difficult to ethically defend and uphold. Although procedures such as informed consent, standard in other fields of medicine, are still not consistently applied in psychotherapy (Trachsel et al. 2015; McKean et al., this volume), clinicians have gradually become sensitized to the power differential inherent to all therapeutic relationships and are well aware that a patient’s values and preferences may not align with their own or those of their profession.

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70   History and Ethics of the Therapeutic Relationship The scandals and radical experiments of the 1960s and 1970s may also have reminded ­practitioners that the asymmetries of the clinical encounter often serve to protect patients from exploitation and abuse, by ensuring that its focus remains the latter’s concerns and needs (see Adshead 2015). Indeed, given the centrality of this kind of “unidirectional” relationship for the practice of psychotherapy, the question arises whether some degree of paternalism is unavoidable in a caring professional relationship.

From Insight to Empathy Political activism and institutional reform weren’t the only drivers of the sweeping changes the field of mental health underwent in the latter half of the twentieth century. A less hierarchical view of the patient–provider relationship had already been proposed by Carl Rogers, whose work would decisively shape relational practices in that period (making them more consistent with the coming demands of the health consumer movements of the 1970s). With far fewer and less pronounced political overtones, the founder of client-centered therapy was critical of experts wielding influence when it came to human relations. The clients themselves set the goals of therapy, Rogers and his students maintained, hence they should also be the ones assessing their therapists’ performance (Lanzoni 2018). Like others who explicitly placed the relationship and the emotional experience—rather than insight— at the heart of their practice, Rogers initially honed his craft treating children. At the Rochester Guidance Center, before his tenure at the University of Chicago, he had come into contact with Rankian ideas and the methods the child guidance counselor and social worker Jessie Taft—Rank’s translator, biographer, and former analysand—was propagating at the Philadelphia School of Social Work (de Carvalho 1999; Kramer 1995; Lanzoni 2018). Rogers was among the first to stress the importance of the psychotherapist’s ability to express empathy and adopt the client’s personal frame of reference (Rogers  1942,  1959). Rogers’ techniques and empathic therapeutic stance had wide-ranging influences, even though—perhaps also because—he insisted that his approach did not constitute a method, but a principle applicable not just to therapy but a broad range of human interactions (Lanzoni 2018).4 However, not all have embraced the idea that empathy is central to therapy; the cognitive therapist Albert Ellis (1962), for instance, explicitly rejected it. Within psychoanalytic circles, as well, the analytic relationship was more lastingly reframed along similar lines, as Freudian drive theory lost ground to alternative theoretical viewpoints and treatment approaches rooted in notions of intersubjectivity. In the 1960s and 1970s, under the influence of the work of Heinz Kohut (2009 [1971]), who emphasized the need for empathy in the psychoanalytic treatment setting, and Otto Kernberg (1975), who proposed a synthesis of American ego psychology and British object relations theory, mainstream psychoanalytic practice in the United States was transformed from within. In addition, moving further beyond the constructs of “ego alliance” (Sterba 1934) and “therapeutic alliance” (Zetzel  1956), concepts such as “working alliance” or “real relationship” were devised to designate aspects of the analytic relationship that could not be reduced to transference but were nonetheless crucial for understanding what transpired during the 4  Rogers’ work has informed, for instance, theoretical frameworks developed in genetic counseling (Marks 1993) and motivational interviewing (Miller and Rollnick 2012).

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Relationship as Skill   71 therapy hour. Establishing and maintaining a therapeutic relationship no longer only served as a tool to uncover the unconscious but was now broadly recognized as a necessary skill to keep patients in treatment and effect change. The concept of the working alliance, first elaborated by the psychoanalyst Ralph Greenson (1967), has proved particularly useful to highlight clinically relevant aspects of the broader therapeutic relationship and has subsequently been adopted by the various psychotherapeutic schools. Integrating different psychoanalytic conceptualizations of the clinical encounter, the psychologist Edward Bordin influentially conceived of the “therapeutic working alliance” as comprised of three parts: a mutual agreement on (a) therapeutic goals as well as (b) the tasks needed to be carried out to achieve said goals, and (c) the development of an emotional bond between therapist and patient (Bordin 1979). A more recent review of theoretical and empirical work by Louise Gaston expanded this framework to also encompass the therapist’s empathy and the patient’s commitment to working in therapy (Gaston  1990). Needless to say, theories of the alliance have identified—and continue to elaborate—various potential components, with a marked degree of heterogeneity.

Collaborative Skills Training The idea that the relationship is not a method but provides the channel through which ­psychotherapeutic techniques are transmitted is particularly prominent in the writings of cognitive-behavioral therapy (CBT). The ways and extent to which the therapeutic relationship has been conceptualized and deliberately utilized, however, varies within the many different currents that comprise CBT. Its early supporters often eschewed the significance of the therapeutic relationship, likely in an attempt to demarcate CBT from other approaches. For instance, in their groundbreaking Cognitive Therapy for Depression, Aaron T. Beck and his co-authors asserted that unlike in “supportive” or “relationship” therapy, cognitive therapists employ the therapeutic relationship “not simply as the instrument to alleviate suffering but as a vehicle to facilitate a common effort in carrying out specific goals. In this sense, the therapist and patient form a ‘team’ ” (Beck et al. 1979: 54). Insofar as cognitive-behavioral interventions are thought of as more or less analogous to (other) medical interventions, the therapeutic relationship arguably becomes the neutral medium through which they are deployed. With their focus on skills training, such interventions promise to endow the patient with greater agency while offering fewer opportunities for engendering emotional dependence. On the other hand, for many practitioners the relationship never disappeared from view. Beginning in the early 1980s, there has been increased recognition among CBT researchers of the importance of relational aspects for treatment outcomes (e.g., Arnkoff 1983). And more recently, others have further emphasized the therapeutic alliance or relationship (Gilbert and Leahy 2007; Kazantzis et al. 2017), at times by drawing on earlier traditions such as Harry Stack Sullivan’s interpersonal theory (e.g., Safran  1990).5 These contributions show that collaborative relationships, like any

5  Beck and colleagues have also pointed out that efficacy significantly depends upon the quality of the therapeutic relationship, which requires “warmth,” “accurate empathy,” and “genuineness” on the part of the therapist (Beck et al. 1993: 135).

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72   History and Ethics of the Therapeutic Relationship other, need to be established, maintained, and eventually resolved; they may also be threatened by ruptures that require—and sometimes are beyond—repair (Kazantzis et al. 2017).6 Cognitive and behavioral interventions are not only transmitted through the relationship however, they are also conveyed in the therapeutic relationship itself. The relationship, in other words, serves as a model for patients. As in any other form of psychotherapy, in CBT the types of interactions the patient comes to expect in therapy are deliberately shaped to foster a particular engagement with oneself and the world. In Beck’s original formulation, for example, the way patients were encouraged to record and survey their experiences—to expose them to critical reflection through dialogue, or to test assumptions or hypotheses—mirrors not only how social scientists study human experience, but also how Beck himself, a trained psychoanalyst, set out to revise psychoanalytic teachings and practices (Rosner 2014). If the therapist or the therapeutic relationship serve as models, questions arise about the values and norms these models embody. As Kazantzis and colleagues recently recognized: “Effective CBT therapists model helpful attitudes and skills to manage and resolve distress”; and to this end they also establish “behavioral norms and expectations,” particularly in the early treatment sessions (Okamoto et al.  2019: 113). What constitutes a “helpful attitude” may be uncontroversial in many instances; conflicts are likely to surface, however, as “clinicians are venturing close to [a] client’s value system tied to their identity and core beliefs” (Okamoto et al. 2019: 115). In this case, the authors warn, therapists must tread lightly and not mistake core beliefs for dysfunctional cognitive distortions that require intervention. The identification of personally significant beliefs, and their distinction from less significant ones, may pose considerable challenges, particularly in cross-cultural settings. The role and importance of cognitive interventions, then, leads to worries about practitioners tacitly endorsing particular social norms, especially those that reflect unjust or oppressive values, or their own biased personal values (Kingdon et al.  2017). Therefore, while CBT’s emphasis on collaboration aims to augment personal agency, it requires attention to the possibility of implicit norms, as it may inevitably go beyond the stringent application of specific skills to conveying some form of self-understanding as well (Biegler, this volume). Other approaches, of course, more deliberately employ the therapeutic relationship as a learning experience or model, particularly for dealing with emotional challenges that arise within interpersonal relationships outside the consulting room.7 Dialectical behavior therapy (DBT) is one such approach, with a direct incorporation of relational dynamics. From its earliest iterations, Marsha Linehan characterized DBT as a break from standard CBT in  its foregrounding of the therapeutic relationship (Linehan  1993a), at times explicitly drawing on the notions of transference and countertransference (Linehan 1993b). As part of its emphasis on balancing the therapeutic goals of acceptance and change, the development of a supportive and validating relationship is central, guided by the therapist (or “skills

6  Such approaches often appeal to general aspects of the therapeutic relationship, such as empathy and active listening, in conjunction with those specific to CBT: collaboration, “collaborative empiricism,” and Socratic dialogue (Tee and Kazantzis 2011; Kazantzis et al. 2017). 7  This may be said, for instance, of the experiences therapeutic communities aim to provide as well as of some of the interventions used in the context of interpersonal psychotherapy.

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Relationship as Skill   73 trainer”) using various styles of communication, including immediate responsiveness, ­strategic self-disclosure, warm engagement, and radical genuineness (Linehan 1993a). Indeed, given that DBT was first developed to treat the emotional dysregulation associated with suicidality and personality disorder, the therapeutic relationship itself was viewed as a veritable lifeline for patients: “At times, this relationship is the only thing that keeps them alive” (Linehan 1993a: 21). But it is also notable that therapists are encouraged to selectively challenge the patient through the use of irreverence and humor. This requires constant calibration on the part of the practitioner, as the effects of each strategy have to be closely monitored in order to successfully maintain a collaborative relationship over time. Advanced interpersonal skills, then, are an essential resource for therapists, in the service of supporting patients in the development of their own social, cognitive, and emotional capacities.8

Relational Labor An often-underappreciated consequence of the shift towards more collaborative psychotherapy concerns what is asked of practitioners. The shifting demands of relational practices have normative implications for practitioners themselves. The demands made on practitioners to fully engage in collaborative processes, and the likelihood that they will take on a unique emotional—and indeed moral—significance for the patient, entails important responsibilities on the part of the practitioner. Thus we should attend to the moral character of practitioners; a view that may lend itself to certain ethical approaches (such as virtue ethics; Radden and Sadler 2010).9 As psychotherapeutic methods have placed greater demands on therapists’ capacity to engage in empathetic understanding and other forms of emotional labor, there are also significant health risks for practitioners. In 1974, the psychoanalyst Harald Freudenberger introduced the concept of “staff burnout,” which he had observed in himself and others involved in the free-clinic movement, providing mental health support in crisis intervention centers (Freudenberger 1974). Since then, the notion of burnout has been applied to various forms of social and professional disengagement outside the field of mental health. More recently, “compassion fatigue” or “empathy fatigue,” originally conceived of as a malign form of countertransference and a reaction to secondary traumatic stress, has become a new potential occupational hazard for members of the helping professions (Figley  1995; Stebnicki 2007). At the least, the emotional toll that relational practices may take on providers has started to receive more systematic attention, leading to calls for p ­ reventive measures that foster “empathy resiliency” (Stebnicki 2016).10

8  This can become more challenging as DBT is increasingly used in different formats, especially group work, and with a broader range of presenting disorders (Linehan 2015). 9  For discussion of virtue in practitioners and patients in psychotherapy, see Waring (2016). 10  Reviews describe high rates of job-related stress and emotional exhaustion in psychiatrists and psychologists (Maslach and Leiter 2016; McCormack et al. 2018). The evidence points to contributing factors such as younger age and less clinical experience; interestingly, a systematic review of burnout in psychotherapists also found that over-involvement with patients was a risk factor for moderate to high levels of burnout (Simionato and Simpson 2018).

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74   History and Ethics of the Therapeutic Relationship

Relationship as Foundation As the epistemic norms regarding what constitutes good medical science and sufficient evidence of treatment efficacy gradually changed, and clinical trials became mandatory for regulatory approval of new medicines in the 1960s, pressures began to mount on psychiatrists to provide comparable evidence of their non-pharmacological methods. The evidence-based medicine movement, often traced to the work of A. L. Cochrane (1972) in the United Kingdom and a group of researchers at McMaster University in Canada (Evidence-Based Working Group 1992), stressed the need to identify and apply, whenever available, those methods that had proven efficacious in large-scale trials. Given their discipline’s methodological commitments and statistical expertise, psychologists would gain an early edge over psychoanalytically trained psychiatrists in demonstrating the efficacy of psychological treatments such as CBT (Buchanan 2003). Over the following decades, however, psychoanalysts, like most therapeutic schools, would also gradually come to espouse the new standard of the randomized control trial. To meet the requirements adopted by health insurance companies, research funding bodies, and the various governmental agencies involved in the provision of mental health care, psychologists followed medicine’s lead or developed their own standards of “empirically supported therapies” (e.g., APA 2006). Although not all clinical persuasions grant it equal importance, the therapeutic alliance or relationship has gained attention as part of this broader shift, particularly in the ongoing debate over the role of specific versus non-specific factors in psychotherapy (Wampold 2015; Wampold and Imel 2015). This is one aspect of a larger discussion concerning the closely related questions of whether psychotherapy works, how and why it works, and if certain approaches work better than others. In short, there is a fairly clear answer to the first, with robust findings correlating different forms of psychotherapy with improved outcomes (particularly symptom reduction); however, much less is known about the second and third questions (Cuijpers 2019). Just what the “mechanisms of change” are for various forms of psychotherapy remain conspicuously under-described. Whether targeting unconscious conflicts grounded in early childhood experience, as in psychoanalysis and other psychodynamic approaches, or biased and automatic cognition, as in CBT, there is little to no evidence that positive changes to such processes are in fact causally responsible for improved outcomes.11 Compounding the problem, data on the comparative effectiveness of different therapies have provided few definitive answers to date, with the potential implication that no one approach—or specific factor therein—has advantages over any others (Cuijpers et al. 2019). These debates are relevant here because the therapeutic alliance or relationship has been forwarded as a “common factor” that may play a causal role in various therapies. There is widely cited meta-analytic support for a correlation between stronger therapeutic alliance and better outcomes in psychotherapy (Flückiger et al. 2018; Horvath et al. 2011; also see Norcross 11  What is needed, according to Cuijpers et al. (2019), is research that tracks temporal relationships and dose–response associations, while controlling for confounding variables, supported by experimental research and convincing theoretical frameworks.

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Relationship as Foundation   75 and Wampold 2011).12 This could help explain the lack of definitive comparative data between divergent approaches, not to mention the apparent insignificance of treatment fidelity (Fonagy and Luyten 2019). Thus for some contemporary researchers and practitioners, the therapeutic alliance is the very foundation of psychotherapy (van Os and Kamp 2019). There are familiar empirical questions, however, regarding whether the alliance is actually playing a causal role, as well as the possibility of a role for other common factors. While the alliance has garnered the most attention, there are other common factors discussed in the literature, such as patient expectations and identification with the therapist (Constantino et al. 2011; Huibers and Cuijpers 2015; Lambert and Ogles 2004; Wampold 2015). The fact remains that the debate over specific versus non-specific factors is empirically unresolved.

Explanatory Challenges The driving force behind these debates, again, is the imperative to provide the best possible treatment; evidence-based commitments are now well established across most forms of psychotherapy. To the extent that the therapeutic alliance or relationship is recognized as a key component of treatment, there is a responsibility to make it work for patients. At minimum, this entails an obligation to avoid harmful effects. There is still much to learn about the potentially negative effects of psychotherapy, including whether such effects should be defined to include symptomatic increase, adverse events, non-response to treatment, or treatment drop-out (Cuijpers 2019). But the need to avoid ineffective—or even harmful— treatments is paramount and will require continued grappling with questions regarding evidentiary standards in psychological research (Lilienfeld 2019; Williams et al. 2020). This will also invariably require facing up to the challenge of developing a better understanding of the therapeutic alliance or relationship. Conceptualized as a common factor across therapies, one rough causal idea, relatively unchanged from Franz Alexander’s early characterization, is that the alliance can help produce a “corrective emotional experience, which then leads to patients facing their fears or dealing with their problems” (Huibers and Cuijpers 2015: 1–2). But again, at this stage it is unclear whether or not the alliance is the real driver of therapeutic change, and in terms of a clear definition or operationalization much remains unresolved.13 The explanatory challenges are numerous, reflecting the broader methodological complexities of psychotherapy research (for detailed discussion, see Cuijpers et al. 2019). The therapeutic relationship is a challenging target of investigation, particularly given that the psychotherapeutic process is inherently dynamic, with patient and practitioner behaviors constantly in flux (van Os and Kamp 2019). But not only is it difficult to design research that isolates and manipulates the relevant processes, there are also ethical obstacles that may arise (Cuijpers et al. 2019). For example, trial designs that incorporate a control condition 12  There are various measures of the therapeutic alliance, but many incorporate aspects of Bordin’s original notion of shared goals, agreed upon tasks, and an emotional bond (Flückiger et al. 2018; Horvath et al. 2011). 13  For discussion, see Horvath et al (2011) and Flückiger et al. (2018). For the broader concept of the  therapeutic relationship, one influential approach is the tripartite model, which includes a “real” relationship, a working alliance, and transference/countertransference (Gelso 2019).

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76   History and Ethics of the Therapeutic Relationship that simply maintains treatment alliance, contrasted with a second condition that strengthens alliance, might be deemed problematic. Though falling far short of traditional concerns about placebo trials, this still may be enough to give researchers pause, given that the treatment-as-usual condition must in some way limit the strength of the therapeutic alliance. These kinds of methodological, and ethical, worries are not unrelated to broader criticisms that have been made against the evidence-based paradigm’s applicability to psychiatry and psychotherapy (e.g., Gupta 2014).

Beyond Psychotherapy Recent empirical research in this area has resulted in at least one clear and consistent finding, which is that the significance of the therapeutic alliance or relationship extends beyond the standard arrangements of psychotherapy. Indeed, there is growing recognition that clinical relationships of all kinds have a positive impact on therapeutic outcome. For example, in some of the early comparative studies, the quality of the alliance was associated with better outcomes from both psychotherapy and pharmacotherapy (Krupnick et al.  1996). These types of findings have gradually shifted the discussion surrounding the therapeutic alliance or relationship to include all clinical interactions, including everything from diagnostic interviews, medication consults, and the diverse types of patient contact during inpatient treatment. There is now a strong case for the importance of the therapeutic relationship in any number of psychiatric settings and interventions (Priebe and McCabe 2008).14 Perhaps the research with the most relevance to the present discussion concerns the ethics of influence and various forms of treatment pressure. Typically discussed in relation to coercive practices on the ward, there is convincing evidence that the quality of relationships with clinical staff impacts patient perspectives on coercion—or “perceived coercion”—and general satisfaction with inpatient treatment (Sheehan and Burns  2011; Theodoridou et al. 2012); this applies to psychotherapy in acute settings (Bolsinger et al. 2020). There are also more subtle forms of interpersonal pressure that have broader application across various clinical settings, often discussed under the heading of “informal coercion” (Hotzy and Jaeger 2016). Much of this work builds on influential typologies of treatment pressure in all its variety, including persuasion, interpersonal leverage, inducements, threats, and compulsory treatment (Szmukler and Appelbaum 2008). It is not difficult to see how such dynamics could factor into any clinical relationship, influencing patient perspectives and decisions about their treatment, lives outside the clinic, and self-conception or personal identity.15 14  There is evidence to suggest that aspects of clinical communication are key components (Priebe et al. 2020). 15  A recent account supplements the traditional categories with ethical guidelines on other methods of influence, including direct recommendations, appeals to values and goals, appeals to social norms, and the framing of information (Blumenthal-Barby et al. 2013). The use of such methods should be contingent upon the patient’s decision-making capacity, the efficacy of the treatment being recommended, and assessment of potential harm. And the use of appeals to patient values and goals must be grounded in knowledge of their beliefs and preferences, and the strategic invocation of social norms should be accurate and free of stigma, prejudiced beliefs, and unjust practices. This framework thus provides helpful guidance relevant to psychotherapy. But questions can also be asked of this model, such as whether it sufficiently accounts for the implicit threat of coercion that pervades psychiatry and the ethical significance of the use of “nudges”—or choice architecture—in the distinctive context of mental health ­treatment (Cratsley 2019).

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Discussion   77

Discussion Whereas the use of language as a means to cure the soul has a long history reaching back to antiquity, the idea that relationships can be used to treat mental disorders emerged only fairly recently, once modern psychotherapies had come into their own. Over the course of its rather brief history, the therapeutic relationship has been employed in a variety of ways. This is hardly surprising given that social relations, in the clinic and beyond, have undergone profound transformations since the end of the nineteenth century. As the field of mental health evolved, responding to broader social and cultural changes as well as to ­shifting professional demands, so did the relationships that clinicians tried to utilize for therapeutic ends.

Emerging Issues Clinical practice is therefore not a static endeavor, and there are any number of newly emerging challenges to navigating the therapeutic relationship. Perhaps the most pressing is the rapid expansion of teletherapy (or telepsychiatry). Moving interventions onto virtual platforms will inevitably change the nature of clinical relationships in interesting and unforeseen ways. As others have recently described, online psychotherapy raises a wide range of ethical questions (Stoll et al. 2020; Stoll and Trachsel, this volume), many of which have direct relevance for the therapeutic relationship. There are other innovative practices that are also worth considering. For example, there is an increasing interest in peer support as an effective intervention (Storm et al. 2020), as well as task-shifting initiatives in global mental health that promote the use of non-specialists in low-resource settings (Singla et  al.  2017). Such innovations rely upon different relational dynamics than traditional psychotherapy, with ethical implications that have yet to be examined in any detail. Another development that will require further analysis is the ongoing push for shared and supported decision-making, with implications for both psychotherapy and other clinical interventions. As part of the move towards implementing standards of shared decision-making and collaborative, person-centered care across the health sector, the field of mental health has started to confront a range of issues (Reiter-Theil and Wetterauer, this volume), especially how best to implement such standards (Slade  2017). There are obvious ethical contours to these developments, particularly since they are often framed as rights-based issues, and one can readily see how they relate to the quality of clinical relationships. Similar concerns apply to the current debate over supported decision-making. By the terms of the United Nations’ Convention on the Rights of Persons with Disabilities (UN 2006), mental health policy, legislation, and services must ensure supported decision-making and the prohibition of substitute decision-making. This raises a number of issues, including questions about appropriate forms of influence within clinical relationships during decision-making processes (Scholten and Gather 2018). There are also challenges emerging from social movements advocating for justice and equality on the basis of race and ethnicity, sexual orientation, gender, disability, and socioeconomic status. Within psychiatry, increased recognition of the social determinants of

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78   History and Ethics of the Therapeutic Relationship mental health has led to welcome calls for cultural and structural competency on the part of practitioners, in order to promote social justice and mitigate health disparities (e.g., Metzl and Hansen 2018). This again puts questions about power, as well as solidarity, at the heart of current debates. But clearly more needs to be done to detail exactly how these issues apply to therapeutic relationships within psychotherapy. In addition, issues raised by advocates of Mad Pride and neurodiversity pose a complex set of challenges, both normative and theoretical, for practitioners. Activists that do not accept psychiatry’s traditional understanding of patients and pathologies may ultimately reshape the very nature of the clinical encounter (Rashed 2019).

Relational Norms Taken together, these recent developments underscore the obligation to extend ethical analysis beyond immediate clinical observations towards critically interrogating the societal forces and unexamined assumptions that structure the therapeutic relationship. Indeed, relational practices in psychotherapy have been shaped just as much by clinical exigencies as by broader social and cultural forces (Foucault 2008). The contemporary framing of the therapeutic relationship as a collaborative relationship thus reflects professional values as well as societal norms. The variability of such norms over time does not necessarily undermine their validity, however, nor does a historical account of the therapeutic relationship render the values that have become embedded in it necessarily suspect. But the historical trends outlined above may serve as a starting point when addressing the lingering concerns about the implicit values operative in any clinical relationship. For one, a historical reflection points to the potential limitations of professional values instilled in the therapeutic relationship. Fostering an openness to experience, a readiness to consider the viewpoint of others, and the values of compassionate listening and mutual understanding, for example, all seem unobjectionable, even deserving of endorsement. They are hardly universal and not always generalizable, though, and therefore may fail to provide practical guidance in many cases. After all, outside the consulting room, patients engage in social relations that differ significantly from the relationships they maintain with their therapists. Furthermore, professional values are necessarily bound up with societal norms, shaped by social institutions, and culturally embedded beliefs. The notion that psychotherapy can function as a neutral tool that can be deployed to treat mental disorder independent of those values and norms—and without a careful consideration of a patient’s own values, needs, and abilities—is questionable, to say the least. To suggest that therapeutic relationships are an embodiment of general principles or natural tendencies runs the danger of establishing implicit norms with regard to what may count as “healthy.” In the first half of the twentieth century, psychotherapists (not just psychoanalysts) would often highlight the artificiality of the social arrangement that is psychotherapy; how the rules governing the interactions between therapist and patient differ from those operating outside the clinical setting (e.g., Taft 1933; Watson 1940). Therapeutic relationships do not represent ideal social relationships, nor have they proven to be harbingers of radical societal change; rather, they have been devised and are maintained to instigate a process of personal change. And as therapeutic relationships have changed over time so have the general aims of relational practices.

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Discussion   79 Whereas the “neutral” psychoanalytic relationship was designed to remind patients of their limits and unresolved conflicts, the “collaborative” therapeutic relationships more common today are geared towards unlocking clients’ potentials by providing them with the  competences to regulate and motivate themselves, and devise new courses of action (Ehrenberg 2019). Although those in treatment are today supported to pursue goals congruent with their own values, in other words, collaborative relationships nevertheless closely track contemporary societal ideals of individualism, according to which an individual’s capacity for change is not beset by limits. Yet the ideal of a self-governing individual, which present forms of psychotherapy arguably align with (Rose 1998), cannot be fully reconciled with how therapeutic relationships spur personal “growth.” To change through a relationship often amounts to being changed by a relationship, which is to say: by another person, in ways that remain opaque. In an asymmetrical clinical relationship, dependency of some degree, if only temporary, is a feature rather than a bug. As others have pointed out, psychotherapy is an inherently normative project, insofar as it engages the patient’s self, their values, and personal experience, often aspiring to make them a “new and better person” (Radden 2002: 55; see also Adshead 2015; Allen 2013). Indeed, psychotherapy can function as a “technology of the self,” to draw on Michel Foucault’s (1988) influential notion, because it engages with ethical concerns about how to live a better life. Since psychotherapy is essentially a moral endeavor, therapists owe it to their patients to reflect upon the professional and personal values that guide their treatments and interactions.

Acknowledgments We would like to thank the editors of the volume, as well as David Haaga, Robert Kramer, Marie Nicolini, Jennifer Radden, and Rachael Rosner for helpful comments on earlier versions of the chapter.

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80   History and Ethics of the Therapeutic Relationship Blumenthal-Barby, J.  S., McCullough, L.  B., Krieger, H., and Coverdale, J. (2013). “Methods of ­Influencing the Decisions of Psychiatric Patients: An Ethical Analysis.” Harvard Review of Psychiatry 21: 275–279. Bolsinger, J., Jaeger, M., Hoff, P., and Theodoridou, A. (2020). “Challenges and Opportunities in Building and Maintaining a Good Therapeutic Relationship in Acute Psychiatric Settings: A Narrative Review.” Frontiers in Psychiatry 10: 965. Boothe, B. and Grimmer, B. (2004). “Die therapeutische Beziehung aus psychoanalytischer Sicht.” In Die therapeutische Beziehung (ed. W. Rössler, pp. 37–58). Berlin: Springer. Bordin, E. S. (1979). “The Generalizability of the Psychoanalytic Concept of the Working Alliance.” Psychotherapy 16: 252–260. Buchanan, R. D. (2003). “Legislative Warriors: American Psychiatrists, Psychologists, and Competing Claims over Psychotherapy in the 1950s.” Journal of the History of the Behavioral Sciences 39: 225–249. de Carvalho, R. J. (1999). “Otto Rank, the Rankian circle in Philadelphia, and the origins of Carl Rogers’ person-centered psychotherapy.” History of Psychology 2: 132–148. Chesler, P. (1997 [1972]). Women and Madness. New York: Four Walls Eight Windows. Cochrane, A. L. (1972). Effectiveness and Efficiency: Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust. Constantino, M. J., Arnkoff, D. B., Glass, C. R., Ametrano, R. M., and Smith, J. A. (2011). “Expectation.” Journal of Clinical Psychology: In Session 67: 184–192. Cratsley, K. (2019). “The Ethics of Coercion and Other Forms of Influence.” In The Bloomsbury Companion to Philosophy of Psychiatry (ed. S. Tekin and R. Bluhm, pp. 283–304). London: Bloomsbury. Cremerius, J. (1984). “Die psychoanalytische Abstinenzregel. Vom regelhaften zum operationalen Gebrauch.” Psyche 38: 769–780. Cuijpers, P. (2019). “Targets and Outcomes of Psychotherapies for Mental Disorders: An Overview.” World Psychiatry 18: 276–285. Cuijpers, P. M., Reijnders, M., and Huibers, M. J. H. (2019). “The Role of Common Factors in Psychotherapy Outcomes.” Annual Review of Clinical Psychology 15: 207–232. Ehrenberg, A. (2019). Die Mechanik der Leidenschaften: Gehirn, Verhalten, Gesellschaft. Frankfurt am Main: Suhrkamp. Eissler, K. R. (1950). “The Chicago Institute of Psychoanalysis and the Sixth Period of the Development of Psychoanalytic Technique.” The Journal of General Psychology 42: 103–157. Ellenberger, H.  F. (1970). The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. New York: Basic Books. Ellis, A. (1962). Reason and Emotion in Psychotherapy. Secaucus, NJ: Citadel Press. Evidence-Based Working Group (1992). “Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine.” JAMA 268: 2420–2425. Ferenczi, S. and Rank, O. (1925 [1924]). The Development of Psychoanalysis. New York: Nervous and Mental Disease Publishing Company. Figley, C. R. (1995). Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in those who Treat the Traumatized. Bristol, PA: Brunner/Mazel. Flückiger, C., Del Re, A.  C., Wampold, B.  E., and Horvath, A.  O. (2018). “The Alliance in Adult ­Psychotherapy: A Meta-Analysis Synthesis.” Psychotherapy 55: 316–340. Fonagy, P. and Luyten, P. (2019). “Fidelity vs. Flexibility in the Implementation of Psychotherapies: Time to Move On.” World Psychiatry 18: 270–271. Foucault, M. (1988). Technologies of the Self: A Seminar with Michel Foucault. Amherst, MA: University of Massachusetts Press. Foucault, M. (2008). Psychiatric Power: Lectures at the Collège de France, 1973–1974. New York: Palgrave Macmillan. Freud, S. (1905). “Fragment of an Analysis of a Case of Hysteria.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud (Volume VII) (ed. J. Strachey, pp. 1–122). London: Hogarth Press.

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Discussion   81 Freud, S. (1910). “The Future Prospects of Psycho-Analytic Therapy.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud (Volume XI) (ed. J. Strachey, pp. 139–151). London: Hogarth Press. Freud, S. (1912). “The Dynamics of Transference.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud (Volume XII) (ed. J. Strachey, pp. 109–120). London: Hogarth Press. Freud, S. (1914). “Observations on Transference Love.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud (Volume XII) (ed. J. Strachey, pp. 157–173). London: Hogarth Press. Freud, S. (1919). “Wege der Psychoanalytischen Therapie.” In Gesammelte Werke (Bd. XII) (ed. A. Freud, J. Bibring, W. Hoffer, E. Kris, and O. Isakower, pp. 183–194). Frankfurt am Main: Fischer. Freudenberger, H. (1974). “Staff Burn-Out.” Journal of Social Issues 50: 159–165. Gabbard, G. O. (2009). “Boundary Violations.” In Psychiatric Ethics (4th ed.; ed. S. Bloch and S. Green, pp. 251–270). New York: Oxford University Press. Gaston, L. (1990). “The Concept of the Alliance and Its Role in Psychotherapy: Theoretical and Empirical Considerations.” Psychotherapy 27: 143–153. Gelso, C. (2019). The Therapeutic Relationship in Psychotherapy Practice. New York: Routledge. Gilbert, P. and Leahy, R.  L. (eds.) (2007). The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies. New York: Routledge. Glover, E. (1955). The Technique of Psychoanalysis. London: Balliere, Tindall & Co. Greenson, R.  R. (1967). The Technique and Practice of Psychoanalysis. New York: International Universities Press. Gupta, M. (2014). Is Evidence Based Psychiatry Ethical? Oxford: Oxford University Press. Hale, N. G. (1995). The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans, 1917–1985. Oxford: Oxford University Press. Hoffer, A. (1985). “Toward a Definition of Psychoanalytic Neutrality.” Journal of the American Psychoanalytic Association 33: 771–795. Horvath, A. O., Del Re, A. C., Flückiger, C., and Symonds, D. (2011). “Alliance in Individual Psychotherapy.” Psychotherapy 48: 9–16. Hotzy, F. and Jaeger, M. (2016). “Clinical Relevance of Informal Coercion in Psychiatric Treatment: A Systematic Review.” Frontiers in Psychiatry 7: 197. Hughes, J. (2019). “ ‘A Ritual of Discourse’: Conceptualizing and Reconceptualizing the Analytic Relationship.” In The Oxford Handbook of Philosophy and Psychoanalysis (ed. R. G. T. Gipps and M. Lacewing, pp. 240–254). Oxford: Oxford University Press. Huibers, M. J. H. and Cuijpers, P. (2015). “Common (Nonspecific) Factors in Psychotherapy.” In The Encyclopedia of Clinical Psychology (ed. R. L. Cautin and S. O. Lilienfeld). New York: Wiley. Kazantzis, N., Dattilio, F.  M., and Dobson, K.  S. (2017). The Therapeutic Relationship in CognitiveBehavioral Therapy: A Clinician’s Guide. New York: Guilford Press. Kernberg, O. (1975). Borderline Conditions and Pathological Narcissism. New York: Jason Aronson. Kim, S. and Rutherford, A. (2015). “From Seduction to Sexism: Feminists Challenge the Ethics of Therapist–Client Sexual Relations in 1970s America.” History of Psychology 18: 283–296. Kingdon, D., Maguire, N., Stalmeisters, D., and Townend, M. (2017). CBT: Values and Ethics. London: Sage Publications. Koch, U. (2017). “Cruel to Be Kind? Professionalization, Politics, and the Image of the Abstinent ­Psychoanalyst, c. 1940–1980.” History of the Human Sciences 30: 88–106. Kohut, H. (2009 [1971]). The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders. Chicago, IL: University of Chicago Press. Kramer, R. (1995). “The Birth of Client-Centered Therapy: Carl Rogers, Otto Rank, and ‘The Beyond’ ”. Journal of Humanistic Psychology 35: 54–110. Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., and Pilkonis, P. A. (1996). “The Role of the Therapeutic Alliance in Psychotherapy and Pharmacotherapy Outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program.” Journal of Consulting and Clinical Psychology 64: 532–539.

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82   History and Ethics of the Therapeutic Relationship Lambert, M. J. and Ogles, B. M. (2004). “The Efficacy and Effectiveness of Psychotherapy.” In ­Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (5th ed.; ed. M.  J.  Lambert, pp. 139–193). New York: John Wiley & Sons. Lanzoni, S. (2018). Empathy: A History. New Haven, CT: Yale University Press. Leider, R. J. (1983). “Analytic Neutrality: A Historical Review.” Psychoanalytic Inquiry 3: 665–674. Lilienfeld, S. O. (2019). “What Is ‘Evidence’ in Psychotherapies?” World Psychiatry 18: 245–246. Linehan, M. M. (1993a). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. Linehan, M. M. (1993b). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press. Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.). New York: Guilford Press. McCormack, H. M., MacIntyre, T. E., O’Shea, D., Herring, M. P., and Campbell, M. J. (2018). “The Prevalence and Cause(s) of Burnout among Applied Psychologists: A Systematic Review.” Frontiers in Psychology 9: 1897. Makari, G.  J. (1992). “A History of Freud’s First Concept of Transference.” International Review of Psycho-Analysis 19: 415–432. Marks, J. H. (1993). “The Training of Genetic Counselors: Origins of a Psychosocial Model.” In Prescribing Our Future: Ethical Challenges in Genetic Counseling (ed. D. M. Bartels, B. S. LeRoy, and A. L. Caplan, pp. 15–24). New York: Aldine de Gruyter. Maslach, C. and Leiter, M. P. (2016). “Understanding the Burnout Experience: Recent Research and Its Implications for Psychiatry.” World Psychiatry 15: 103–111. Metzl, J. M. and Hansen, H. (2018). “Structural Competency and Psychiatry.” JAMA Psychiatry 75: 115–116. Miller, W. R. and Rollnick, S. (eds.) (2012). Motivational Interviewing: Helping People Change (3rd ed.). New York: Guilford Press. Norcross, J. C. and Wampold, B. E. (2011). “Evidence-Based Therapy Relationships: Research Conclusions and Clinical Practices.” Psychotherapy 48: 98–102. Okamoto, A., Dattilio, F. M., Dobson, K. S., and Kazantzis, N. (2019). “The Therapeutic Relationship in Cognitive-Behavioral Therapy: Essential Features and Common Challenges.” Practice Innovations 4: 112–123. Priebe, S., Conneely, M., McCabe, R., and Bird, V. (2020). “What Can Clinicians Do to Improve Outcomes across Psychiatric Treatments: A Conceptual Review of Non-Specific Components.” Epidemiology and Psychiatric Services e48: 1–8. Priebe, S. and McCabe, R. (2008). “Therapeutic Relationships in Psychiatry: The Basis of Therapy or Therapy in Itself?” International Review of Psychiatry 20: 521–526. Radden, J. (2002). “Notes Towards a Professional Ethics for Psychiatry.” Australian and New Zealand Journal of Psychiatry 36: 52–59. Radden, J. and Sadler, J. Z. (2010). The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice. Oxford: Oxford University Press. Rader, J. and Gilbert, L. A. (2005). “The Egalitarian Relationship in Feminist Therapy.” Psychology of Women Quarterly 29: 427–435. Rashed, M. (2019). Madness and the Demand for Recognition: A Philosophical Inquiry into Identity and Mental Health Activism. Oxford: Oxford University Press. Richert, L. (2019). Break on Through: Radical Psychiatry and the American Counterculture. Cambridge, MA: MIT Press. Rieff, P. (2006 [1966]). The Triumph of the Therapeutic: Uses of Faith after Freud. Wilmington, DE: ISI Books. Rogers, C. R. (1942). Counseling and Psychotherapy. Boston, MA: Houghton Mifflin. Rogers, C. R. (1959). “A theory of therapy, personality, and interpersonal relationships, as developed in the client-centered framework.” In Psychology: A Study of a Science (Vol. 3) (ed. S. Koch, pp. 184–256). New York, NY: McGraw-Hill.

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Discussion   83 Rose, N. (1998). Inventing Our Selves: Psychology, Power and Personhood. Cambridge: Cambridge ­University Press. Rosner, R. I. (2014). “The ‘Splendid Isolation’ of Aaron T. Beck.” Isis 105: 734–758. Safran, J. D. (1990). “Towards a Refinement of Cognitive Therapy in Light of Interpersonal Theory: I. Theory.” Clinical Psychology Review 10: 87–105. Scholten, M. and Gather, J. (2018). “Adverse Consequences of Article 12 of the UN Convention on the Rights of Persons with Disabilities for Persons with Mental Disabilities and an Alternative Way Forward.” Journal of Medical Ethics 44: 226–233. Shamdasani, S. (2003). “The Psychoanalytic Body.” In Companion to Medicine in the Twentieth Century (ed. R. Cooter and P. Pickstone, pp. 307–322). London: Routledge. Sheehan, K. A. and Burns, T. (2011). “Perceived Coercion and the Therapeutic Relationship: A Neglected Association?” Psychiatric Services 62: 471–476. Shorter, E. (1992). “The History of the Doctor–Patient Relationship.” In Companion Encyclopedia of the History of Medicine (Vol. 2) (ed. W. F. Bynum and R. Porter, pp. 783–800). London: Routledge. Simionato, G. K. and Simpson, S. (2018). “Personal Risk Factors Associated with Burnout among Psychotherapists: A Systematic Review of the Literature.” Journal of Clinical Psychology 74: 1431–1456. Singla, D. R., Kohrt, B. A., Murray, L. K., Anand, A., Chorpita, B. F., and Patel, V. (2017). “Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries.” Annual Review of Clinical Psychology 13: 149–181. Slade, M. (2017). “Implementing Shared Decision Making in Routine Mental Health Care.” World Psychiatry 16: 146–153. Staub, M. E. (2011). Madness Is Civilization: When the Diagnosis was Social, 1948–1980. Chicago, IL: University of Chicago Press. Stebnicki, M.  A. (2007). “Empathy Fatigue: Healing the Mind, Body, and Spirit of Professional Counselors.” American Journal of Psychiatric Rehabilitation 10: 317–338. Stebnicki, M. A. (2016). “From Empathy Fatigue to Empathy Resiliency.” In The Professional Counselor’s Desk Reference (ed. I. Marini and M. A. Stebnicki, pp. 533–545). New York: Springer. Steiner, C. (1981). “Radical Psychiatry.” In Handbook of Innovative Psychotherapies (ed. R. J. Corsini, pp. 724–735). New York: John Wiley & Sons. Sterba, R. (1934). “The Fate of the Ego in Analytic Therapy.” International Journal of Psychoanalysis 15: 117–126. Stoll, J., Muller, J. A., and Trachsel, M. (2020). “Ethical Issues in Online Psychotherapy: A Narrative Review.” Frontiers in Psychiatry 10: 993. Storm, M., Fortuna, K. L., Brooks, J. M., and Bartels, S. J. (2020). “Peer Support in Coordination of Physical Health and Mental Health Services for People with Lived Experience of a Serious Mental Illness.” Frontiers in Psychiatry 11: 365. Sullivan, H. S. (1954). The Psychiatric Interview. New York: W. W. Norton. Szmukler, G. and Appelbaum, P. S. (2008). “Treatment Pressures, Leverage, Coercion, and Compulsion in Mental Health Care.” Journal of Mental Health 17: 233–244. Taft, J. (1933). The Dynamics of Therapy in a Controlled Relationship. New York: Macmillan. Tändler, M. (2016). Das therapeutische Jahrzehnt: der Psychoboom in den siebziger Jahren. Göttingen: Wallstein Verlag. Tee, J. and Kazantzis, N. (2011). “Collaborative Empiricism in Cognitive Therapy: A Definition and Theory for the Relationship Construct.” Clinical Psychology: Science and Practice 18: 47–61. Theodoridou, A., Schlatter, F., Ajdacic, V., Rossler, W., and Jager, M. (2012). “Therapeutic Relationship in the Context of Perceived Coercion in a Psychiatric Population.” Psychiatry Research 200: 939–944. Trachsel, M., Grosse Holtforth, M., Biller-Andorno, N., and Appelbaum, P.  S. (2015). “Informed Consent for Psychotherapy: Still Not Routine.” Lancet Psychiatry 2: 775–777. United Nations (2006). Convention on the Rights of Persons with Disabilities. van Os, J. and Kamp, D. (2019). “Putting the Psychotherapy Spotlight Back on the Self-Reflecting Actors Who Make It Work.” World Psychiatry 18: 292–293.

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84   History and Ethics of the Therapeutic Relationship Wampold, B. E. (2015). “How Important Are the Common Factors in Psychotherapy? An Update.” World Psychiatry 14: 270–277. Wampold, B. E. and Imel, Z. E. (2015). The Great Psychotherapy Debate (2nd ed.). London: Routledge. Waring, D. (2016). The Healing Virtues: Character Ethics in Psychotherapy. Oxford: Oxford University Press. Watson, G. (1940). “Areas of Agreement in Psychotherapy: Section Meeting, 1940.” American Journal of Orthopsychiatry 10: 698–709. Williams, A. J., Botanov, Y., Kilshaw, R. E., Wong, R. E., and Sakaluk, J. K. (2020). “Potentially Harmful Therapies: A Meta-Scientific Review of Evidential Value.” Clinical Psychology Science and Practice. Advance online. doi:10.1111/cpsp.12331 Zaretsky, E. (2015). Political Freud: A History. New York: Columbia University Press. Zetzel, E. (1956). “Current Concepts of Transference.” International Journal of Psychoanalysis 37: 369–375.

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Section II

C ONC E P T S A N D T H E OR I E S FOR P SYC HOT H E R A PY ET H IC S

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Chapter 5

Au tonom y as a G oa l of Psychother a py Paul Biegler

Introduction After what might seem like an eternity in the shadows, the world has definitely turned for the ethical principle of autonomy. The change has been most notable in medical practice where, for years, the paternalistic dogma of “doctor knows best” provided tacit justification for physicians to direct the nature of treatment, provide minimal information and, mostly, fail to solicit the views of patients on what they thought best. This approach of “beneficent authoritarianism” (Pellegrino and Thomasma 1988: 5) was grounded in the idea that good decisions about medical treatment hinged on a scientific understanding of what worked, a realm of knowledge to which the doctor, justifiably, claimed superior access. Such an approach ignored, however, the notion that facts about a treatment’s efficacy are always interpreted in light of a patient’s particular values, values that not only vary in a pluralistic society, but also impact decisively on what treatment an individual might prefer (Buchanan and Brock 1990: 29–30). In the medical domain, cancer chemotherapy provides a case in point. The possible life extension offered by chemotherapy might be identical for two patients, but whether that is considered a worthwhile gain—and reason to undergo treatment—when weighed against side effects such as intractable nausea, is ultimately determined by the individual’s particular values. Against this backdrop, respect for personal autonomy has emerged as a key driver of informed patient choices which, in turn, permit assessments of a patient’s best interests to  accommodate their idiosyncratic circumstances, goals, and values. Scholars Faden, Beauchamp, and King (1986) encapsulate this in the notion of informed consent as an “autonomous authorization” of treatment, where treatment choice is an expression of selfdetermination by a competent agent. Indeed, backed by intense efforts to enmesh ethics training into medical curricula, respect for autonomy as part of informed consent is now routine in most healthcare settings. For a number of reasons, however, acknowledgment of the importance of autonomy in psychological therapy has been later to arrive (Trachsel et al.  2015). Insight-­oriented

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88   Autonomy as a Goal of Psychotherapy ­ sychotherapies such as psychoanalysis, for example, center on the acquisition of selfp knowledge, an open-­ended process that can be uncertain about how, when, and to what degree distressing thoughts and feelings will be relieved. Informed consent in this type of therapy is more problematic than for outcome-­oriented, symptom-­focused treatments such as Cognitive Behavioral Therapy (CBT), whose procedures, goals, and time frames can be stated with greater certainty (Trachsel et al. 2015). At least part of the shift that now sees informed consent enshrined in the psychotherapy guidelines of countries including the United States (American Psychological Association 2017), the United Kingdom (British Association for Counselling and Psychotherapy 2016), and Australia (Australian Psychological Society 2007) can be traced to the case of Osheroff v. Chestnut Lodge (Klerman  1990). In this case the patient was hospitalized with severe depression, at significant expense, for seven months, yet offered only psychotherapy which was ultimately unsuccessful. The man, who was eventually successfully treated elsewhere with medication, launched legal action which was ultimately settled. The case highlighted the importance of information disclosure, in particular, about ­psychological diagnosis and the availability of alternative effective treatments, as key to respecting autonomy through informed consent. In tandem with recognition of the critical nature of information provision to autonomous consent, there has been an upsurge in research aimed at establishing an evidence base for psychotherapy, utilizing the same hierarchy of evidence adopted in physical medicine, with the randomized controlled trial as a gold stand­ard (American Psychological Association 2013). In trying to discern the role of autonomy in psychotherapy there is, however, another key consideration that muddies the waters. Autonomy is increasingly argued to be not just a capacity that must be respected through informed consent, but a trait that ought to be promoted, in and of itself, as an outcome of psychotherapy (Biegler  2011; Ryan et al.  2011). Such arguments typically appeal to dual notions about the value of autonomy, both as an instrument to the agent achieving their own conception of the good, and as a trait with intrinsic worth, irrespective of the outcomes that its exercise might bring about. Those arguments give rise to intense controversy about what the true goals of psychotherapy ought to be, because the goal of autonomy promotion can diverge from the more established aim of symptom reduction, including, in particular, enhanced positive affect. That debate can only be furthered if the discussants are properly informed about the notion of autonomy itself.

Autonomy Theories of autonomy can, roughly, be divided along Kantian and Millian lines (Taylor 2008), after the German Enlightenment philosopher Immanuel Kant, and the nineteenth-­century British philosopher John Stuart Mill, who is often lauded as the father of liberalism. On a Kantian view, autonomy—the ability to be self-­governing or self-­determining—is strictly a property of rational beings. For Kant, it is through the exercise of rational will alone that agents can draw up legitimate rules of self-­government, an idea with parallels in statehood; only the democratically solicited views of the citizenry can ground rules that

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Autonomy   89 bind the entire polity (Johnson and Cureton 2017). And, just as any state would cede autonomy if it were governed by another, so too the individual sacrifices autonomy should their decisions arise from an external source; in such cases, autonomy is surrendered to heteronomy. But for Kant, not only does rationality permit the individual to direct their own life, it also confers moral status upon its owner. Non-­rational beings—“animals”—are, on Kant’s view, merely “things” that can never command moral respect (Kant 1965: 55; Korsgaard 2013). And it is this moral status that is at the heart of the Kantian idea that persons—rational beings with interests—ought to be respected as ends in themselves, never merely as means, a specification that holds irrespective of any putatively worthy outcomes of pursuing the latter. In biomedical ethics, for example, Kantian arguments have been made against the so-­called “commodification of bodies” in various contexts, including gestational surrogacy, organ donation, and participation in risky human research programs, on the grounds that, in such cases, actors are impermissibly treated as mere means (Green 2001). A corollary of the reverence accorded rationality on Kant’s view, is that true selfgovernance cannot be driven by mere desire, a conclusion that forms a point of difference with Millian conceptions of autonomy. On a Millian account, autonomy means acting in accordance with one’s authentic desires, goals, and values, a precept that valorizes individuality and places sharp constraints on any justification for state interference with the agent’s actions. For Mill, it is the power of the autonomous individual to further their own good, and so of the community to advance overall utility, that gives normative force to his formulation. As Mill put it, “The only freedom which deserves the name, is that of pursuing our own good in our own way” (Mill 1863: 28–29). Moreover, because competent individuals are, for Mill, the ultimate arbiters of their own good, interfering with a person’s actions, on the grounds that it would be better for them to do so, is never justified. Mill’s Harm Principle states that, rather, the only warrant for constraining the will of a person “in the maturity of their faculties” is to prevent harm to others (Mill 1863: 23–24). Each of these formulations gives rise to theories about why we should value autonomy at all. For Kantians, autonomy has intrinsic value as an expression of the moral worth, dignity, or rights of persons; there is no need to appeal to the outcomes of autonomous behavior to justify its exercise (Young 1982). Mill’s account, on the other hand, champions the instrumental value of autonomy as a means by which people can best advance their own interests. In healthcare, each justification is appealed to as grounds for respecting and promoting autonomy. When a competent person rejects treatment, even when that portends an outcome that seems bad from the health provider’s perspective, a Kantian view of the intrinsic value of autonomy counsels respect for that action. In contrast, the Millian view that autonomous choice promotes individual good and, consistent with that, better health outcomes, is perhaps the predominant reason for the increasing weight accorded respect for personal autonomy through informed consent. Practitioners owe clients a duty of care that entails acting in their best interests at all times, and so establishing the link between autonomous choices and better health outcomes provides forceful reason to see respect for autonomy as a key means of discharging that duty of beneficence. It is worth looking more closely, then, at precisely how a psychotherapist might best respect the client’s autonomy.

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90   Autonomy as a Goal of Psychotherapy

Respecting Autonomy Some clients with impaired decision-­making capacity may be incapable of autonomous choice and informed consent. Indeed, if illness renders a person incompetent to make decisions about their own treatment, respect for autonomy becomes largely otiose and practitioners must be guided by other means to ensure they act in the client’s best interests. An important exception is the advance healthcare directive, which may extend autonomous decision-­making to a future time when the person lacks competence (see, e.g., Queensland Health 2017). Even so, while some people with mental health advance directives “endorse feelings of self-­determination, autonomy, and empowerment” (Zelle et al. 2015: 278), barriers to their use remain. Challenges include adequately informing clients in the face of sometimes complex documents and coordinating the use of directives across multiple medical systems (Kemp et al. 2015). In the setting of intact decision capacity, however, at the heart of respect for client autonomy and informed choice is the provision of information. That will include, broadly, information about the nature and purpose of the therapeutic intervention and of alternative treatments, as well as the risks and benefits of those treatments and of no treatment at all (Stewart and Biegler 2004; see also McKean et al., this volume). The possibility that a psychological disorder could be treated with medication, for example, is an epistemic requirement of informed consent. At a deeper level, however, the provision of “material” information is required, which is, according to a prominent judicial summary, information that “a reasonable person in the patient’s position . . . would be likely to attach significance to” (Rogers v. Whitaker, 175 CLR 479, 1992, at 490). It would, for example, be significant for a person seeking treatment for an anxiety disorder, that exposure to an anxiety-­provoking situation might be required as part of a behavioral treatment. A therapist might be motivated by a sense of beneficence to withhold certain information. If it is thought, for example, that mentioning the need for immersion in a feared environment could provoke needless anxiety, a therapist may wish not to divulge it at the outset, but delay disclosure until a later time. Can such an approach be justified? Withholding information from clients, for their own good, has been appealed to as permissible under the principle of “therapeutic privilege,” which condones non-­disclosure on beneficence grounds. However, while instinctively it might seem that withholding potentially distressing information averts harm, and is justified under a therapist’s duty of care, there is also an argument that it constitutes unjustified paternalism. Paternalism entails limiting a person’s freedom for their own good. On the formulation of American legal theorist Joel Feinberg (1971) paternalism in medicine can be justified, and is termed “weak” or “soft” paternalism, when a patient is not competent to make treatment decisions. To clarify this, consider for a moment a distinction between the allied concepts of competence and autonomy. Competence is a legally defined capacity to consent to or refuse medical treatment, that a person either does or does not possess (Stewart and Biegler 2004). To attain the competence threshold a person must be able to understand and rationally weigh information material to a proposed treatment (Biegler and Stewart  2001). The principle of personal autonomy, by contrast, is more nuanced, and allows the exercise of self-­determination to

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Respecting Autonomy   91 admit of degrees (Christman 2018). A person hospitalized with severe depression may, for example, lack sufficient autonomy to participate in treatment decisions, yet still retain the ability to autonomously choose which visitors they will see. Failing a competence test, then, implies a person lacks the requisite autonomy to give meaningful consent to treatment, or indeed refuse it. It is this standard that is appealed to in the claim that soft paternalism is justified. For instance, a head-­injured person with an altered conscious state might be restrained against their stated will, on the grounds their decision-­making is impaired to a degree that makes the healthcare provider a better judge of that person’s interests. In a similar way, withholding information from a client who lacked competence, for their own good, might be defended as an exercise of soft—permissible— paternalism. Here, justification rests on the premise that the therapist, and not the client, is best placed to judge what information should be disclosed. But Feinberg also delineated hard, or strong paternalism, where a person has their freedom limited, for their own good, despite having intact decision-­making capacity. Limiting a person’s freedom to make decisions in such cases is widely held to be unjustified, because competent (and therefore adequately autonomous) people are, on a broadly Millian view, best placed to determine what is in their own interests. Should a competent person decline psychotherapy on learning that exposure therapy will be involved, a view that supports autonomous choice as an instrument to well-­being would suggest that to be the best choice for them. Withholding information to mold a choice the therapist thinks best becomes, on this formulation, hard paternalism and, therefore, unjustified. In addition, for consent to be truly autonomous it must also be voluntary and, thus, free from coercion. Coercion occurs when undue pressure is placed on a client’s decisions by a therapist whose efforts to persuade include a threat of harm. A therapist who sought, for example, to convince a client to comply with treatment by threatening to write a negative report to a court, would undermine the autonomy of their client’s consent (Szmukler and Appelbaum 2008). A further issue is the degree to which the evidence, or lack thereof, for the effectiveness of a particular psychotherapy ought to be considered as part of autonomous consent. The conundrum is deepened by the highly variable nature of evidence across different psychotherapeutic approaches. Intensively researched therapies, such as CBT and Interpersonal Therapy (IPT), have accrued evidence for outcomes with broad appeal, namely, the reduction of defined symptoms for clearly categorized disorders (Jorm et al. 2013). Other approaches, for example, those loosely classified as psychodynamic therapies have, historically, been less subject to  rigorous research (British Psychoanalytic Council  2015)—although that is changing (Fonagy 2015). Must the evidence for likely outcomes be disclosed to ensure autonomous consent to treatment? The answer hinges on whether such information is likely to be material to clients and will, almost invariably, be “yes.” The question of whether a given parcel of information will be material turns on the degree to which it might impact on a client’s interests, and can be usefully contrasted with the notion of information that is merely relevant to a given intervention (Faden et al. 1986: 304). Consider virtual reality (VR) exposure therapy for an anxiety disorder. It may well be material to a client with a disability, for whom physically accessing a feared public place may be a particular hardship, that an alternative provider could offer VR therapy with no

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92   Autonomy as a Goal of Psychotherapy need to leave the consulting room. For an able-­bodied client, however, the possibility that VR therapy might be accessed elsewhere, while relevant to psychotherapy broadly, may not be material to their autonomous consent. Material information is, then, highly subjective, and best identified through open dialogue with clients about what therapy involves. A corollary is that the likelihood a treatment will address a client’s distressing thoughts, feelings, or behaviors is significant to most people seeking psychological help and is, therefore, plausibly material to autonomous consent across the board (Blease et al. 2018). Another consideration is the degree to which outcomes of therapy might be mediated by so-­called “common factors” (Wampold  2015), for example, the nature of the therapeutic alliance, the manner of the therapist, and any positive expectations engendered in the client (Blease et al. 2016). Given the therapeutic importance of these factors, understanding that a poor relationship with a particular therapist militates against beneficial outcomes would be material to most clients—who might choose to terminate the arrangement early as a result— and, therefore, something they ought to be apprised of in order to give autonomous consent. A range of other information can also be material, including the cost of treatment, its likely duration, the limits of confidentiality, including the possibility that information about risk to third parties might need to be divulged for legal reasons, and so on. But the special nature of psychotherapy means that, in relation to client autonomy, the duties of practitioners may be more onerous than for other healthcare providers.

Promoting Autonomy Psychotherapy has been contrasted with medical treatments, such as surgery, in which patients are more readily seen as passive recipients of a treatment that is “done to” them (Beahrs and Gutheil  2001). That is, of course, an oversimplification—consider the self­motivation required for rehabilitation after, say, knee replacement surgery. Nonetheless, the homework, behavioral exercises, and self-­reflection central to psychotherapy suggest clients are, in a very real sense, agents of their own change. The transformation comes with a burgeoning autonomy that, for a number of reasons, is a trait that merits focused attention in psychotherapy. Promoting autonomy, specifically, a self-­reliance born of insights into, and greater skills in managing distress, has been linked to better compliance with treatment (Ryan et al. 2011), less “regressive dependency” on therapists (Beahrs and Gutheil 2001), and more successful outcomes (Lynch et al. 2011). These observations reinforce an ethical imperative to promote autonomy on beneficence grounds, as a means to the realization of treatment aims, in particular, the reduction of symptoms. But promotion of autonomy has also been mooted to be an even loftier aim of psychotherapy. In an era that has seen steep rises in the prescribing of medication for psychological disorder, notably antidepressants in mood disorders, the capacity of psychotherapy to deliver outcomes beyond mere symptom reduction and restoration of euthymia, has been brought into stark relief. Many treatment guidelines, in depression for example, accord evidence-­based psychotherapies a status largely equivalent to medication, based on their comparable efficacy in reducing symptoms (Malhi et al. 2015). Recent Australian guidelines concluded, for instance,

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Autonomy as a Goal of Psychotherapy   93 that in a choice between medication and psychotherapy for depression, it’s “not so much what you do but that you keep doing it” (Ellis and Smith 2002). But recognition that psychotherapy can promote insights into the meaning of emotional crises, as well as mastery over, rather than mere passive subjugation to distressing thoughts and feelings, is a differentiating feature that heralds enhanced autonomy, in and of itself, as a worthy goal of treatment. Delivery of CBT in the treatment of depression, for example, involves identifying triggering stressors, including financial, personal, health, and work-­related issues, that typically present a major threat to the person’s interests (Hammen 2005). Such stressful life events require attention in their own right, independent of concerns about alleviating negative affect. Moreover, the use of therapeutic tools, such as mindfulness in relation to negative automatic thoughts and distressing feelings, and collaborative empiricism to challenge and debias depressive pessimism, equips sufferers to deal with future depressogenic scenarios (Piet and Hougaard 2011). Such insights plausibly permit people to make sense of depressive episodes as, in most cases, responses to environmental contingencies that warrant targeted redress, while also mitigating dysphoria and, indeed, reducing likelihood of depressive relapse (Clarke et al. 2015). Consider, for example, an executive who becomes distanced from his family and develops depressive symptoms in the face of increasing demands from a controlling boss. While alleviating psychic distress is important, so too is linking depression to challenges at work in order to make informed decisions about whether, for example, to be more assertive or look for a new job. One way to construe these outcomes is as enhanced autonomy, perhaps even “emotional autonomy”; furnished with material information about the causes and effects of depression, agents can navigate depressogenic scenarios more successfully, generating outcomes that reflect their rational will and authentic desires. Notably, while more positive affect will likely accompany these changes, it is not intrinsic to the aim of greater autonomy, an observation central to debates about what the true goals of mental health treatment ought to be. These debates reflect discussions that trace back to the Socratic dialogues. In Plato’s Philebus, Socrates concluded that, while both “mind” (wisdom and knowledge) and “pleasure” (joy, delight, and positive feelings) contribute to the good, “mind is ten thousand times nearer to the chief good than pleasure” (Plato 2016). It is worth looking closer, then, at arguments about the relative merits of symptom reduction and mood elevation, against the promoting of insight and greater autonomy, as goals in the treatment of psychological disorders.

Autonomy as a Goal of Psychotherapy The overarching duty of the psychotherapist, like any provider of healthcare, is to act in the best interests of the client, a duty enshrined in the ethical principle of beneficence. But while that duty is, prima facie, absolute, it is by no means clear what it actually means. How, for example, does one divine precisely what the interests of the client are? One means, outlined in the preceding discussion, is to simply ask them. Consistent with Mill’s account of utility, a client’s informed, rational, and voluntary desires—their autonomous wishes—are an invaluable guide to determining what is good

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94   Autonomy as a Goal of Psychotherapy for them. For most, those wishes will include a rapid relief from psychological distress, and so it is tempting to conclude that what most clients value, above all, is to experience positive affect, or at least the lifting of negative mood. An exclusive focus on affect as a measure of well-­being would, however, be too limited. According to theories of so-­called “prudential value”—which explore the nature of wellbeing, interests, or “the good” for people—such an approach is consistent with a mental statist conception of the good (Griffin 1986: 8). On this view, well-­being is a function of the person’s subjective mental states, sometimes specified in simple hedonistic terms as the degree to which pleasure outweighs pain (Tannsjo 2007). But there are other views of well-­being that place less emphasis on the experience of ­positive affect as intrinsic to the good. So-­called “informed desire” theories suggest that what ought to be valued, rather, is the satisfaction of rational and fully informed desires, irrespective of the affective result (Griffin 1986: 11). Such theories lay strong claim to reflect values inherent in the real world. University students, for example, do not typically volunteer that their studies cause them perpetual joy but, rather, justify their labors as having an intellectual worth not measurable in terms of mere affect, or as being sacrifices on the path to other rewards, such as the practice of a profession. The inadequacy of quantum of affect as a measure of well-­being is also illustrated by the theory of “preference hedonism.” The philosopher Derek Parfit (1984: 493) points out that people often wish to experience mental states that arise from the fulfillment of their rational but idiosyncratic preferences, regardless of whether those mental states are accompanied by positive affect. Someone who seeks out a Shakespearean tragedy, or perhaps one of Ingmar Bergman’s darker films, for example, is gratified by the result in ways that cannot be meas­ured by simply totting up “hedons.” Similarly, the penance of psychological illness is not one that can be neatly quantified as a pleasure debt that must be restored, but is also reflected as impaired autonomy, a reduced ability to direct life as one wishes in virtue of a concatenation of errant emotions, cognitions, and behaviors. And so restoring, or indeed enhancing self-­determination through psychotherapy, affords the client a good that will not manifest in purely affective terms, but as the ability to pursue relationships, projects, and ambitions that accord with their authentic wishes, even if the result is a somber sense of achievement rather than anything more akin to joy or its affective cousins. For example, a person experiencing a mood disorder in the setting of financial hardship has an interest not just in regaining affective equilibrium but in making prudent decisions about such things as accounting advice, mortgage renegotiation, and budgeting. An ability to navigate dysphoria in a way that addresses the financial threat preserves interests beyond those linked to negative affect. The suggested conclusion is that autonomy is inseparable from well-­being, and so fostering greater autonomy ought to count as points when tallying a patient’s best interests. That conclusion presents, however, something of a Gordian knot for practitioners. What of clients who do not value the promise of greater insight and autonomy, and opt to leave the care of a therapist in favor of the services of a psychiatrist or general practitioner who will only prescribe medication? The conundrum is a loose reflection of the problem John Stuart Mill framed in the example of the person who wants to sell themselves into slavery (Mill 1863: 198). Can one autonomously choose to sacrifice one’s autonomy or, more pertinent to psychotherapy, to forgo greater autonomy?

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Conclusion   95 Mill’s answer in the slavery example was to opine that freedom was too valuable a commodity to permit be sacrificed and so, he concluded, liberal society simply cannot countenance the existence of slavery within its confines (Kleinig 1983). But within the walls of the consulting suite (and acknowledging the tenuousness of the slavery analogy) there is room for greater tolerance. If a client autonomously rejects a treatment that promises greater emotional insight, perhaps simply because their personality reflects a lesser “need for cognition,” the contention that respect for autonomy entails not promoting autonomy (and so forgoing psychotherapy) is a compelling one, if worryingly oxymoronic. There are, of course, autonomy-­promoting facets of treatment with medication alone. In depression, for example, there is evidence that SSRIs counter aversive social cognitions and negative biases through effects on similar brain regions to those that undergo change with CBT (Harmer et al. 2009). These data suggest that at least one way pharmacotherapy might augment autonomy is by promoting greater accuracy in the individual’s social appraisals. Even granting this, however, it remains the case that drug therapy on its own cannot offer insight into the kinds of stressful life events likely to trigger depression, nor how they might be better managed. Nor can medication teach techniques to debias the unrealistic pessimism that will accompany negative affect during future depressogenic scenarios. Each capability is central to preserving autonomy during periods where the threat posed by depressive triggers is significant. Autonomy is not, of course, the only ethical principle and some have argued its recent pre-­eminence is something of a hegemony that wrongly diminishes the importance of related principles such as beneficence. Lepping and Raveesh (2014), for example, refer to cases in an Indian context where care is effectively delivered by enlisting the aid of family members, sometimes in the absence of explicit client consent. In such cases autonomy is clearly sacrificed to the goal of beneficence in what seems a paradigmatic instance of hard, unjustified paternalism. Can such an approach be defended? On one view, a Western conception of autonomy values the “atomized” freedom of individual agency at the expense of a more communitarian approach that embraces the benefits of social connectedness (Kirmayer 2004: 175). The cost of free agency, on such an account, is communal belonging. It is important to stress, however, that in pluralist liberal societies autonomy promotion often synergizes with beneficence by allowing outcomes to be tailored to an individual’s preferences. Autonomy as an instrument to the good makes it a hard principle to overlook. Moreover, and especially in an era where privacy threats abound, the importance of deference to client choices about whom to involve in their care cannot be understated.

Conclusion Autonomy has figured far more prominently in the ethics discourse of “traditional” medicine than it has in the therapist’s suite. In recent years, however, the importance of autonomy and, in particular, respect for client autonomy through the process of informed consent, has entered the lexicon through the guidelines of numerous professional ­psychological bodies.

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96   Autonomy as a Goal of Psychotherapy Nonetheless, discussion of autonomy as a key competence that might flow from ­ sychotherapy remains limited. Indeed, when autonomy is presented as a valid goal of therapy, p it is typically framed as a means to enhanced compliance, lessened therapist dependency, and reduction of symptoms. While those are, undoubtedly, worthy outcomes, autonomy is also in the ascendance as a treatment goal in its own right. The emerging prominence of autonomy as a mental health goal is recognition that self-knowledge and emotional insight allow people to preserve their broader interests, not just their interest in maintaining positive mood, during periods where the risk of recurrent psychological illness is high. This key advantage of psychotherapy over treatment with medication alone is something the discipline of psychotherapy might highlight in a zeitgeist where pharmacotherapy is the dominant mental health treatment. Ultimately, elevation of the importance of autonomy affirms that a preserved ability to pursue life plans, rather than the mere satisfaction of aspirations to positive mood, delivers on a more defensible measure of well-­being, and places this ethical principle front and center in the debate on what the goals of mental health treatment ought to be.

References American Psychological Association (2013). “Recognition of Psychotherapy Effectiveness.” Psychotherapy (Chic) 50: 102–109. American Psychological Association (2017). Ethical Principles of Psychologists and Code of Conduct. Washington, DC: Author. Australian Psychological Society (2007). Code of Ethics. Melbourne: Author. Beahrs, J. O. and Gutheil, T. G. (2001). “Informed Consent in Psychotherapy.” American Journal of Psychiatry 158: 4–10. Biegler, P. (2011). The Ethical Treatment of Depression: Autonomy through Psychotherapy. Cambridge, MA: MIT Press. Biegler, P. and Stewart, C. (2001). “Assessing Competence to Refuse Medical Treatment.” Medical Journal of Australia 174: 522–525. Blease, C., Kelley, J. M., and Trachsel, M. (2018). “Informed Consent in Psychotherapy: Implications of Evidence-Based Practice.” Journal of Contemporary Psychotherapy 48: 69–78. Blease, C., Trachsel, M., and Grosse Holtforth, M. (2016). “Paternalism, Placebos, and Informed Consent in Psychotherapy: The Challenge of Ethical Disclosure.” Verhaltenstherapie 26: 22–30. British Association for Counselling and Psychotherapy (2016). Ethical Framework for the Counselling Professions. Lutterworth: Author. British Psychoanalytic Council (2015). Psychoanalytic Psychotherapy: What’s the Evidence? London: Author. Buchanan, A. E. and Brock, D. W. (1990). Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge: Cambridge University Press. Christman, J. (2018). “Autonomy in Moral and Political Philosophy.” In The Stanford Encyclopedia of Philosophy (ed. E. N. Zalta). Retrieved from https://plato.stanford.edu/entries/autonomy-moral/ Clarke, K., Mayo-Wilson, E., Kenny, J., and Pilling, S. (2015). “Can Non-Pharmacological Interventions Prevent Relapse in Adults Who Have Recovered from Depression? A Systematic Review and Meta-Analysis of Randomised Controlled Trials.” Clinical Psychology Review 39: 58–70. Ellis, P. M. and Smith, D. A. (2002). “Treating Depression: The Beyondblue Guidelines for Treating Depression in Primary Care—‘Not so much what you do but that you keep doing it.’ ” Medical Journal of Australia 176 Suppl.: S77–S83. Faden, R. R., Beauchamp, T. L., and King, N. M. P. (1986). A History and Theory of Informed Consent. New York: Oxford University Press.

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Conclusion   97 Feinberg, J. (1971). “Legal Paternalism.” Canadian Journal of Philosophy 1: 105–124. Fonagy, P. (2015). “The Effectiveness of Psychodynamic Psychotherapies: An Update.” World Psychiatry 14: 137–150. Green, R. M. (2001). “What Does It Mean to Use Someone as ‘a Means Only’: Rereading Kant.” Kennedy Institute of Ethics Journal 11: 247–261. Griffin, J. (1986). Well-Being: Its Meaning, Measurement, and Moral Importance. Oxford: Clarendon Press. Hammen, C. (2005). “Stress and Depression.” Annual Review of Clinical Psychology 1: 293–319. Harmer, C. J., Goodwin, G. M., and Cowen, P. J. (2009). “Why Do Antidepressants Take so Long to Work? A Cognitive Neuropsychological Model of Antidepressant Drug Action.” British Journal of Psychiatry 195: 102–108. Johnson, R. C. and Cureton, A. (2017). “Kant’s Moral Philosophy.” In The Stanford Encyclopedia of Philosophy (ed. E. N. Zalta). Retrieved from https://plato.stanford.edu/entries/kant-moral/ Jorm, A. F., Allen, N. B., Morgan, A. J., Ryan, S., and Purcell, R. (2013). A Guide to What Works for Depression (2nd ed.). Melbourne: beyondblue. Kant, I. (1965). Fundamental Principles of the Metaphysic of Ethics. London: Longmans. Kemp, K., Zelle, H., and Bonnie, R. J. (2015). “Embedding Advance Directives in Routine Care for Persons with Serious Mental Illness: Implementation Challenges.” Psychiatric Services 66: 10–14. Kirmayer, L. (2004). “The Sound of One Hand Clapping: Listening to Prozac in Japan.” In Prozac as a Way of Life (ed. C. Elliott and T. Chambers, pp. 164–193). Chapel Hill, NC: University of North Carolina Press. Kleinig, J. (1983). “John Stuart Mill and Voluntary Slavery Contracts.” Politics 18: 76–83. Klerman, G. L. (1990). “The Psychiatric Patient’s Right to Effective Treatment: Implications of Osheroff v. Chestnut Lodge.” American Journal of Psychiatry 147: 409–418. Korsgaard, C. M. (2013). “Kantian Ethics, Animals, and the Law.” Oxford Journal of Legal Studies 33: 629–648. Lepping, P. and Raveesh, B. N. (2014). “Overvaluing Autonomous Decision-Making.” British Journal of Psychiatry 204: 1–2. Lynch, M.  F., Vansteenkiste, M., Deci, E.  L., and Ryan, R.  M. (2011). “Autonomy as Process and Outcome: Revisiting Cultural and Practical Issues in Motivation for Counseling.” The Counseling Psychologist 39: 286–302. Malhi, G. S., Bassett, D., Boyce, P., Bryant, R., Fitzgerald, P. B., Fritz, K., Hopwood, M., Lyndon, B., Mulder, R., Murray, G., Porter, R., and Singh, A. B. (2015). “Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for Mood Disorders.” Australian & New Zealand Journal of Psychiatry 49, 1087–1206. Mill, J. S. (1863). On Liberty. Boston, MA: Ticknor & Fields. Parfit, D. (1984). Reasons and Persons. Oxford: Clarendon Press. Pellegrino, E. D. and Thomasma, D. C. (1988). For the Patient’s Good: The Restoration of Beneficence in Health Care. New York: Oxford University Press. Piet, J. and Hougaard, E. (2011). “The Effect of Mindfulness-Based Cognitive Therapy for Prevention of Relapse in Recurrent Major Depressive Disorder: A Systematic Review and Meta-Analysis.” Clinical Psychology Review 31: 1032–1040. Plato (2016). Philebus. Retrieved from https://ebooks.adelaide.edu.au/p/plato/p71phi/introduction. html Queensland Health (2017). Advance Health Directive for Mental Health. Herston, State of Queensland: Author. Rogers v. Whitaker, 175 CLR 479, 1992, at 490. Ryan, R. M., Lynch, M. F., Vansteenkiste, M., and Deci, E. L. (2011). “Motivation and Autonomy in Counseling, Psychotherapy, and Behavior Change: A Look at Theory and Practice.” The Counseling Psychologist 39: 193–260. Stewart, C. and Biegler, P. (2004). “A Primer on the Law of Competence to Refuse Medical Treatment.” Australian Law Journal 78: 325–342.

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98   Autonomy as a Goal of Psychotherapy Szmukler, G. and Appelbaum, P. S. (2008). “Treatment Pressures, Leverage, Coercion, and Compulsion in Mental Health Care.” Journal of Mental Health 17: 233–244. Tannsjo, T. (2007). “Narrow Hedonism.” Journal of Happiness Studies 8: 79–98. Taylor, J. S. (2008). “Autonomy.” In Encyclopedia of Business Ethics and Society (ed. R. W. Kolb). Thousand Oaks, CA: Sage. Trachsel, M., Holtforth, M. G., Biller-Andorno, N., and Appelbaum, P. S. (2015). “Informed Consent for Psychotherapy: Still Not Routine.” Lancet Psychiatry 2: 775–777. Wampold, B. E. (2015). “How Important Are the Common Factors in Psychotherapy? An Update.” World Psychiatry 14: 270–277. Young, R. (1982). “The Value of Autonomy.” Philosophical Quarterly 32: 35–44. Zelle, H., Kemp, K., and Bonnie, R. J. (2015). “Advance Directives in Mental Health Care: Evidence, Challenges and Promise.” World Psychiatry 14: 278–280.

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Chapter 6

Patien t Protection a n d Pater na lism i n Psychother a py Marco Annoni

Introduction Historically, medicine has been primarily based on considerations of beneficence and nonmaleficence. For instance, in the Decorum—a book retrospectively attributed to Hippocrates, the father of Western medicine—physicians are advised to “reveal [. . .] nothing of the patient's future or present condition,” for an honest revelation may often cause “a turn for the worse” (Annoni 2019). The doctor was then regarded as someone who knew what was “best” for patients, and was thus expected to act from a position of benevolent authority. Usually, this required only the skillful persuasion of patients to follow certain therapeutic regimes. Yet, on other occasions, it also justified the deliberate use of deception and, in extreme cases, of physical restraints and coercive treatments. Unsurprisingly, the “Hippocratic Oath” prescribes that physicians ought to “help the sick” and abstain from harm, but it remains silent as to what are their moral obligations toward truthfulness, veracity, and the respect of patients’ preferences. However, in the last seventy years, the ethical, cultural, and legal paradigm regulating clinical relationships has undergone an unprecedented revolution, especially in Western countries (Ten Have and Gordijn 2011; Chattopadhyay and De Vries 2013). This has been due to different factors, the most important of which has been the recognition of patient autonomy as one of the fundamental values in biomedical ethics alongside beneficence and nonmaleficence (Faden and Beauchamp 1986). After the discovery of inhumane scientific experiments during World War II, and of other scandals over the following decades, the paternalistic model of clinical decision-­making has been gradually replaced with a new model grounded in the respect of patient autonomy and informed consent (Beauchamp 2011; McKean, Trachsel, and Croarkin, in this handbook). Arguably, in the last years, a further shift has occurred, as scholars have begun to advocate for a new model grounded in “shared decision-making” (Annoni and Blease  2020; Gaab et al.  2020). These paradigm-­shifts have reshaped the concept of “therapeutic relationship” across all health-­related and

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100   Patient Protection and Paternalism in Psychotherapy patient-centered practices, from surgery to psychotherapy (Blease et al. 2016; Trachsel and Gaab 2016; McKean, Trachsel, and Croarkin, in this handbook). Yet, different to other areas of biomedical ethics, so far the ethics of paternalism in ­psychotherapy has been only partially explored. This is problematic for two reasons. First, because paternalism raises a host of delicate questions due the specific nature of the psychotherapeutic relationship (Blease et al. 2018). Second, because psychotherapists are already expected to navigate complex moral issues concerning the respect of patient autonomy as part of their standard professional and ethical duties (American Medical Association 2015; Blease 2015; Trachsel et al. 2015a). Against this background, this chapter provides a synthetic overview of the moral implications of paternalism in psychotherapy with a focus on patient protection from self-harm. What follows is divided into four sections. Section one will introduce the ethical dilemma of dealing with patients who are at risk of significant self-­harm. Then, section two will outline some key theoretical features of paternalism in clinical settings. On this basis, section three will address the problem of justifying paternalism with substantially autonomous and nonautonomous agents. Lastly, section four will discuss the merits and limits of three rationales that may justify the involuntary hospitalization of persons with mental illness.

Patient Protection, Psychotherapy, and Involuntary Hospitalization Ethical dilemmas about coercive care are common in psychiatry but may occur also in psychotherapy. Consider the following case: a therapist is listening to a patient describing her detailed plan to commit suicide. The patient discloses that she has 94 pills of a—in this dose—lethal medication at home. She knows exactly how many pills she has and counts them every day as a sort of preparing ritual. Upon further questioning, she confirms that she does not have merely suicidal thoughts and that she actually intends to commit suicide that very night: after retrieving the pills, she will move to a motel and carry out her plan. After more probing for signs of hope, desire to live, or ambivalence, the therapist is convinced that the patient is at imminent risk of suicide and proposes to her voluntary hospitalization. The patient answers that she would “prefer to die before going to the hospital” and that, in case she is involuntarily hospitalized, she will quit therapy forever out of distrust and hate for the therapist (adapted from Freedenthal 2013). What should the therapist do? If she lets the patient walk away, there is a high chance that the patient will commit suicide. If the therapist intervenes, instead, the likely outcome is the patient’s involuntary hospitalization. This choice is particularly difficult because it hints at a fundamental tension in psychotherapy. On the one hand, psychotherapy is meant to provide patients with the opportunity to reveal and explore their deepest thoughts and emotions without the fear of being judged or coercively treated. To this end, the voluntary participation of the patient is paramount in psychotherapy—so much so that the concept of an “involuntary psychotherapy” is almost paradoxical. On the other hand, a therapist may have an ethical duty to intervene if patients disclose the intention to harm themselves or others. Sometimes, to prevent harm, the therapist

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Paternalism, Autonomy, Beneficence, and Nonmaleficence   101 could be forced to breach confidentiality; in other cases, instead, the only plausible course of action is the involuntary hospitalization of the patient. However, coercive hospitalization may jeopardize or even rupture the therapeutic relationship which enabled patients to express their feelings, thoughts, and values in the first place. For instance, patients may become angry about needing to go to a hospital for an admission or evaluation and may find it unsafe to ever confide again in the therapist or in any other mental health professional (Newton-­Howes and Mullen 2011; Freedenthal 2013; Akther et al. 2019). Furthermore, involuntary hospitalization is problematic under other respects (Widder­ shoven and Berghmans 2007; Sashidharan and Saraceno 2017). Persons involuntarily committed to psychiatric wards may experience assault and trauma (Robins et al. 2005). More importantly, involuntary hospitalization may be ineffective (Kallert 2008; Kisely et al. 2017). For many conditions—e.g., serious eating disorders—it is still disputed whether and to what extent coercive hospitalization is effective in preventing harm and promoting recovery (Douzenis and Michopoulos  2015). Finally, criteria and procedures regulating involuntary hospitalization for mental illness vary greatly from one country to another; sometimes even within the same country (Salize et al.  2002; Salize and Dressing  2004; Bowers et al.  2007; Hotzy et al. 2018). Studies have also suggested that the criteria justifying coercive admission in psychiatric wards may often be inconsistently interpreted and applied (Seo et al. 2011). The possibility that psychotherapists might consider coercive measures to prevent selfharm in patients precipitates important questions about the ethics of such interventions. On what grounds is involuntary hospitalization ethically justifiable? And, more in general, under what conditions is paternalism justifiable in medicine and psychotherapy? Answering these questions requires a confrontation with the ethics of paternalism in ­biomedicine as well as with the specific situations that might be encountered in psychotherapeutic contexts.

Paternalism, Autonomy, Beneficence, and Nonmaleficence Paternalism is a widely debated topic in philosophy, politics, behavioral sciences, and ­medical ethics (Nys et al. 2007; Thaler and Sunstein 2008; Sunstein 2015). Today, there is a plethora of theories related to the definition, justification, and implications of paternalism (Dworkin 2002). According to Dworkin (2002: 1), “paternalism” refers to “the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm.” Similarly, Beauchamp and Childress (2009: 208) define “paternalism” in relation to biomedical settings as “the intentional overriding of one person’s preferences or actions by another person, where the person who overrides justifies this action by appeal to the goal of benefiting or of preventing or mitigating harm to the person whose preferences or actions are overridden.” These definitions are in substantial agreement and highlight three im­por­tant features of paternalism. The first is that, in order for an act to be paternalistic, it must interfere with someone’s state—i.e., override someone’s preferences or actions. Therefore, a paternalistic act always entails an infringement of autonomy. While autonomy is a multifaceted concept, following

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102   Patient Protection and Paternalism in Psychotherapy Beauchamp and Childress (2009: 99), it can be understood as “self-­rule that is free from both controlling interference by others and from certain limitations such as an inadequate understanding that prevents meaningful choice.” The ethical duty of respecting patient autonomy can be further analyzed as the conjunction of a positive and a negative obligation. As a negative obligation, it entails respecting patients’ liberty, i.e., their ability to act free from external constraints. As a positive obligation, instead, it consists in enabling and promoting patients’ agency, i.e., capacity to decide and act according to a self-­chosen plan. In this sense, there are but two possible ways to interfere with the autonomy of another person: dishonesty and coercion. Dishonesty includes lying, deception, manipulation, and the omission of information, and thus an infringement of someone’s agency (Annoni 2019). Coercion, instead, entails the use (or the threat) of force and violence and thus restricting someone’s liberty. Second, to be such, a paternalistic act must be primarily motivated by reasons of beneficence and/or nonmaleficence. Generally, beneficence is concerned with the promotion of the good, while nonmaleficence is concerned with the prevention and mitigation of harm. Thus, moral dilemmas involving paternalism typically regard situations in which an agent must choose either to benefit/prevent harm to a person or to respect his or her autonomy. Third, an act is paternalistic only if the person who will (supposedly) benefit from it and the person whose autonomy is interfered with are one and the same. Thus, paternalism does not concern the good or harm caused to other persons. Similarly, paternalism is not concerned with the promotion of the good, or the prevention of harm, of the person acting paternalistically. By definition, a self-­interested act is not a paternalistic act. While this may appear obvious, there are conceivable cases in which it may be unclear whether a decision to restrict someone’s autonomy is primarily motivated by paternalistic or self-­interested reasons. For instance, a therapist may hospitalize a patient to assuage his/her anxiety about the patient’s safety; to avoid confronting the emotional, psychological, and professional consequences of the patient’s suicide; or because he or she fears the professional censure associated with possible licensure constraints, peer censure, and lawsuits. Although these concerns may to some extent be legitimate, they are primarily self-­interested and therefore they cannot be invoked to justify involuntary hospitalization on paternalistic grounds. As the next sections explain in further detail, paternalism in clinical contexts ought to be considered as a last resort that may be justifiable only in two cases. First, where considerations of nonmaleficence or beneficence justifiably outweigh concerns for patient autonomy. Second, when paternalism represents the only or the best means to restore or protect longterm autonomy. In both cases, however, the crucial requisite for the paternalistic act to be ethically justifiable is that it is primarily meant for the good of the patient and not for the good of the therapist.

“Soft” vs. “Hard” Paternalism and the Challenge of Assessing Competency Paternalism involves interfering with someone’s autonomy. However, consider a sleepwalker who is at risk of falling from a balcony. In this case, it might be argued that restraining the movements of this person is paternalistic, as it entails a restriction of his or her liberty to

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“Soft ” vs. “Hard” Paternalism and the Assessment of Competency   103 prevent harm. On the other hand, this person is not acting autonomously, as sleepwalking is a non-­voluntary behavior. To characterize cases of paternalism involving substantially non-­voluntary agents, scholars have proposed to distinguish between “soft” (or “weak”) and “hard” (or “strong”) paternalism (Feinberg 1971; Dworkin 2002; Beauchamp and Childress 2009). Soft paternalistic interventions interfere with the life of someone who is “substantially non-­voluntary or can be presumed to be so in absence of evidence to the contrary” (Feinberg 1971: 124). Examples of non-­voluntary agents are persons who are intoxicated, suffer from hallucinations, or are otherwise unable to make autonomous choices due to a compromised emotional, physical, or psychological state. In contrast, hard paternalistic interventions interfere with the life of someone by overriding his or her explicit, informed, and voluntary preferences. Thus, instances of a hard paternalistic intervention are when competent persons are forced to receive medical treatments (e.g., a life-­saving blood-­transfusion) for their own good despite their explicit and informed refusal. Soft paternalistic interventions are generally considered ethically uncontroversial. As noted by Beauchamp and Childress (2009: 210), “that we should protect persons from harm caused to them by conditions beyond their control is not controversial. Hence, soft paternalism does not involve a real conflict between the principles of respect for autonomy and beneficence.” For this reason, refraining from soft paternalism “is not an example of respect for autonomy because soft paternalism only tries to prevent the harmful consequences of a patient’s actions that the patient did not autonomously choose” (Beauchamp and Childress 2009: 210). Hard paternalistic interventions, instead, presuppose a real infringement on patient autonomy and therefore stand in need of a more articulated ethical justification. Depending on the normative theory assumed such process may vary considerably. According to Beauchamp and Childress’s (2009) four principle approach, for instance, when the prima facie duty to respect autonomy conflicts with the prima facie duty of nonmaleficence, one has to engage in a process of moral deliberation in which the reasons in favor and against the respect of each duty are identified and then “weighted and balanced” in order to decide which one should justifiably prevail, all things considered. Specifically, to facilitate the identification and evaluation of the relevant moral reasons in cases of proposed hard paternalism, Beauchamp and Childress propose the following five conditions (2009: 216): “(i) A patient is at risk of a significant, preventable harm; (ii) The paternalistic action will probably prevent the harm; (iii) The projected benefits to the patient of the paternalistic action outweigh its risks to the patient; (iv) There is no reasonable alternative to the limitation of autonomy; (v) The least autonomy-­restrictive alternative that will secure the benefits and reduce the risks is adopted.” On many occasions evaluating these conditions will lead to reject the use of paternalistic interventions that cannot be considered as a last resort. For instance, condition (iv) requires, at least, the prior identification and evaluation of other reasonable alternatives to the paternalistic intervention. These reasonable alternatives will depend on the patient’s conditions, and may entail the scheduling of more frequent visits with the therapist; the adoption of different techniques to enlist the patient’s cooperation; the implementation of monitoring procedures to prevent and manage the patient’s crises; or the involvement of the patient’s family or guardians (Touyz and Carney 2010). Importantly, from condition (iv) it also follows that it may be permissible to consider involuntary hospitalization only when all possible ways of securing the patient’s voluntary hospitalization have been exhausted.

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104   Patient Protection and Paternalism in Psychotherapy Similarly, condition (v) requires the prior identification and evaluation of which paternalist intervention, among those that are available, has the least possible impact on patient autonomy. For instance, this entails that involuntary hospitalization should be for the shortest possible time, and that appropriate procedures are in place to identify whether it is no longer necessary. This also implies that, if a hard paternalistic intervention is eventually judged ethically permissible, then those proposing the paternalistic intervention must be also able to provide sufficiently good reasons to argue that paternalism was in that case the  only viable option, and that among the possible paternalistic interventions the least restrictive has been selected. It should also be noted that this procedural framework may be specified in different ways—for instance, by arguing that in different situations certain values should “weight” more than others. Condition (iii), in fact, prescribes only that the projected benefits “outweigh” the risks for the patient; yet which “weights” are eventually assigned depend on the agents conducting the process of moral justification. It is thus possible that different agents evaluating the same paternalistic intervention may legitimately arrive at different conclusions concerning its moral permissibility. Rather than providing algorithmic solutions to ethical dilemmas, this methodology ensures that those acting paternalistically (or not) have at least “good reasons” for doing so, meaning that they are able to justify why they have decided to act in a certain way. Being able to justify such a choice may prove essential to restore patient’s cooperation once the need for paternalistic hospitalization is over. This is especially important in the case of depression or eating disorders, where hospitalization may be required in the short term, but where ultimately it will be “the therapeutic relationship and a supportive milieu that will produce the best outcome” (Touyz and Carney 2010: 221). Also, notwithstanding the possible differences in specific cases, in most situations this view provides a clear default attitude for clinicians and therapists: other things being equal, paternalism infringes on patient autonomy and, therefore, is prima facie wrong. This applies not only to extreme cases such as those involving involuntary hospitalization, but also to other instances of deliberate paternalism, including the use of lies, deception, manipulation, and omission of relevant information (Annoni 2019). A corollary is that, in dilemmatic cases, this view indicates a procedural way to overcome the indecision: identify and balance the moral reasons in favor and against the paternalistic act to determine which course of action should eventually prevail. It must be noted, however, that this theory does not represent the only option, as it is possible to approach the ethics of medical paternalism also from a more consequentialist or deontological perspective and thus without assuming conflicts between prima facie duties. That being said, a common problem to all accounts endorsing the distinction between soft and hard paternalism is that such distinction is premised on the capacity to distinguish  between substantially autonomous (or competent) and non-­autonomous (and non-competent) agents. Drawing such a distinction is often challenging, especially in patients with mental health issues. Mental health is a multidimensional construct and a central determinant of a person’s ability for autonomous decision-­making (Douzenis and Michopoulos 2015). In many cases, it is unclear to what extent a mental illness may compromise autonomous decision-­making. An example is anorexia nervosa (AN), a psychiatric condition with a high mortality and morbidity rate (Touyz and Carney 2010; Douzenis and Michopoulos 2015). AN involves body image distortion, intense fear of weight gain, and

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Paternalism, Involuntary Hospitalization, and Mental Illness   105 self-­induced weight loss leading to physical and mental abnormalities (Westmoreland et al. 2017). Importantly, AN is also an egosyntonic disorder: the patient feels the “disorder” is a part of themselves, and do not want it to go away (Touyz and Carney 2010; Douzenis and Michopoulos 2015). Issues of consent and autonomy are thus particularly challenging in patients with AN, as it is often unclear whether patients with AN are competent and substantially autonomous (Guarda 2008; Trachsel et al. 2015b). Similar considerations may apply to other serious eating disorders and psychiatric conditions, such as major depression, in which patients may fail to acknowledge that they are ill (Hindmarch et al. 2013). Despite the existence of various scales, standards, and tests to assess competency, in most if not all cases such assessments remain a matter of clinical judgment. Unsurprisingly, these judgments are often difficult and controversial (Beauchamp and Childress 2009; Douzenis and Michopoulos 2015). What is relevant for the present discussion, however, is the recognition that such judgments have always clinical and normative implications, as they provide the basis also to decide whether an intervention ought to be justified as an instance of “soft” or “hard” paternalism (Hermann et al. 2020).

Paternalism, Involuntary Hospitalization, and Mental Illness Ethical dilemmas involving coercive care for paternalistic reasons involve a conflict between considerations of respect for autonomy and considerations of beneficence or nonmaleficence. In addition, such dilemmas may possess an additional layer of complexity when they involve mentally ill patients. On what ground can a paternalistic intervention—such as involuntary hospitalization—be justifiable in these cases? As noted, there exists an ample heterogeneity in how different countries regulate involuntary commitment (Salize et al. 2002). Moreover, the legal, cultural, and social aspects regarding coercion are known to fluctuate between countries, and even within a single country’s states or regions (Hotzy et al. 2018). Nonetheless, most contemporary regulations allow involuntary hospitalization as a last resort, if other less restrictive measures are unavailable or have failed, and on grounds of one or more of these rationales: (i) patient’s needs, (ii) the prevention of harm, (iii) and patient’s incompetency (Seo et al. 2011; Hotzy et al. 2018). Hence, Tännsjö (1999) distinguishes three rationales or models that may be invoked to justify involuntary hospitalization: the need model, the life rescue model, and the incompetency model. These models do not exhaust all the logical possibilities; still, they allow to identify a set of general cases in which the paternalistic hospitalization of a person with a mental illness may be morally unjustifiable from the standpoint of a normative theory in which the respect of autonomy is not automatically subordinated to beneficence and nonmaleficence. According to the need model, people suffering from a mental illness, who need medical treatment for it, and who do not assent to the treatment, should be involuntarily hospitalized (Tännsjö 1999). Versions of the need model are currently adopted in countries such as Australia or Switzerland (Salize et al.  2002; Hotzy et al.  2018). This model provides the broadest rationale to justify the involuntary commitment of someone with mental illness as it allows to coercively hospitalize someone for a mental illness even though this person may

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106   Patient Protection and Paternalism in Psychotherapy be sufficiently competent to decide and does not pose a threat of harm to him or herself and others. For this reason, other things being equal, the duty of respecting patient autonomy provides a strong presumption to reject the need model as the only rationale justifying involuntary hospitalization. If a person is not at risk of causing harm, and is sufficiently autonomous to express an informed and voluntary refusal, then it is morally unjustifiable to coercively treat this person—even if she could benefit from such a treatment. Like in clinical practice, the fact that someone is in need of a treatment does not provide a sufficient ground to force this person into receiving such a treatment without consent. Thus, as long as a mental illness (or other factors) do not substantially interfere with a person’s capacity for autonomous decision-­making, the need model cannot provide the only rationale to involuntarily hospitalize someone who is mentally ill and not at risk of causing harm. Next is the life rescue model for which only people who suffer from mental illness, who need medical treatment for it, who are at risk of causing harm to themselves (or others), and who do not consent to treatment, should be involuntarily hospitalized (Tännsjö 1999). The rescue model is more restrictive than the need model, as only persons who are mentally ill and dangerous may be involuntarily hospitalized. This criterion is currently adopted in many national jurisdictions and also by the Council of Europe’s Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine, in which it is stated: “Subject to protective conditions prescribed by law, including supervisory, control and appeal procedures, a person who has a mental disorder of a serious nature may be subjected, without his or her consent, to an intervention aimed at treating his or her mental disorder only where, without such treatment, serious harm is likely to result to his or her health” (Council of Europe 1997: art. 7). Despite its popularity and prima facie attractiveness, I concur with Tännsjö (1999) that we should resist adopting the life rescue model as the sole ground for justifying involuntary hospitalization—unless other conditions are in place. Again, the main reason is that also this model does not exclude possible cases in which a person is at risk of self-­harm, suffers from a mental illness, but he or she is still substantially able to make autonomous choices. In this respect, the relevant example is that of adult and competent Jehovah’s witnesses who, in clinical settings, decide to refuse life-­saving blood-­transfusions for their religious beliefs. If these patients are allowed (as they should be) to refuse even a life-­saving treatment out of considerations of respect for their autonomy, then such considerations should apply also to  other patients who are substantially autonomous and deliberately refuse treatment or hospitalization, even if mentally ill. This implies that, as long as a person has a mental illness but is judged sufficiently competent to make an autonomous choice, then such a person should not be automatically hospitalized for paternalistic reasons. In extreme cases, after all other opportunities to provide care have proved ineffective, this view entails that a substantially autonomous patient with a mental illness, and who has deliberately and repeatedly expressed a wish to end his or her own life, should be allowed to do so without being forcefully hospitalized or otherwise constrained. A different argument could be made for persons who are substantially autonomous and dangerous to others; however, these cases do not fall under the ethics of paternalism and therefore must be evaluated according to a different normative framework. Finally, there is the incompetency model, for which only people who suffer from mental illness, who need medical treatment for it, who are not capable of making an autonomous decision about their medical needs, and who do not assent to the treatment should be

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Conclusion   107 coercively treated for their mental illness (Tännsjö 1999). No country or legislation adopts the incompetency model as the only ground for involuntary commitment, but the incompetency rationale is often cited alongside the risk of causing harm. This is, for instance, the position of The Declaration of Hawaii by the World Psychiatric Association (WPA), in which it is stated: “No procedure shall be performed nor treatment given against or independent of a patient’s own will, unless, because of mental illness, the patient cannot form a judgement as to what is in his or her best interest and without which treatment serious impairment is likely to occur to the patient or others” (WPA 1983: art. 5). In difference to the need and life rescue models, the incompetency rationale assumes that people with mental illness may be coercively treated for paternalistic reasons only if their mental illness is impairing their capacity to make autonomous decisions about which treatment they want to receive or refuse. Endorsing the incompetency model allows justifying soft paternalistic interventions for reasons of beneficence/nonmaleficence—from the administration of antibiotics to cure pneumonia up to the involuntary hospitalization of a person who is at risk of causing significant harm to him/herself. Furthermore, it also allows to better characterize the goal of further paternalistic interventions. As noted by The Declaration of Hawaii, if the main reason for involuntary hospitalization is the lack of substantial autonomy, then, if possible, the primary goal of such measure should be that of restoring one’s autonomy, and “As soon as the conditions for compulsory treatment no ­longer apply, the psychiatrist should release the patient from the compulsory nature of the treatment and if further therapy is necessary it should obtain voluntary consent” (WPA 1983: art. 6). Thus, among the three options, the incompetency rationale seems to be the only one that may be sufficient to justify involuntary hospitalization and treatment on paternalistic grounds. In sum, different rationales may be invoked to justify the coercive treatment of a mentally ill person. Yet, not all of them are equally persuasive as the primary moral ground to justify a hard paternalistic intervention—at least from the point of view of a normative theory in which the respect of patient autonomy in held paramount. In this respect, the incompetency model provides a better starting point to evaluate involuntary hospitalization than the need or the life rescue model. However, adopting this model presupposes the capacity to evaluate the competency of a person with mental illness, a task that, as noted above, may often prove quite challenging.

Conclusion The deliberate use of paternalistic interventions to protect patients from self-­harm raises complex ethical dilemmas involving, on the one hand, the respect of patient autonomy and, on the other hand, considerations of beneficence and/or nonmaleficence. While similar dilemmas occur also in standard clinical practice, in relation to psychotherapy they often entail additional complexities due to the specific nature of the psychotherapeutic relationship and the difficulty to assess the competency of the person who will supposedly benefit from the paternalistic intervention. Regardless of the specific circumstances, however, the coercive hospitalization of a patient always represents a traumatic event, which may have lasting consequences not just

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108   Patient Protection and Paternalism in Psychotherapy for the person involuntarily hospitalized but also for the therapist who had to make such a difficult decision. For this reason, in relation to psychotherapy, involuntary hospitalization for paternalistic reasons ought to be considered only as a last resort, and only after other less autonomy-­restrictive options have been exhausted. As I have suggested in this chapter, resources drawn from biomedical ethics may aid therapists in confronting these ethical dilemmas by supplying a series of useful conceptual distinctions and methodologies. While in many cases these conceptual tools will not eliminate or ease the burden of making difficult decisions about the ethics of paternalism in psychotherapy, what they could do is to increase the chances that whatever choice is eventually made, such a choice has been made primarily for the good of the patient, and not for the good of the therapist or society.

Acknowledgments I am grateful to Irving Kirsch, Manuel Trachsel, and John Sadler for their useful comments on an earlier draft of this chapter.

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Conclusion   109 Douzenis, A. and Michopoulos, I. (2015). “Involuntary Admission: The Case of Anorexia Nervosa.” International Journal of Law and Psychiatry 39: 31–35. Dworkin, G. (2002). “Paternalism.” In The Stanford Encyclopedia of Philosophy (ed. E. N. Zalta). Retrieved from https://plato.stanford.edu/entries/paternalism/ Faden, R. R. and Beauchamp, T. L. (1986). A History and Theory of Informed Consent. New York: Oxford University Press. Feinberg, J. (1971). “Legal Paternalism.” Canadian Journal of Philosophy 1: 105–124. Freedenthal, S. (2013). “Involuntary Hospitalization: From Ally to Adversary?” [Online]. Retrieved from https://www.speakingofsuicide.com/2013/05/20/from-ally-to-adversary/ (accessed 14.04.2020). Gaab, J., Annoni, M., Blease, C., Gerger, H., and Locher, C. (2020). “The Good Treatment: A ­Biopsychosocioethical Proposition.” In Person Centred Care: Advanced Philosophical Perspectives (ed. L. Williamson and M. Loughlin). London: Aesculapius Medical Press. Guarda, A. S. (2008). “Treatment of Anorexia Nervosa: Insights and Obstacles.” Physiology and Behavior 94: 113–120. Hermann, H., Feuz, M., Trachsel, M., and Biller-Andorno, N. (2020). “Decision-Making Capacity: From Testing to Evaluation.” Medicine, Healthcare, and Philosophy 23: 253–259. Hindmarch, T., Hotopf, M. and Owen, G. S. (2013). “Depression and Decision-Making Capacity for Treatment or Research: A Systematic Review.” BMC Medical Ethics 14: 54. Hotzy, F., Kerner J., Maatz, A., Jaeger, M., and Schneeberger, A. R. (2018). “Cross-Cultural Notions of  Risk and Liberty: A Comparison of Involuntary Psychiatric Hospitalization and Outpatient Treatment in New York, United States and Zurich, Switzerland.” Frontiers in Psychiatry 9: 267. Kallert, T. W. (2008). “Coercion in Psychiatry.” Current Opinion in Psychiatry 21: 485–489. Kisely, S.  R., Campbell, L.  A., and O’Reilly, R. (2017). “Compulsory Community and Involuntary Outpatient Treatment for People with Severe Mental Disorders.” Cochrane Database of Systematic Reviews 3. Newton-Howes, G. and Mullen  R. (2011). “Coercion in Psychiatric Care: Systematic Review of Correlates and Themes.” Psychiatric Services 62: 465–470. Nys, T., Denier, Y., and Vandervelde, T. (eds) (2007). Autonomy and Paternalism: Reflection on the Theory and Practice of Health Care. Leuven: Peeters. Robins, C. S., Sauvageot, J. A., Cusak, K. J., Suffoletta-Maierle, S., and Frueh, B. C. (2005). “Special Section on Seclusion and Restraint: Consumers’ Perceptions of Negative Experiences and ‘Sanctuary Harm’ in Psychiatric Settings.” Psychiatric Services 9: 1134–1138. Salize, H. J. and Dressing, H. (2004). “Epidemiology of Involuntary Placement of Mentally Ill People across the European Union.” British Journal of Psychiatry 184: 163–168. Salize, H. J., Dressing, H., and Peitz, M. (2002). “Compulsory Admission and Involuntary Treatment of Mentally Ill Patients—Legislation and Practice in EU-Member States” [Online]. Retrieved from http://www.mentalhealthalliance.org.uk/pre2007/documents/salize.pdf Sashidharan, S. P. and Saraceno, B. (2017). “Is Psychiatry Becoming More Coercive?” British Medical Journal 357: j2904. Seo, M. K., Kim, S. H., and Rhee, M. (2011). “Coercion in Psychiatric Care: Can Paternalism Justify Coercion?” International Journal of Social Psychiatry 59: 217–223. Sunstein, C. R. (2015). “Nudging and Choice Architecture: Ethical Considerations.” Yale Journal on Regulation, Forthcoming. Tännsjö, T. (1999). Coercive Care. The Ethics of Choice in Health and Medicine. London: Routledge. Ten Have, H. and Gordijn, B. (2011). “Travelling Bioethics.” Medicine, Health Care and Philosophy 14: 1–3. Thaler, R. H. and Sunstein, C. R. (2008). Nudge: Improving Decisions about Health, Wealth and Happiness. New Haven, CT: Yale University Press. Touyz, S. and Carney, T. A. O. (2010). “Compulsory (Involuntary) Treatment for Anorexia Nervosa.” In The Treatment of Eating Disorders: A Clinical Handbook (ed. C. Grilo and J. Mitchell, pp. 212–224). New York: Guilford Press. Trachsel, M. and Gaab, J. (2016). “Disclosure of Incidental Constituents of Psychotherapy as a Moral Obligation for Psychiatrists and Psychotherapists.” Journal of Medical Ethics 42: 493–495.

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110   Patient Protection and Paternalism in Psychotherapy Trachsel, M., Holtforth, M. G., Biller-Andorno, N., and Appelbaum, P. S. (2015a). “Informed Consent for Psychotherapy: Still Not Routine.” Lancet Psychiatry 2: 775–777. Trachsel, M., Wild, V., Biller-Andorno, N., and Krones, T. (2015b). “Compulsory Treatment in Chronic Anorexia Nervosa by All Means? Searching for a Middle Ground Between a Curative and a Palliative Approach.” American Journal of Bioethics 15: 55–56. Widderrshoven, G. and Berghmans, R. (2007). “Coercion and Pressure in Psychiatry: Lessons from Ulysses.” Journal of Medical Ethics 33: 560–563. Westmoreland, P., Johnson, C., Stafford, M., Martinez, R., and Mehler, Philip S. (2017). “Involuntary Treatment of Patients With Life-Threatening Anorexia Nervosa.” Journal of the American Academy of Psychiatry and the Law 45: 419–425. World Psychiatric Association (WPA) (1983). The Declaration of Hawaii [Online]. Retrieved from http://www.codex.vr.se/texts/hawaii.html

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chapter 7

Em path y, Hon est y, a n d I n tegr it y i n the  Ther a pist A Person-Centered Perspective Jeffrey H. D. Cornelius-White and Gillian Proctor

Introduction In this chapter, we focus on the values of empathy, honesty, and integrity in therapy. These values centralize the focus on the importance of the quality of the therapy relationship and the client’s trust in the practitioner, which has been shown to be central not only in outcomes of psychotherapy (Cooper 2008) but also for medical interventions (Birkhäuer et al. 2017). This chapter addresses this issue from the perspective of the person-centered approach, as person-centered therapy (PCT) was one of the first to have highlighted the necessity of empathy, honesty, and integrity for personal change, and indeed, along with unconditional positive regard, these attitudes were posited as not just necessary but ­sufficient conditions in all psychotherapy for constructive personality change to occur (Rogers 1957). Rogers (1957, 1959) situated empathy as the centerpiece of the six necessary and sufficient conditions posited for successful psychotherapy, in the sense that it is the most visible, taught, researched, and practiced. Countless clinicians have observed Rogers’s demonstration of therapy sessions, highlighting and instilling a basic understanding of what empathic understanding looked like in his practice (Lietaer and Gondrum  2018). Generations of therapists have been encouraged by his example to value the practice and process of empathy. In the sense of honesty and integrity as moral qualities, PCT empathy offers a realization of a relational ethics that sincerely and unconditionally protects the self-determination and power of clients. In other ways, honesty and integrity are intrinsically related to the congruence of the therapist, another key condition of PCT. We consider how each of these values forms a part of the ethical foundations of PCT.

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112   Empathy, Honesty, and Integrity in the Therapist In this chapter we are taking a relational approach to ethics and values (see Proctor 2014; Proctor and Keys 2013), rather than the more traditional biomedical ethical approach of principlism (Beauchamp and Childress 2001) or virtue ethics. We see relationships as the starting point, rather than individuals, a view consistent with the idea of a person being both autonomous and relational in the person-centered approach (see Schmid 2013). This view aligns with the explanation of Rogers’s conditions (1957, 1959) as a description of the therapy relationship itself, not as offerings from the therapist to the client and with feminist conceptualizations of the person-centered approach (Cornelius-White & Godfrey,  2004; Proctor, 2004). It also represents the relational approach to ethics in psychotherapy described by Bond (2007, 2010).

Empathy Empathy is now one of the most researched and empirically supported relationship ­components in psychotherapy from any orientation (Norcross  2001,  2011; Norcross and Lambert 2018). Empathy is acknowledged by almost every approach to psychotherapy as an important foundation or at least part of successful therapy. For example, empathy is one of the best predictors for success by beginning therapists, in particular, many of whom may not have well-defined theoretical orientations (Elliott et al. 2011). Empathy measured from the client’s perspective in particular best predicts outcome (Cornelius-White,  2002). Likewise, directive, manualized, specific treatments, such as those performed by cognitive behavioral therapists have been shown to be more effective with more empathy (Elliott et al. 2011), and cognitive behavioral therapists argue for the inclusion and explicit practice of empathy (Vyskocilova et al. 2011). While empathy may be viewed as a foundational practice for any counseling or helping professional, or as an empirically validated component in successful therapy relationships, a classical PCT posits that empathy is fundamentally neither. Empathy from a personcentered conceptualization is a principled, ethical, and interpersonal process to be contemplated and returned to again and again as a standard by which to learn, apply, and judge. While empathy is also now known to be an innate component of humanity in the sense of having neurobiological evidence (Lux  2013), this chapter explores empathy in relation to the concept of integrity, specifically the definition of integrity that refers to having and living from a moral stance. Likewise, empathy in PCT is inseparable from the concept of unconditional positive regard in providing a compassionate interpersonal process based on non-possessive love. In this sense, the authors assert that empathy is a relational value and forms the basis for the PCT approach, and is not just a part of a theory or a set of techniques.

Empathy as Therapist Attitude Rogers (1957,  1959) posited six necessary and sufficient conditions for therapy, which he suggested apply generically across any approach to therapy and in a closely related way apply specifically in PCT. Briefly summarized these are that a client is in contact (Condition 1)

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empathy   113 with a therapist and incongruent, vulnerable, anxious, or otherwise subceiving some ­suffering or internal conflict (Condition 2). The psychotherapist is congruent, integrated, genuine (Condition 3) in their empathic understanding (Condition 4) and unconditional positive regard (Condition 5) toward the client, who in turn perceives that genuine empathy and unconditionality (Condition 6). This view shows the conditions, especially the role of empathy, as a relational and circular process, in which the therapist and client together experience the therapist’s empathy through the client’s perceptions, and those perceptions in turn help fine tune the therapist’s empathy. For the therapist to empathically understand the client, they need to sense the client’s internal world (or frame of reference) as if it were the therapist’s own world. The as if part of this condition is often emphasized, describing the ethical movement of the therapist toward the client, with the intention of trying to understand more and more what it is like to be this unique human at this time and in relation to this experience. It is not about imagining how the therapist would react to this particular client experience, but an attempt to move as far as possible into the body and being of the client and be as close as possible to their experience. One might debate about how far this is possible and how much we all understand each other from our own frame of reference, but the important ethical point is the intention of the therapist to make this move toward the perspective of the client as far as possible. This empathic process does not need to be understood solely as a move from the therapist toward the client, but also as a process arising through the relationship and the intersubjectivity of the therapist and client. The perception of empathy by the client (Condition 6) may in turn be perceived by the therapist to form a circular process of improving.

Empathy as a Practice Resulting from a Nondirective Attitude The singular motivational concept in PCT is the actualizing tendency, the inclination toward the maintenance and enhancement of the whole person (Rogers 1959). The ethical corollary of the actualizing nature of clients (i.e., persons) is a therapist’s nondirective attitude, a respect of the client’s right to self-determination. Raskin (2005) discusses the nondirective attitude, which was cited by Rogers (1951) in his classic Client-Centered Therapy. Raskin wrote (and Rogers wrote in the margins, “yes”): “The counselor makes a maximum effort  . . .  in a word, to absorb himself completely in the attitudes of the other. And in struggling to do this, there is simply no room for any other type of counselor activity or attitude” (quoted in Rogers 1951: 6). In this sense, the gestalt phenomenology of a disciplined person-centered practice is to cultivate a relational context characterized by the conditions which is to embody this nondirective attitude. Brodley (1997), Grant (1990, 2010), and others have referred to this as respecting a client’s right to self-determination. Here the term self-determination is the broad concept associated with nondirectivity, not merely the self-concept, which aims to offer respect to the wisdom of the person beyond their explicit identifications and direct awareness. In this sense, the unconditional regard and empathy are meant to protect, and not block, the self-righting tendencies of the person. Bohart and Tallman (2010) have shown how the “client” is likely the most powerful and, ironically, neglected, common factor in psychotherapy success. In an overly simplified stance, one might summarize that the goal in PCT is to “get out of

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114   Empathy, Honesty, and Integrity in the Therapist the way.” However, this getting out of the way has a unique tenor, one which Bozarth (1998) suggests is best accomplished in a way that is neither “being” nor “doing” but something in between, a synergistic and integrated process of being-with and behaving in a way that profoundly protects the client’s agency through a balance of companionship and boundary. In contrast to how many outside PCT have critiqued the approach as parroting or just reflecting word for word or reflecting feelings going back at least seventy years, Raskin (2005), Rogers (1975), and Lietaer and Gondrum (2018) at very different time periods have emphasized a more complicated, experiential, and nuanced understanding of empathy in PCT. Despite how it has often been measured for convenience in research, empathy is first and foremost not a measurable behavior. It is a practice of acknowledging and articulating a client’s expression, perception, choice, and action without undue influence beyond the humanity and resonance of the nondirective therapist. The ethical basis of PCT in a client’s right to self-determination reflects a prioritization of the principle of respect for autonomy, in biomedical ethics (Beauchamp and Childress 2001), which provided a necessary corrective to older ideas of paternalistic approaches to biomedical ethics, focused on the principles of beneficence and non-maleficence. In this sense, PCT has a principled ethical stance. Grant (1990) posited that PCT can be thought of as supported by an instrumental or principled basis. Instrumentally, one practices empathy in order to accomplish a goal. In other words, the effectiveness or efficacy of empathy, or how it establishes an alliance as a basis for other interventions, warrants its practice. In contrast principled PCT is practiced because it is moral in its own right, regardless of the immediate or observed effects or associations. “Principled nondirectiveness is an attitude that provides a space for growth, not one that intends to cause it. Nondirectiveness, like love, is not acted upon for what it achieves, but for what it honors” (Grant 1990: 79). In other words, there is ends–means consistency in PCT empathy. In this sense, any “use” of empathy for an end that does not protect the right to self-determination of the client is not a practice of person-centered empathy at all. Empathy in PCT is its own end.

Empathy as a Conduit for Love The key active ingredient in PCT is unconditional positive regard. Rogers defined unconditional positive regard as basic acceptance, valuing of the person, or non-possessive love. Cornelius-White (2016) describes unconditional positive regard in terms of a benign neutrality that is open to any expression from the client, but also has a tenor of grace and compassion, an appreciation and valuing of persons even in their most vulnerable, whether from their own ethical failures or in response to trauma thrust upon them from outside. Utilizing Rogers’s (1959) explanation of how people mature through therapy, Bozarth (1998) discussed the functional elements in PCT. A client releases conditions of worth to move from an incongruent to a more congruent state as a function of a client’s experience of authentic unconditional positive regard in the relationship with the therapist. In this sense, empathy is the vehicle by which unconditional positive regard is received precisely in the very places where it is needed. In other words, empathy is the conduit for the active ingredient in PCT, love.

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empathy   115

Empathy as a Relational Ethic or Morality Approaches to ethics within therapy have moved recently from a principlism approach, as in the traditional approach to biomedical ethics of Beauchamp and Childress (2001) to the idea of relational ethics (see Proctor 2014). From this perspective, empathic understanding is not just a principle but a value and way of relating in the therapy relationship to build trust. It is not something done or offered by the therapist to the client, but relies on the interaction, on the therapist’s intention to empathically understand the client and the client’s willingness and ability to express their internal framework to the therapist, and the perception and responsiveness of each to the other. Given the impossibility to completely be able to enter the internal framework of another, and the inevitable limitations on how much we can ever understand another from our own frame of reference, ruptures and misunderstandings are inevitable. Relational trust is crucial to recover from and even sometimes benefit from these ruptures. Bond defines this saying: “Trust is a relationship of sufficient quality and resilience to withstand the challenges arising from difference, inequality, risk and uncertainty” (2007: 436, italics in original). The therapist’s relational capacity and responsibility (Gabriel 2009) to monitor and respond to the client’s responses to their intention to empathically understand is of crucial significance here. This is emphasized by Rogers’s sixth condition (Rogers 1957, 1959) of the importance of the client’s perception of the therapist’s empathic understanding.

Empathy as Cooperative Intent/Power With and Minimizing Power-Over Proctor (2017) has discussed three aspects of power within the therapy relationship and applied various theories of power to explore the ethics of power in therapy. Starhawk (1987) usefully distinguishes between three types of power. Power-over is coercion or domination. Power-with is collaboration and power-from-within is akin to Rogers’s (1989) conception of personal power, meaning power that originates from self-determination, or a sense of agency. Proctor (2017) argues that the aim of the therapist with respect to power is to avoid power-over the client, and to increase both the client’s and the therapist’s power-from-within and to harness power-with inside the therapy relationship. Starhawk’s concept of power-with is an important positive use of relational power, and derives from Arendt’s earlier concept of power through collectivity, which she argues “rested on reciprocity and mutuality” (1963: 181). A recent meta-synthesis of both quantitative and qualitative research on mutuality in psychotherapy suggests a unique role for such shared power, especially in terms of its high correlation with the perceived successfulness of individual psychotherapy sessions (Cornelius-White et al. 2018). For Arendt, collective power refers to the human ability to act in concert with others, where we join together to increase the power and freedom of all. Starhawk (1987) emphasizes the importance of perceived equality among those who experience power-with or power through collectivity. Proctor (2017) argues that therapy is an opportunity to use power-with inside the therapy relationship, where therapist and client work together for the

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116   Empathy, Honesty, and Integrity in the Therapist freedom and power of both. Although the therapy relationship will always be asymmetrical with a focus on the client, the process of empathic understanding facilitates the experience of equality between people, but the potential for power-with (as opposed to a more hierarchical helping from a position of power) is limited by the extent to which the client is able to perceive their own power-from-within and inherent worth as a person equal to the therapist. Here we argue that the intention of empathic understanding from the therapist to the client is a move away from power-over (coercion and domination) and toward power-with or collaboration, by the therapist and client working together to understand the unique internal framework of the client. Empathy enables the therapist’s focus on the value of the unique client (unconditional positive regard) and the increase in understanding deriving from the empathic process facilitates an increase in the power-from-within of the client and the therapist. As the client’s power-from-within increases, so too does the client’s ability to perceive themselves as of worth (unconditional positive self-regard) and equal to the therapist, thus facilitating the possibility of power-with. In PCT, empathy is a moral practice grounded in relational ethics that respect the right for self-determination, minimizing power-over, being powerful with, and facilitating the client’s experience of their own power-from-within.

Honesty: A Partial Synonym for Congruence In an attempt to bring together and illuminate the many meanings of the core concept of congruence, Cornelius-White (2007a) described five levels of congruence. Two of these levels are captured by the terms genuineness and transparence, which bear the closest similarity to two uses of the term honesty.

Honesty and Genuineness Honesty conventionally refers to sincerity, the freedom from any deceit or role playing. In PCT, honesty is one of the most basic components of congruence. In this sense, the synonym genuineness is often used in PCT literature. A person-centered therapist is aiming not to pretend to be empathic like a therapist is supposed to be, but to truly experience empathy at a full human level. One might say that the honesty element of congruence characterizes the tenor of empathy and unconditional positive regard in the relationship. Honesty assures the means–ends consistency ethic, that is, that unconditional empathy is provided sincerely, freely without any hidden agenda.

Honesty and Transparence Another synonym used for congruence that is relevant here is transparence. While trainers of PCT often advise a quiet presence over a loud self-disclosing one, the element of

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integrity: a closer synonym for congruence   117 transparence suggests that an honest PCT therapist does self-disclose or own their experience verbally if not doing so would obscure their genuineness. In this case, the expression is often spontaneous, not scripted. Brodley (1997) described transparence as an expression of congruence, but not the quality itself, suggesting that the quality itself is closer to integrity.

Integrity: A Closer Synonym for Congruence Integrity is perhaps a more complicated term than honesty, at least in its relationship to PCT. Integrity refers to a character trait marked by honesty (just described above) and morality (described under empathy as a relational ethic). Thirdly, integrity refers to the state of wholeness and integration, again suggesting honesty in the sense of genuineness and transparence. However, it also suggests a maturation with cognitive and behavioral markers, captured by other synonyms in PCT, such as self-awareness, self-acceptance, fully functioning, and extensionality.

Integrity: Internal Empathy and Unconditional Positive Regard To further elaborate Cornelius-White’s (2007a) five levels of congruence, congruence is often used to refer to self-awareness and self-acceptance. It is at this level where one sees how congruence represents a microcosm of the therapist attitudes, just one applied in relation to one’s self not others. At this level of congruence, one experiences an understanding of one’s feelings, thoughts, reactions, and ultimately self. In this sense, PCT understanding of integrity involves self-awareness, or empathy toward one’s experiences. Likewise, by being aware of one’s reactions without attachment to express those, but without an active concealing of them either, one may have self-acceptance. In this sense, beingwith one’s own experience is a type of mindful, unconditional regard toward one’s own experience. In this sense, a PCT understanding of integrity involves self-acceptance. It is this level of congruence for which one may strive their entire life, a maturation of sorts. However, PCT congruence is not encapsulated, or ultimately navel gazing, it is also extensional out into the world, and ideally transcendent. Indeed, Rogers (1959) stresses that the therapist needs to be congruent “in the relationship” with the client. Integrity here again is part of a relational ethic in PCT.

Integrity: Extensionality and Fully Functioning To track the final two of the five levels of congruence (Cornelius-White 2007a), CorneliusWhite’s (2007b) exploration of the under-discussed element of congruence as extensionality is helpful. Cornelius-White (2007b: 198) writes: “Extensionality highlights two aspects of

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118   Empathy, Honesty, and Integrity in the Therapist congruence—first, the personal perceptual practice of seeing and being aware of experience itself, or factual, low-inference reality, and second, the development of critical-creative thinking which holds and evaluates multiple experiential viewpoints.” In this sense of congruence, having integrity means maturing to interact with reality through personal perceptions rather than denying or distorting with interpretations or ideologies (Cornelius-White 2013). It is a low-inference, phenomenologically grounded way of being whereby “a congruent person lives their own subjectivity, never an objective reality” (Cornelius-White  2007b: 199), what Brodley called the “attitude of personal perception” (1997: 66). In the final sense, having integrity involves a fully functional sense of identity based on process, where one is open to their experience both internal and external, with little attachment to self, but more so to the experience as it unfolds (Rogers 1962).

Practical Implications Typical Implication: Practicing PCT The first implication of an ethical understanding of empathy and integrity from a personcentered perspective, is that of practicing therapy with a rich understanding, refined through all of one’s experience, reflection, and meditation on being human and one’s feedback from clients themselves, supervisors, and assessments of process and outcome. In this practice, PCT involves an empathic therapist, responsive to the communications of clients, both about their narrative, their reactions to their narrative, and their relationship with the therapist directly. There is a courage modeled by the therapist to gently but unwaveringly listen for a client’s experience to help clients in turn develop self-awareness and self-acceptance, which in turn leads to greater extensionality and maturation.

When the Unexpected Occurs: Avoiding Power-Over Proctor (2017) argues that the intention of the therapist should be to minimize power-over, and aim to increase the power-from-within of the therapist and client and harness the power-with inside the therapy relationship. This follows from the values and beliefs of the therapist that each client is a unique and worthy human and is visible in PCT empathy. Whenever a therapist wavers from their belief in the client’s self-direction, or begins to feel that they know better than the client, the therapist is at risk of losing their integrity and taking power, or blocking power-from-within or power-with by asserting power-over the client. They risk dishonesty, in the sense of their empathy and unconditional positive regard no longer being sincere. This demonstrates the crucial significance of the therapist’s congruence and self-awareness to monitor and notice when this may happen within the therapy relationship and take steps to return to their trust in the actualizing tendency and autonomy of the client. This may be a time where the therapist chooses to communicate from their own frame of reference to be able to return to the client’s frame of reference and their process of unconditional positive regard and empathic understanding (see Brodley and Moon 2011) or ask questions and attempt a meta or immediacy discussion about the

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conclusion   119 relationship between the therapist and the client directly, sharing their own intent to ­reorient to  the client’s frame of reference. Also, such times are sometimes described as empathic ruptures but also opportunities for reciprocal understanding from a relational depth (Mearns and Cooper 2005) or mutuality lens (Cornelius-White et al. 2018; Proctor 2010). However, from a classical PCT standpoint, such self-disclosures, questions, or discussions are spontaneous congruent expressions, congruence that necessarily includes an attitude of unconditional positive regard and empathic intent. Even in these uncharacteristic PCT situations, the therapist aims to be steadfast in avoiding the use of power-over a client, instead resting on a trust in the self-determination of persons.

Conclusion Empathy, honesty, and integrity are central to therapy and in particular to PCT. They have been explored to show subtle relationships to the concepts of empathic understanding, unconditional positive regard, congruence, a nondirective attitude, power-over, power-with, power-from-within, self-awareness, and acceptance.

References Arendt, H. (1963). On Revolution. London: Penguin. Beauchamp, T. and Childress, J. (2001). Principles of Biomedical Ethics (5th ed.). New York: Oxford University Press. Birkhäuer, J., Gaab, J., Kossowsky, J.,  . . .  and Gerger, H. (2017). “Trust in the Health Care Professional and Health Outcome: A Meta-Analysis.” PLoS ONE 12: 1–13. Bohart, A. C. and Tallman, K. (2010). “Clients: The Neglected Common Factor in Psychotherapy.” In The Heart and Soul of Change: Delivering What Works in Therapy (ed. B. L. Duncan, S. D. Miller, B.  E.  Wampold, and M.  A.  Hubble, pp. 83–111). Washington, DC: American Psychological ­Association. Bond, T. (2007). “Ethics and Psychotherapy: An Issue of Trust.” In Principles of Healthcare Ethics (ed. R. E. Ashcroft, A. Dawson, H. Draper, and J. R. McMillan, pp. 435–442). Chichester: John Wiley. Bond, T. (2010). Standards and Ethics for Counselling in Action (3rd ed.). London: Sage. Bozarth, J. (1998). Person-Centered Therapy: A Revolutionary Paradigm. Ross-on-Wye: PCCS Books. Brodley, B. T. (1997). “The Nondirective Attitude in Client-Centered Therapy.” The Person-Centered Journal 4: 18–30. Brodley, B. T. and Moon, K. A. (2011). Practicing Client-Centrered Therapy: Selected Writings of Barbara Temaner Brodley. Ross-on-Wye: PCCS Books. Cooper, M. (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts Are Friendly. London: Sage. Cornelius-White, J. H. D. (2002). “The Phoenix of Empirically Supported Therapy Relationships: The Overlooked Person-Centered Basis.” Psychotherapy: Theory, Research, Practice, Training 39: 219–222. Cornelius-White, J. H. D. (2007a). “Congruence: An Integrative Five-Dimension Model.” PersonCentered and Experiential Psychotherapies 6: 229–239. Cornelius-White, J. H. D. (2007b). “Congruence as Extensionality.” Person-Centered and Experiential Psychotherapies 6: 196–204. Cornelius-White, J. H. D. (2013). “Congruence.” In The Handbook of Person-Centred Psychotherapy and Counseling (2nd ed.; ed. M. Cooper, M. O’Hara, P. Schmid, and A. C. Bohart, pp. 193–208). Basingstoke: Palgrave Macmillan.

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120   Empathy, Honesty, and Integrity in the Therapist Cornelius-White, J. H. D. (2016). Person-Centered Approaches for Counselors. Thousand Oaks, CA: Sage. Cornelius-White, J.  H.  D., & Godfrey, P. (2004). “Pedagogical Crossroads: Integrating Feminist Critical Pedagogies and the Person-Centered Approach to In Education.” In Encountering Feminism: Intersections of Feminism and the Person-Centered Approach. (ed. G. Proctor and M. B. Napier, pp. 166–178). Ross-on-Wye: PCCS Books. Cornelius-White, J., Kanamori, Y., Murphy, D., and Tickle, M. (2018). “Mutuality in Psychotherapy: A  Meta-Analysis and Meta-Synthesis.” Journal of Psychotherapy Integration 28: 489–504. Elliott, R., Bohart, A., Watson, J., and Greenberg, L. (2011). “Empathy.” Psychotherapy: Theory, Research, Practice, Training 48: 43–49. Gabriel, L. (2009). “Relational Ethics, Boundary Riders and Process Sentinels: Allies for Ethical Practice.” Relational Ethics in Practice: Narratives from Counselling and Psychotherapy (ed. L.  Gabriel and R. Casemor, pp. 9–22). London: Routledge. Grant, B. (1990). “Principled and Instrumental Nondirectiveness in Person-Centered and ClientCentered Therapy.” Person-Centered Review 5: 77–88. Grant, B. (2010). “Getting the Point: Empathic Understanding in Nondirective Client-Centered ­Therapy.” Person-Centered and Experiential Psychotherapies 9: 220–235. Lietaer, G. and Gondrum, M. (2018). “His Master’s Voice: Carl Rogers’ Verbal Response Modes in Therapy and Demonstration Sessions throughout his Career: A Quantitative Analysis and some Qualitative-Clinical Comments.” Person-Centered and Experiential Psychotherapies 17: 275–333. Lux, M. (2013). “The Circle of Contact: A Neuroscience View on the Formation of Relationships.” In Interdisciplinary Handbook of the Person-Centered Approach: Research and Theory (ed. J. H. D. Cornelius-White, R. Motschnig-Pitrik, and M. Lux, pp. 79–94). New York: Springer. Mearns, D. and Cooper, M. (2005). Working at Relational Depth in Counselling and Psychotherapy. London: Sage. Norcross, J. C. (ed.) (2001). “Empirically Supported Therapy Relationships: Summary Report of the Division 29 Task Force.” Psychotherapy 38: 345–356. Norcross, J.  C. (ed.) (2011). Psychotherapy Relationships That Work: Therapist Contributions and ­Responsiveness to Patient Needs (2nd ed.). New York: Oxford University Press. Norcross, J. C. and Lambert, M. J. (2018). “Psychotherapy Relationships That Work III.” Psychotherapy 55: 303–315. Proctor, G. (2004). “What Can Person-Centred Therapy Learn from Feminism?” In Encountering Feminism: Intersections between Feminism and the Person-Centred Approach (ed. G. Proctor and M. B. Napier, pp. 129–140). Ross-on-Wye: PCCS Books. Proctor, G. (2010). “Boundaries or Mutuality in Therapy: Is Mutuality Really Possible or Is Therapy Doomed from the Start?” Politics and Psychology 8: 44–58. Proctor, G. (2014). Values and Ethics in Counselling and Psychotherapy. London: Sage. Proctor, G. (2017). The Dynamics of Power in Counselling and Psychotherapy: Ethics, Politics and Practice (2nd ed.). Ross-on-Wye: PCCS Books. Proctor, G. and Keys, S. (2013). “Ethics in Practice in Person-Centred Therapy.” In The Handbook of Person-Centred Psychotherapy and Counseling (2nd ed.; ed. M. Cooper, M. O’Hara, P. Schmid, and A. C. Bohart, pp. 422–435). Basingstoke: Palgrave Macmillan. Raskin, N. J. (2005). “The Nondirective Attitude.” The Person-Centered Journal 12: 5–22. Rogers, C. R. (1951). Client-Centered Therapy. New York: Houghton Mifflin. Rogers, C. R. (1957). “The Necessary and Sufficient Conditions of Therapeutic Personality Change.” Journal of Consulting Psychology 21: 95–103. Rogers, C. R. (1959). “A Theory of Therapy, Personality and Interpersonal Relationships as Developed in the Client-Centered Framework.” In Psychology: A Study of a Science, Vol. 3: Formulations of the Person and the Social Context (ed. S. Koch, pp. 184–256). New York: McGraw-Hill. Rogers, C. R. (1962). “Towards Becoming a Fully Functioning Person.” In Perceiving, Behaving, Becoming: Lessons Learned (ed. H. J. Freiberg, pp. 35–51). Alexandria, VA: ASCD.

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conclusion   121 Rogers, C. R. (1975). “Empathic: An Underappreciated Way of Being.” The Counseling Psychologist 5: 2–10. Rogers, C. R. (1989). The Carl Rogers Reader (ed. H. Kirschenbaum and V. L. Henderson). Boston, MA: Houghton Mifflin. Schmid, P. (2013). “The Anthropological, Relational and Ethical Foundations of Person-Centred Therapy.” In The Handbook of Person-Centred Psychotherapy and Counseling (2nd ed.; ed. M. Cooper, M. O’Hara, P. Schmid, and A. C. Bohart, pp. 66–83). Basingstoke: Palgrave Macmillan. Starhawk (1987). Truth or Dare: Encounters with Power, Authority and Mystery. San Francisco, CA: Harper & Row. Vyskocilova, J., Prasko, J., and Slepecky, M. (2011). “Empathy in Cognitive Behavioral Therapy and Supervision.” Activas Nervosa Superior Rediva 53: 72–83.

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Chapter 8

Fa ir n e ss, J ustice , a n d Economica l Thi n k i ng i n Psychother a py Marta Herschkopf and Rebecca Weintraub Brendel

Introduction In October 2018, the Lancet published a 46-­page report on the findings of a Commission on Global Mental Health, summarizing the current state of global mental health and future directions to improve it. The results were bleak: the report concluded that there was a “global health crisis” in which unequal and limited access to mental health resources meant that when it came to mental health, “all countries can be thought of as developing countries” (Patel et al. 2018: 1553). The report emphasized the significant global burden of disease attributable to mental illness and decried the dearth of attention and resources that have been devoted to improving global mental health, despite the research available to guide significant and efficient improvements. The Lancet assessment further characterized mental health as not only a global public good, i.e., a key part of a country’s human capital, but also a fundamental human right. It provided a roadmap for countries to devote resources to improve the mental health of their residents, both by addressing the social determinants of mental health and also by expanding services available for the prevention and treatment of mental illness (Patel et al. 2018). Against this backdrop of what may be seen as a global mental health crisis broadly requiring the investment of serious attention and resources, psychotherapy is one intervention known to treat mental illness and to benefit mental health with an existing, and growing, evidence base of support (American Psychological Association 2012). Nonetheless, access to psychotherapy may be limited in terms of modality, amount, and therapist options in the service of cost-­containment. Psychotherapy as a subset of mental health services for the treatment of mental illness is one dimension in which fairness, justice, and economical thinking may be engaged. In this view, specifically, engaging questions of access to and provision of psychotherapy might be framed in the context of efficacy, cost, benefit,

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theories of justice  123 and outcomes for the treatment of diagnosed mental illness. Approached from this vantage point, then, psychotherapy must be considered in terms of its evidence base for the treatment of mental health conditions amongst the available alternatives—most notably psychopharmacology but also including somatic therapies—in achieving outcomes of symptom reduction and functional restoration. However, psychotherapy may also be seen as a subset of available resources to serve individual and societal welfare more broadly. Psychotherapy, then, may serve human welfare through the treatment of illness per se and also through the promotion of well-­being more generally towards a goal of a broader human flourishing encompassing both personal and societal benefit. On this second view, psychotherapy must compete for resources not only with medical treatment of mental illness, but also with other individual and social welfare considerations and resources such as, e.g., education, vocational training, public safety, and overall public health. Not surprisingly, psychotherapy has faced challenges on both fronts, i.e., critiques both from the perspective of symptomreduction outcomes (as opposed to, e.g., medication) and from the standpoint of other social welfare services as restrictive or limited in its reach (as opposed to, e.g., public education and infrastructure). By focusing on different theories of justice, this chapter aims to consider (a) whether a case might be made for the unique value of psychotherapy amongst other competing services (both medical and social welfare), and (b) if not, what criteria might be relevant in assessing its relative cost and value to society nonetheless. It begins by reviewing several relevant approaches to justice, chosen to highlight and explore the ways in which varied features and foci of conceptions of justice might be applicable to consideration of population-­based mental health and allocation of psychotherapy resources. It then turns to a discussion of how these conceptions of justice can offer guidance to navigate outcomes and cost-­effectiveness research regarding mental health services and psychotherapy. The chapter concludes with a brief discussion of psychotherapy in low- and under-­resourced settings.

Theories of Justice There are a variety of theories of justice that might be applied to the considerations above. We will focus here on four: Rawlsian, capabilities, utilitarian, and communitarian. These accounts are chosen not as an exhaustive survey of justice theory, which is beyond the scope of this chapter, but rather as a set of frameworks relevant to core features of justice for considering psychotherapy’s aims and contributions to society as well as for informing broad questions about psychotherapy resource allocation.

Rawlsian Theory In his chapter on justice and fairness in this collection’s companion volume on psychiatric ethics, Kious focuses on theories of distributive justice following the framework outlined by John Rawls (Kious 2015). Rawlsian justice emphasizes two foundational principles. First, every person has a right to basic liberty, and all persons should be afforded equal basic liberties (and even more to enable the maximum amount of liberty that does not infringe

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124   Fairness, Justice, and Economical Thinking in Psychotherapy upon the least endowed). This basic liberty criterion is a sine qua non of justice. Second, the Rawlsian account of justice requires fair distribution of shares of social and economic benefit. While inequality is permissible in this account, it may be justified only by the satisfaction of two additional considerations. First, per the fair opportunity rule, there must be equal opportunity for all to access social positions and opportunities. Second, per the difference principle, inequalities in primary social goods are permissible only if they benefit everyone and, more specifically, are to the greatest benefit of the least advantaged (Rawls 1971). Rawls himself did not apply his conception of justice to health, but the philosopher Norman Daniels focused squarely on this application of Rawlsian justice. Arguing that public health and healthcare lead to normal functioning, which in turn leads to access to opportunity, Daniels claims that Rawlsian justice requires equitable access to and distribution of healthcare. For Daniels, this claim extends to fair distribution of the social determinants of health as well. Given that societies must struggle with how many resources to devote to healthcare versus other social goods that affect health, Daniels provides a process of procedural justice to achieve just distribution, including transparency and an emphasis on rationales relevant to the people affected by these decisions. He explicitly acknowledges the tension between prioritizing those worst off versus distributing healthcare to as many people as possible (Daniels 2001). In summary then, the Rawlsian perspective highlights fair distribution, attention to the least advantaged, and procedural safeguards as relevant considerations to approaching questions of fairness. Applying the Rawls–Daniels approach to mental health follows directly from its application to general health: poor mental health significantly impedes access to opportunity and other liberties. The strength of this approach is recognition of a universal entitlement to mental health treatment as a condition of justice. However, the amount of mental health treatment (including psychotherapy) allotted to each individual is that needed to achieve normal functioning, which at a minimum might be only symptomatic abatement to allow opportunity and basic liberty. In other words, while the argument for broad provision of mental health care is strong, the amount of mental health care provided and the resources allocated could meet the criteria for justice at a minimal symptom-­focused level. A second implication of a Rawlsian justice applied to mental health is the relationship between social inequalities and determinants of mental health. To the extent that mental health concerns can result from social inequalities—although discerning the relative ­contributions of environment and genetics, while ethically relevant, is beyond modern ­science—Daniels’s application of Rawlsian justice would require fair distribution of social resources relevant to baseline mental health beyond the mental health care itself. The extent to which resource prioritization should flow to the most severely affected as opposed to the many is a tension that will nonetheless ensue. Finally, the contribution of procedural considerations to mental health allocation is a feature highlighted by this approach.

Capabilities Theory A second conception of justice is a capabilities approach, which is based on promoting core capabilities of a life lived well. Dimensions of capabilities theory include not only access to basic liberties and opportunities cited by Rawls, but also that justice requires the opportunity to attain a level of functioning through access to core elements including living a full

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theories of justice  125 life span, health and bodily integrity, emotion, play, and practical reason. This theory of justice therefore holds that societies have a duty not only to refrain from impeding access to resources serving these capabilities, but also to actively support their citizens in realizing them (Beauchamp and Childress 2013: 259–261; Nussbaum 2011). The capabilities approach to justice asks us to focus on the critical importance of persons’ access to essential features of full lives. In the context of mental health, there may be particular relevance to psychotherapy in providing development of core capabilities including the ability to express one’s thoughts, develop emotional attachments, maintain health, and experience imagination and play (Beauchamp and Childress 2013: 259). Applying capabilities arguments to mental health follows from their applicability to general health: poor mental health may limit a person’s capabilities in a variety of ways by impeding or preventing attainment of a life well lived across the domain of capabilities. Indeed, the Lancet Commission cites Amartya Sen, a pioneer of capabilities theory, in its definition of what constitutes mental health and well-­being: a combination of pleasure/ satisfaction and meaningful functioning (Patel et al. 2018: 1561–1563). On this view, then, access to mental health resources, including psychotherapy, is required as a condition of justice to allow persons to achieve more than just basic functioning; justice requires access to mental health and psychotherapy resources as means of achieving a full and well-­lived life along the continuum of capabilities. That said, actual policies regarding funding mental health resources alongside other programs (such as education) that contribute to human flourishing remain a challenge.

Utilitarian Theory Approaches to justice emphasizing the maximizing of net social utility and the importance of general welfare, may also be applied to health and, by extension, mental health. One appeal of utilitarian theory is its broad distributional relevance, i.e., that the maximum health ought to be apportioned to the maximum number of recipients (Timmons  2013: 111–175). In other words, a utilitarian notion of justice would lead to the most benefit to the greatest number, thereby incorporating maximizing quantity and quality of mental health (and the care to promote it) to the greatest number of recipients. In this regard, by focusing on outcomes and net benefit (or utility), the utilitarian approach would favor evidence-­based interventions with a strong evidence base supporting positive outcomes. However, mental health would need to be considered relative to other welfare promoting social goods for distribution assuming that there is not a limitless supply of goods to go around, meaning that the priority of mental health—and by extension the availability of psychotherapy to achieve it—would be subject to assessing the overall net importance of mental health in the calculation of generating the greatest good for society. While a utilitarian approach, then, would focus on maximizing mental health and treatment to achieve it, it might not provide as strong an argument for fundamental importance as Daniels’s application of a Rawlsian or a capabilities approach because it does not, explicitly, recognize the inherent importance of health as central to the project of justice but rather as one factor to be balanced with others in the calculation of net utility and social welfare. This is not to say, of course, that there are not compelling arguments in favor of health and mental health’s inclusion as key contenders for societal provision. Furthermore, insofar as physical and

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126   Fairness, Justice, and Economical Thinking in Psychotherapy mental illness might inhibit a person’s ability to contribute to overall social utility economically (as a taxpaying member of the workforce, for example), a utilitarian view of justice would favor interventions that address these aspects of health and disability.

Communitarian Theory Finally, communitarian theories reject an emphasis on individual rights as the focus, instead prioritizing shared commitments such as to broad welfare, community, and institutions as central to the justice enterprise. The emphasis on the good of the community over the good of individuals is the hallmark of the many iterations of communitarian theories (Beauchamp and Childress  2013: 257–258). To illustrate what a commitment to community over the claims of individuals might look like in the context of health, Daniel Callahan provides one glimpse through his discussion of the application of communitarian commitments to the American healthcare system. Specifically, he has argued that a communitarian approach would favor limiting or cutting medical services for the elderly so that children and working adults might have more resources. This argument is based on a consideration of the costs of care for the elderly and the overall benefit to society of conserving those resources for availability more broadly for enjoyment across the lifespan—something that the elderly would have had access to during their lives (Callahan 2011). In the context of mental health, and interventions such as psychotherapy to promote it, communitarian theory’s focus on the greater good does not include guarantees of health resources to individuals (similarly to utilitarian theory). For those with mental illness, a focus on general welfare on the one hand would at least suggest that through the lens of communitarian approaches, health in all its dimensions would at least be high on the list of relevant considerations for societal provision and something that as a community we ought to be willing to provide for each other. However, in thinking about the good of the community over individual entitlements, those who are most burdened with mental illness may have less of an individual claim for costly and intensive treatment and resources as the needs of that individual grasp at resources that might be seen as better conserved for the benefit of the many, which could also exacerbate stigma. Furthermore, mental illness often interferes with community attachments, and many communities are already too willing to see those with severe mental illness as not their responsibility.

Summary In summary, varying theories of justice emphasize different core principles in a just distribution of resources. Any discussion of fairness and justice in mental health care, including psychotherapy, is multidimensional and requires, at a minimum, consideration of individual claims, community and societal considerations, procedural transparency and safeguards, and a values-­based decision about the role and ends of psychotherapy itself (e.g., providing for basic access to opportunity at a minimum to a broad-­based capabilities approach emphasizing maximal individual flourishing at the opposite pole). Different theories will consider these factors differently. Therefore, the resources devoted to achieving and promoting mental health generally, and psychotherapy specifically, both by government

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outcomes  127 and third-­party payers and by persons who access psychotherapy services themselves, are resources that from a justice perspective must be considered both in the context of their contribution and importance to individuals’ lives and in light of the claim on resources of society more broadly. From the perspective of publicly funded access to psychotherapy, for example, polities are faced with considerations of the relative importance and claims of psychotherapy in light of resources that could arguably be devoted to other personal and social goods and asked to justify devoting resources to psychotherapy as opposed to, for example, other aspects of medical care, law enforcement, unemployment/retirement benefits, education, etc. In decisions to spend personal resources on psychotherapy, however, the considerations may be different. Finally, in the sphere of commercial and third-­party payers, at a minimum transparency and procedural measures serve to address questions of justice in the context of contractual relationships. Considerations of justice and fairness are not value-­neutral; an explicit recognition of the assumptions, approaches, and entitlements to mental health and psychotherapy as introduced above are helpful in considerations of psychotherapeutic options and their provision as a public or societal good.

Outcomes Regardless of the conception of justice chosen or advocated within a society, outcomes ­matter in establishing claims for devoting resources to psychotherapy. There are too many studies that support the effectiveness of psychotherapy in a variety of specified conditions to be cited in this chapter—evidence to wit of the general acceptability of the claim that psychotherapy as a broad category of intervention possesses a sufficient evidence base to lay claim to societal resources and claims of access. This claim is based on the wide-­ranging studies that support the short- and long-­term effectiveness of various forms of psychotherapy for a variety of mental health conditions, most convincingly arguing for resources in situations in which the superiority of psychotherapy to pharmacologic and other interventions is demonstrated (cf. American Psychological Association 2012; Cuijpers et al. 2013). Unlike other medical specialties, psychiatry does not yet have chemical or imaging ­biomarkers that can be used routinely as outcome measures for interventions, even as scientists are making great progress in establishing these for dementias and other illnesses (Venkatasubramanian and Keshevan  2016). However, the burdens of mental illness are measurable in other ways. Psychological instruments, including rating scales for symptoms, psychological functioning, social functioning, and ability to work, have been developed and standardized. Other outcomes include social and economic functioning, as well as utilization of other healthcare resources. The choice of which outcomes to privilege in assessment of psychotherapeutic priority is not value-­neutral. Historically, the study and practice of psychotherapy have been heavily influenced by the biomedical disease model, with the result that the bulk of psychotherapy effectiveness studies focus on measuring psychotherapy’s short-­term ability to reduce specific symptoms in the context of a specific mental illness. Yet a person may begin psychotherapy with a variety of goals, including symptom reduction, improved social or occupational functioning, or increased insight into one’s own personality. In recent years, the positive mental health movement has emphasized the fact that psychologists and

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128   Fairness, Justice, and Economical Thinking in Psychotherapy psychiatrists need not devote themselves solely to the treatment of mental illness, but also to the strengthening of mental health and resilience (Jeste et al. 2015). Understanding the role of psychotherapy not only to decrease the burden of disease, but also to promote other aspects of human flourishing, adds additional dimensions to its claim on resources.

Symptom Reduction as Outcome, and Its Limitations There are many reasons to favor symptom reduction as the outcome of choice in studying the effectiveness of psychotherapy. Utilizing symptom scales and comparing scores before and after a treatment is transparent and compelling. It is easy and efficient to use this meas­ure in randomized controlled trials, the gold standard of biomedical effectiveness research. Psychotherapy, like other mental health treatments, is particularly susceptible to placebo effects, and robustly designed randomized controlled trials help keep practitioners accountable to delivering scientifically-­supported interventions (Eysenck 1994). Symptom reduction also has the added strength of being the outcome measure most frequently used in the medical model contexts of evaluating pharmacologic and somatic treatment modalities other than psychotherapy, and thus allows for comparison between, for example, a psychotherapy for depression or an anxiety-­spectrum disorder as opposed to an antidepressant or anxiolytic medication. Nonetheless, while part of the appeal of traditional evidence-­based psychiatry is its apparent objectivity, it is hardly value-­neutral. In this book’s companion volume, Gupta devotes a chapter to delineating the explicit and implicit values of evidence-­based medicine, and raises the question of whether these values serve the goals of psychiatric clinicians, patients, and families. As one example, she points out that an emphasis on randomized controlled trials privileges interventions that have potential commercial value, that is, interventions that can be standardized and mass produced for a common ailment, such as antidepressant medications. Gupta also criticizes the role that industrial interests play in the determination of diagnostic categories that serve their commercial interests (Gupta 2015). Sadler systematically demonstrates this latter point in the US context, describing the role of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in the development and perpetuation of a mental health medical-­industrial complex that serves the needs of a variety of business interests, including the pharmaceutical and private insurance industries (Sadler 2013). Many clinicians and researchers argue that emphasizing symptom reduction as an outcome is not an effective or ethical way to assess the value of psychotherapy. In a survey of psychiatrists regarding the use of mental health guidelines to direct care, Berghmans and colleagues (2004) explored the tensions between (a) standardized guidelines informed by cost-­effectiveness studies to help control costs and extend resources, and (b) addressing the needs and values of an individual patient that might be better addressed with a psychotherapeutic intervention. A second concern raised by the authors focuses on the limits of randomized controlled trials as a whole, which tend to focus on a single intervention in an idealized population with a single clearly-­defined diagnosis, which may not be generalizable to real-­life practice for patients with multiple comorbidities (Berghmans et al.  2004). Similarly, some core aspects of randomized controlled trials, such as blinding, may be difficult to incorporate into psychotherapy studies due to the nature of the intervention,

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outcomes  129 r­ elationship/contact vs. therapy-­specific effects, and methodological challenges. Some studies have addressed this concern by using a clinic waiting list population as a control group.

Other Outcomes The limitations of this approach have led scholars to consider other types of evidence to psychiatry generally and psychotherapy in particular. One major benefit that mental health clinicians can bring to their patients is the ability to apply treatments flexibly and individually. Some have argued that to serve this aim, the goals of evidence-­based psychology should change from the development of manualized treatments to empirically grounded principles of therapeutic change (Ingram et al. 2000). The field of positive mental health similarly has brought attention to new areas of scientific inquiry, including the biological correlates and systematic assessment of positive psychological characteristics (Jeste et al. 2015) Researchers looking to establish an evidence base for psychoanalytically-­oriented therapies emphasize the importance of studying a diversity of l­ong-­term outcomes beyond symptom remission (Shedler 2010). However, even relatively specific outcomes over time may not yield a clearly determinative course of action regarding choice of treatment and the resources to devote to specific treatments to inform broader considerations of resource allocation. One example illustrating this point is the Helsinki Psychotherapy Study, conducted from 1994 to 2000, which involved randomizing 326 patients with mood and/or anxiety disorders to either solution-­focused therapy (a manualized treatment focusing on goals), short-­ term psychodynamic therapy, or long-­ term psychodynamic therapy. The short-­ term therapies lasted an average of 6 months, and the long-­term therapy lasted an average of 3 years. Outcomes measured included symptom rating scales, scales of psychosocial functioning, and subjective/objective measures of work ability. Participants and data were tracked for 10 years after the start of treatment, with results published at years 3, 5, and 10. Overall, the authors found that all three therapies were effective. The effectiveness of the two short-­term therapies was generally similar and the effectiveness of long-­term therapy was superior on several measures, although there was variability within these results. The authors note that the fact that patients were randomly assigned to therapy groups, rather than therapy being selected based on patients’ individual needs and preferences, may have led to less robust effects (Knekt et al. 2016). At 3 years, the authors found that while results were seen more quickly in the short-­term therapy groups, they plateaued after the conclusion of treatment (which lasted for several months), whereas improvements in both symptom scales (Knekt et al. 2008b) and measures of work ability (Knekt et al. 2008a) were seen to continue in the long-­term therapy group (most of whom were still in active treatment at the 3-­year mark). The authors concluded that in the long run, long-­term psychotherapies may be more effective (Knekt et al. 2008a, 2008b). Subsequent studies at the 5-­year mark showed a more limited difference between short- and long-­term therapies’ effectiveness, although those in the short-­term arms did frequently seek auxiliary psychotherapy treatment after their experimental treatment was complete. The authors do note that long-­term psychotherapy brought greater benefits in terms of scales measuring an increased sense of coherence and perceived competence (Knekt et al. 2015). Finally, at the 10-­year mark, the authors found that the overall rate of

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130   Fairness, Justice, and Economical Thinking in Psychotherapy remission (defined as a 50 percent decrease in symptoms) was 52 percent not including those still in treatment, and 74 percent if including those in active auxiliary psychotherapy or psychopharmacology treatment. Given that those in the long-­term therapy group had higher rates of remission (81 percent), less use of auxiliary treatments, and a higher mean score on measures of work ability, the authors concluded that this was a superior therapy. However, they noted that it was surprisingly not superior in scales measuring personality functioning, and noted that there were subjects who did not experience remission in any of the groups (Knekt et al. 2016). Another important classification of outcomes justifying resource allocation to psychotherapies that we have not yet discussed is to what degree a given mental health treatment, and for the purposes of this discussion a psychotherapy in particular, might reduce other costs. Many modern cost-­effectiveness studies (which will be discussed in more detail in the next section) consider cost-­offset outcomes such as reduction in utilization of other, more costly, interventions, such as medical or psychiatric hospitalization. Other outcomes look at economic productivity, using measures such as reduction in lost workdays (Lazar et  al. 2010). These outcomes may be more meaningful to third-­party payers and public/ government funders than to individual patients. While staying out of the hospital may be a worthy individual goal, it is likely tied more to values of independence, functioning, and a life lived well rather than overall lifetime cost concerns per se.

Justice Considerations Returning our attention to the conceptions of justice introduced in the last section may help to guide prioritization of outcome measures in considerations of psychotherapy and justice. For example, capabilities theories of justice emphasize the importance of a broad range of outcomes other than symptom reduction due to their relevance to a good life lived well. A psychodynamically-­oriented psychotherapy treatment intervention, for example, might help a person understand and undo self-­destructive patterns that are limiting their ability to pursue personal goals of a life well-­lived although the same therapy might not appear robust in a diagnosis or small symptom subset outcome study. Other forms of supportive, behavioral, or other therapies may share goals of improved functioning in a variety of domains, including social and economic spheres. From a Rawlsian perspective, too, while symptoms can indeed impede the pursuit of other basic liberties, psychotherapy may provide a means to address other impediments to basic opportunity and liberty beyond simply poor health. However, as mentioned previously, the source of these patterns and limitations is arguably relevant according to Daniels’s theory, yet we lack the tools to truly understand how much of a given mental health issue is determined by unequally-­distributed social goods in the first instance. Engaging a communitarian perspective may add to the complexity of justice considerations by favoring outcomes that serve the interests or reflect the values of the community as a whole. The content of those values will vary depending on the particularities of a given community but would arguably include outcomes beyond symptom reduction to include the ability to contribute to the greater good of the community through citizenship. Similarly, a utilitarian approach might consider the benefits of broader social utility represented by outcomes that improve patients’ abilities to contribute to the workforce and society economically and in other ways.

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cost-­effectiveness  131 In summary, outcomes as a basis for claims of access to, provision of, or limits on access to psychotherapy are not value-­neutral. Engaging a varied set of justice-­based lenses and commitments can identify the implications of choices about both the relevance and relative weight of various outcome measures as well as the design of future impact and effectiveness studies. Keeping justice considerations front and center in the evaluation of psychotherapeutic interventions allows for a broad and rich engagement of our research and assessment from the design of studies and outcomes to the subsequent choices about the availability of and resources allocated both to psychotherapy interventions themselves, and mental health promotion most broadly.

Cost-­E ffectiveness Psychotherapy does not occur in a vacuum—it is one among many modalities in the treatment of mental and physical illness, and in the promotion of a human flourishing. Funding sources must weigh the benefits of psychotherapy against other programs for the treatment of mental illness, and public funding sources must weigh the benefits of mental health care and psychotherapy against other social welfare programs. Many studies support the idea that investing in programs to address the social determinants of mental health can have a profound impact on the burden of disease. For example, studies comparing a variety of health and mental health outcomes for high-­income countries have found that countries that invest more resources in social services tend to have better health and mental health outcomes than countries that invest more resources in healthcare (cf. Bradley et al. 2017; Park et al. 2020) Historically, mental health generally receives only a small part of public resources. As one example, according to 2017 data collected by the World Health Organization, government expenditure on mental health as a percentage of its total health expenditure varies significantly. There is a mild correlation between decreased percentage spent in lower-­income countries, but even amongst higher-­income countries there is significant variability, such as between the United States at the lower end (less than 0.05 percent, or ~344 USD/person) and France at the upper end (15 percent, or ~350 EUR/person) (World Health Organization 2018).1 Cost considerations, of which cost-­effectiveness is one, are another central area of inquiry in considerations of justice related to psychotherapy. Most particularly, for example, utilitarian approaches will value psychotherapy insofar as it can be shown to maximize utility by promoting the greatest good for the most people—in other words demonstrate efficiency and cost-­effectiveness.

Definitions A first aspect of this inquiry relates squarely to the prior discussion of outcomes. Specifically, focusing on symptom reduction as a sole outcome measure arguably leads to a significant 1  It should be noted that part of this variability is due to the particularly large denominator of total healthcare expenditures in the United States.

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132   Fairness, Justice, and Economical Thinking in Psychotherapy underestimation of the cost-­effectiveness of psychotherapy as it does not include cost-­offset measures. As discussed above, one relevant outcome of psychotherapy is that it may reduce utilization of other, more expensive, modalities of care, such as inpatient hospitalization. The costs of mental illness also include utilization of social services and inability to contribute to society in tangible ways. Such studies distinguish between direct and indirect costs of mental illness and mental health treatment, and the idea of cost-­effectiveness vs. cost-­offset (Sturm 2001). Direct costs are the costs of treatment, both mental health and non-­mental health care: fees for medication, psychotherapy, emergency room visits, hospitalizations, etc. Indirect costs are lost productivity, including missing time at work (for therapy appointments, hospitalization, or mental health days), being unable to complete housework, needing more help at home, etc. Cost-­effectiveness is a measure of the amount paid relative to the benefit of the good or service paid for. Cost-­offset refers to saving from resources that are not used in light of providing the good or service that is paid for. For example, continued employment as a result of psychotherapy could lead to a cost-­offset in terms of reducing the need for public services and benefits the social safety net would otherwise provide, in other words, accounting for the ways that paying for services and interventions might save resources elsewhere (Sturm 2001).

Cost-­Offsets of Psychotherapy The 2010 volume Psychotherapy is Worth It, edited by Susan Lazar, takes as its mission to demonstrate that psychotherapy is indeed cost-­effective, and at times cost-­saving, for a variety of diagnoses. In their introductory chapter, Lazar and colleagues (Lazar et al. 2010) provide a helpful overview of cost-­effectiveness studies that consider how access to mental health services relates to savings in terms of other medical costs. Early studies cited by the authors did not distinguish based on diagnoses or modalities of treatment but rather looked at populations and their access to mental health services. Several studies in the 1990s focused on specific companies and demonstrated that providing mental health benefits to workers led to a reduction in overall healthcare costs and lost workdays (Klarreich et al. 1987; Mynors-­Wallis et al. 1997). Subsequent chapters of the Lazar volume examine psychotherapeutic interventions more specifically, reviewing the cost-­effectiveness literature for a variety of mental health conditions and diagnoses. In a chapter on psychosocial interventions in schizophrenia, for example, Rockland concluded that while studies after 1998 showed mixed results, any intervention that reduces days spent in the hospital will likely be cost-­effective, and psychotherapeutic interventions that show particular promise include family interventions and social skills training (Rockland  2010). In a chapter on borderline personality disorder, Waldinger concluded that long-­term (> 1-­year) psychotherapeutic interventions for patients with borderline personality disorder were not only effective in improving quality of life, but were also potentially cost-­effective by decreasing direct and indirect costs related to emergency room/inpatient psychiatry visits, as well as medical visits and days absent from work (Waldinger 2010). Rosenblatt similarly delineated some of the high costs associated with anxiety disorders, such as medical comorbidities of high blood pressure and cerebrovascular disease, psychiatric comorbidities of substance use disorders and hypochondriasis, lost

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cost-­effectiveness  133 workplace productivity, and a trend towards more financial dependence and unemployment (Rosenblatt  2010). A subsequent 2014 article by Lazar included additional articles from 2007–2012 with similar results (Lazar 2014). The argument for psychotherapy’s cost-­effectiveness based on its ability to decrease other direct and indirect costs is compelling although not without debate (cf. Layard and Clark  2015). Multiple studies over the past decade continue to support these costeffectiveness arguments. A study examining a heterogeneous German cohort of 22,294 insured persons with a variety of mental health diagnoses found that insurance-­covered psychotherapy reduced direct healthcare costs significantly in the two years following treatment (Altmann et al. 2016). A recent review of borderline personality disorder studies also concluded that, overall, several forms of effective psychotherapy led to cost savings (Meuldijk et al. 2017). There have been some more recent large-­scale cost-­effectiveness studies with more nuanced results. A subsequent cost-­effectiveness analysis using data from the Helsinki psychotherapy study described above examined both direct and indirect costs during the therapy as well as for a 5-­year follow-­up period. The investigators found that while the direct costs of long-­term psychotherapy were significantly higher than those of short-­term psychotherapy during treatment itself, in a 5-­year follow-­up period, directs costs of the short-­term therapy groups rose due to the use of additional mental health resources, including auxiliary non-­study psychotherapy. The authors concluded that while in the short-­term, long-­term psychotherapy does not appear to be cost-­effective, a longer follow-­up period would potentially demonstrate greater cost-­effectiveness compared with shorter-­term therapies (Maljanen et al. 2016). Similarly, a utilization-­oriented, intention-­to-­treat, follow-­up to the German study cited above (Altmann et al.  2016) specifically compared those who completed psychotherapy with those who terminated early, either for reasons such as moving, or “quality-­related” reasons such as therapist–patient mismatch. In a subsequent report, the investigators found that while benefits were strongest for those completing therapy (measured in terms of symptom reduction as well as direct healthcare costs and indirect disability workdays), there were still benefits seen in the groups terminating treatment prematurely (Altmann et al. 2018).

Limitations There are limitations, however, to the argument that paying for psychotherapy is justified by cost saving in other domains in countries with adequate resources to make the choice of providing psychotherapy rather than other treatment for mental illness and/or other social welfare benefits. Studies cited earlier in this chapter demonstrate that many mental health outcomes are more reliably associated with funding social services than with funding health and mental healthcare generally (cf. Bradley et al. 2017; Park et al. 2020), although these studies analyze data at a macro level and focus on large scalable outcomes. Conversely, in countries like the one in which the authors reside (USA) that have privatized health insurance, the costs saved would have been incurred by a variety of third-­party payers and not returned to the public coffers that fund the social safety net and other

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134   Fairness, Justice, and Economical Thinking in Psychotherapy services (although the patients themselves could contribute via taxpaying and other aspects of good citizenry). In private systems in particular, additional inefficiencies may be introduced, such as through the transaction costs and effects of subcontracting of mental health services, in which companies providing mental health insurance benefit management and payment would not realize the cost savings in other domains of health. Similarly, private insurance companies may have little incentive to incorporate the costs of lost work productivity in benefit determinations as those costs are externalized and not borne by the insurer directly, although most private insurance is employer funded. Even in countries with government-­ funded healthcare systems, the phenomenon of “silo budgeting” can disincentivize the most cost-­efficient interventions, as the agencies that bear the costs of an intervention may not be the ones to see the cost-­saving benefit (Knapp and Wong  2020). For example, the United Kingdom’s National Health Service is funded and administered by the Department of Health and Social Care. Its schools are funded and administered by the Department of Education. Costs associated with undertreated pediatric mental illness fall heavily on schools, which must devote resources for both specialized educational interventions and behavioral management (Snell et al.  2013). Increased access to pediatric mental health services outside of the school system would be funded by the National Health Service, with the cost savings accruing to the school system. Furthermore, just as the decision of outcomes measured is not value-­neutral, the choice of which costs to include can be idiosyncratic and even potentially biased. As a result, findings of cost-­effectiveness and offset studies are often difficult to compare and analyze in a systematic way. Review articles published since 2010 have pointed out how a diversity of outcome measures make it difficult to draw conclusions about the cost-­effectiveness data for treatment of borderline personality disorder (Brettschneider et al. 2014), major depression (Karyotki et al. 2017), and anxiety disorders (Ophuis et al. 2017), notwithstanding the data presented above. Conversely, there are times during which an increase in direct costs may represent treatment success; for example, a symptom of social anxiety disorder may be avoidance of medical physician visits, and successful treatment of these symptoms will result in more (presumably needed) medical care and increased direct costs (Egger et al. 2016). Therefore, the implications of cost-­effectiveness studies potentially favor psychotherapy only for people whose illness is resulting in clear, measurable, and significant costs to society. While a need-­based allocation framework is therefore ethically defensible, a focus on monetized outcomes becomes more problematic, particularly when one moves from an outcomes-­based conception of justice for society, such as a utilitarian approach, to an individual rights-­based conception of entitlements to public goods and essential qualities of the good life. Again, empirical data alone cannot define the policy path forward without a robust inclusion of core values of justice. Finally, while comprehensive cost-­effectiveness data are useful, the development and implementation of such studies is expensive. Thus, we are left with studies that are often difficult to compare and interpret (as discussed above). That said, these studies can nonetheless help guide treatment and public policy. In fact, Soeteman and colleagues conducted a study assessing the cost-­effectiveness of further implementation and cost-­effectiveness research on psychotherapeutic treatments for cluster B and C personality disorders, concluding that further research, while requiring significant up-­front costs, would in fact help save money in the longer term (Soeteman et al. 2011).

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summary and conclusions  135

The Global Context The previous two sections focused on studies in well-­resourced countries and areas in which access to specialty mental health care is assumed. This is not the case in many parts of the world. As mentioned above, lower-­income countries tend to devote an even smaller percentage of their overall healthcare expenditures to mental health treatments, with the majority of this going specifically to mental hospitals (World Health Organization 2018). Mental health projects are also generally not supported by outside funding organizations. A comprehensive review of global development-­related assistance projects between 2006 and 2016 demonstrated that development assistance specifically for mental health comprised only 0.3 percent of the total funds given to support health generally (Liese et al. 2019). The Lancet report mentioned above recognizes the limitations of resources that lowerincome countries can offer. At the same time, the Commission continues to emphasize the need to expand resources for mental health care, with an emphasis on the availability of psychosocial interventions (Patel et al. 2018). The authors delineate a staged set of recommendations for low-, medium-, and highresource settings. The first step is training local community health workers/lay counselors to deliver care that is consistent with the needs and values of the local community, and also training non-­mental health professionals to deliver mental health care in a primary care setting. They suggest using technology to help increase access to both education/training and care by being able to interact with trainees and patients remotely, as well as to help with education campaigns, screening, and symptom-­tracking/medication adherence (Patel et al. 2018). Studies have shown the effectiveness of these interventions. A Cochrane review examined articles focusing on the use of non-­specialist health workers and other professionals with health roles (such as teachers) compared with care as usual. The review included 38 studies from 22 low- and middle-­income countries. The authors found that these interventions were associated with better outcomes in the prevalence and symptom burden of depression, anxiety, and/or PTSD; in improved symptoms for people with dementia and their caregivers; and in reduction in quantity of alcohol consumed by those with alcohol use disorders. That said, the quality of the evidence was judged to generally be low (although for those with dementia and their caregivers, the quality was judged to be moderate). While three of the studies included economic data, there was not sufficient evidence to draw conclusions about cost-­effectiveness (van Ginneken et al. 2013).

Summary and Conclusions In summary, considerations of fairness, effectiveness, cost, and justice are central to broader questions of access to and funding for psychotherapy. This chapter has explored and advocated for the use of a pluralistic inquiry into justice considerations as a lens through which to consider questions of fairness and economical thinking in psychotherapy and mental health treatment as a societal good.

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136   Fairness, Justice, and Economical Thinking in Psychotherapy Rawlsian and communitarian concepts of justice can help make a case for the unique value of mental health services and psychotherapy. By focusing on mental illness as both an outcome of and contributor to social inequalities, Rawlsian theories establish individuals’ rights to services to address them. Specific outcomes supporting access to other liberties may privilege psychotherapy over other mental health services. Capabilities theories give the strongest argument for the uniqueness of psychotherapy in the service of various domains of human flourishing that may be difficult to promote directly with other services. Utilitarian concepts of justice call for rigorous attention to cost-­effectiveness studies that take a broad view of costs and outcomes of psychotherapy, including cost-offset. Finally, communitarian concepts of justice invoke community-­specific values while recognizing the social aspect of mental health and human flourishing. In future research, treatment, and policymaking, explicit considerations, strengths, and limitations of outcomes data must be incorporated not only into considerations of resource allocation and definitions of efficacy, but also into the design of future cost-­effectiveness and outcomes studies themselves to continue to inform advances in mental health and well-­being. In addition, cost-­effectiveness of mental health interventions including psychotherapy is a critically important factor to consider regarding justice claims and policies, yet also requires additional attention and focus to promote its relevance to and guidance of mental health policy and practice. Finally, considerations of mental health and the benefits and costs of psychotherapy require consideration of both individual and community claims in advancing the mental health of the global community and identification of explicit value and values.

References Altmann, U., Thielemann, D., Zimmermann, A., Steffanowski, A., Bruckmeier, E., Pfaffinger, I., Fembacher, A., and Strauß, B. (2018). “Outpatient Psychotherapy Improves Symptoms and Reduces Health Care Costs in Regularly and Prematurely Terminated Therapies.” Frontiers in Psychology 9. doi:10.3389/fpsyg.2018.00748 Altmann, U., Zimmermann, A., Kirchmann, H.  A., Kramer, D., Fembacher, A., Bruckmayer, E., Pfaffinger, I., von Heymann, F., Auch, E., Steyer, R., and Strauss, B. M. (2016). “Outpatient Psychotherapy Reduces Health-Care Costs: A Study of 22,294 Insurants over 5 Years.” Frontiers in Psychiatry 7. doi:10.3389/fpsyt.2016.00098 American Psychological Association (2012). Recognition of Psychotherapy Effectiveness. Retrieved from https://www.apa.org/about/policy/resolution-psychotherapy.aspx Beauchamp, T. L. and Childress, J. F. (2013). Principles of Biomedical Ethics (7th ed.). New York: Oxford University Press. Berghmans, R., Berg, M., van den Burg, M., and ter Meulen, R. (2004). “Ethical Issues of Cost Effectiveness Analysis and Guideline Setting in Mental Health Care.” Journal of Medical Ethics 30: 146–150. Bradley, E. H., Sipsma, H., and Taylor, L. A. (2017). “American Health Care Paradox: High Spending on Health Care and Poor Health.” QJM: An International Journal of Medicine 110: 61–65. Brettschneider, C., Riedel-Heller, S., and König, H.  H. (2014). “A Systematic Review of Economic Evaluations of Treatments for Borderline Personality Disorder.” PLoS ONE 9: e107748. doi:10.1371/ journal.pone.0107748 Callahan, D. (2011). “Health Care Reform: Can a Communitarian Perspective be Salvaged?” Theoretical Medicine and Bioethics 32: 351–362.

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summary and conclusions  137 Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., Reynolds III, C. F. (2013). “The Efficacy of Psychotherapy and Pharmacotherapy in Treating Depressive and Anxiety Disorders: A Meta-Analysis of Direct Comparisons.” World Psychiatry 12: 137–148. Daniels, N. (2001). “Justice, Health, and Healthcare.” American Journal of Bioethics 1: 2–16. Egger, N., Konnopka, A., Beutel, M.  E., Herpertz, S., Hiller, W., Hoyer, J., Salzer, S., Stangier, U., Strauss, B., Willutzki, U., Wiltink, J., Leibing, E., Leichsenring, F., and König, H. H. (2016). “LongTerm Cost-Effectiveness of Cognitive Behavioral Therapy versus Psychodynamic Therapy in Social Anxiety Disorder.” Depression and Anxiety 33: 1114–1122. Eysenck, H. J. (1994). “The Outcome Problem in Psychotherapy: What Have We Learned?” Behaviour Research and Therapy 32: 477–495. Gupta, M. (2015). “Ethical Issues in Evidence-Based Psychiatry.” In The Oxford Handbook of Psychiatric Ethics (Vol. 2) (ed. J. Sadler, W. V. Van Staden, and K. W. M. Fulford, pp. 929–944). Oxford: Oxford University Press. Ingram, R.E., Hayes, A., and Scott, W. (2000). “Empirically Supported Treatments: A Critical Analysis.” In Handbook of Psychological Change: Psychotherapy Processes & Practices for the 21st Century (ed. C. R. Snyder and R. E. Ingram, pp. 40–60). New York: John Wiley & Sons. Jeste, D. V., Palmer, B. W., Rettew, D. C., and Boardman, S. (2015). “Positive Psychiatry: Its Time Has Come.” Journal of Clinical Psychiatry 76: 675–683. Karyotaki, E., Tordrup, D., Buntrock, C., Bertollini, R., and Cuijpers, P. (2017). “Economic Evidence for the Clinical Management of Major Depressive Disorder: A Systematic Review and Quality ­Appraisal of Economic Evaluations alongside Randomised Controlled Trials.” Epidemiology and Psychiatric Sciences 26: 501–516. Kious, B. M. (2015). “Justice, Fairness, and Mental Health Care.” In The Oxford Handbook of Psychiatric Ethics (Vol. 1) (ed. J. Sadler, W. V. Van Staden, and K. W. M. Fulford, pp. 282–294). Oxford: Oxford University Press. Klarreich, S., DiGiuseppe, R., and DiMattia, D. (1987). “Cost Effectiveness of an Employee Assistance Program with Rational-Emotive Therapy.” Professional Psychology: Research and Practice 18: 140–144. Knapp, M. and Wong, G. (2020). “Economics and Mental Health: The Current Scenario.” World Psychiatry 19: 3–14. Knekt, P., Lindfors, O., Laaksonen, M.A., Raitasalo, R., Haaramo, P., Järvikoski, A., The Helsinki ­Psychotherapy Study Group (2008a). “Effectiveness of Short-Term and Long-Term Psychotherapy on Work Ability and Functional Capacity: A Randomized Clinical Trial on Depressive and Anxiety Disorders.” Journal of Affective Disorders 107: 95–106. Knekt, P., Lindfors, O., Härkänen, T., Välikoski, M., Virtala, E., Laaksonen, M. A., Marttunen, M., Kaipainen, M., Renlund, C., The Helsinki Psychotherapy Study Group (2008b). “Randomized Trial on the Effectiveness of Long- and Short-Term Psychodynamic Psychotherapy and Solution-Focused Therapy on Psychiatric Symptoms during a 3-Year Follow-up.” Psychological Medicine 38: 689–703. Knekt, P., Heinonen, E., Härkäpää, K., Järvikoski, A., Virtala, E., Rissanen, J., Lindfors, O., The Hel­sinki Psychotherapy Study Group (2015). “Randomized Trial on the Effectiveness of Long- and Short-Term Psychotherapy on Psychosocial Functioning and Quality of Life during a 5-Year Follow-up.” Psychiatry Research 229: 381–388. Knekt, P., Virtula, E., Härkänen, T., Vaarama, M., Lehtonen, J., and Lindfors, O. (2016). “The Outcome of Short- and Long-Term Psychotherapy 10 Years after Start of Treatment.” Psychological Medicine 46: 1175–1188. Layard, R. and Clark, D. M. (2015). “Why More Psychological Therapy Would Cost Nothing.” Frontiers in Psychology 6: 1713. doi:10.3389/fpsyg.2015.01713 Lazar, S. G. (ed.) (2010). Psychotherapy is Worth It: A Comprehensive Review of Its Cost-Effectiveness. Washington, DC: American Psychiatric Publishing. Lazar, S. G. (2014). “The Cost-Effectiveness of Psychotherapy for the Major Psychiatric Diagnoses.” Psychodynamic Psychiatry 42: 423–457.

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138   Fairness, Justice, and Economical Thinking in Psychotherapy Lazar, S.  G., Sledge, W.  H., and Adler, A. (2010). “Introduction.” In Psychotherapy is Worth It: A ­Comprehensive Review of Its Cost-Effectiveness (ed. S. G. Lazar, pp. 1–29). Washington, DC: American Psychiatric Publishing. Liese, B. H., Gribble, R. S. F., and Wickremsinhe, M. N. (2019). “International Funding for Mental Health: A Review of the Last Decade.” International Health 11: 361–369. Maljanen, T., Knekt, P., Lindfors, O., Virtala, E., Tillman, P., Härkänen, T., The Helsinki Psychotherapy Study Group (2016). “The Cost-Effectiveness of Short-Term and Long-Term Psychotherapy in the Treatment of Depressive and Anxiety Disorders during a 5-Year Follow-up.” Journal of Affective Disorders 190: 254–263. Meuldijk, D., McCarthy, A., Bourke, M.  E., Grenyer, B.  F.  S. (2017). “The Value of Psychological Treatment for Borderline Personality Disorder: Systematic Review and Cost Offset Analysis of Economic Evaluations.” PLoS ONE 12: e0171592. doi:10.1371/journal.pone.0171592 Mynors-Wallis, L., Davies, I., Gray, A., Barbour, F., and Gath, D. (1997). “A Randomised Controlled Trial and Cost Analysis of Problem-Solving Treatment for Emotional Disorders Given by Community Nurses in Primary Care.” The British Journal of Psychiatry 170: 113–119. Nussbaum, M. C. (2011). Creating Capabilities: The Human Development Approach. Cambridge, MA: Harvard University Press. Ophuis, R. H., Lokkerbol, J., Heemskerk, S. C. M., van Balkom, A. J. L. M., Hiligsmann, M., and Evers, S. M. A. A. (2017). “Cost-Effectiveness of Interventions for Treating Anxiety Disorders: A Systematic Review.” Journal of Affective Disorders 210: 1–13. Park, D. S., Han, J., Torabi, M., and Forget, E. L. (2020). “Managing Mental Health: Why We Need to Redress the Balance between Healthcare Spending and Social Spending.” BMC Public Health 20: 393. doi:10.1186/s12889-020-08491-1 Patel, V., Saxena, S., Lund, C., Thornicroft, G., Baingana, F., Bolton, P., Chisholm, D., Collins, P. Y., Cooper, J. L., Eaton, J., Herrman, H., Herzallah, M. M., Huang, Y., Jordans, M. J. D., Kleinman, A., Medina-Mora, M.  E., Morgan, E., Niaz, U., Omigbodun, O., Prince, M., Rahman, A., Saraceno, B., Sarkar, B. K., De Silva, M., Singh, I., Stein, D. J., Sunkel, C., and Unützer, J. (2018). “The Lancet Commission on Global Mental Health and Sustainable Development.” The Lancet 392: 1553–1598. Rawls, J. (1971). A Theory of Justice. Cambridge, MA: Harvard University Press. Rockland, L. H. (2010). “Psychotherapeutic and Psychosocial Interventions in Schizophrenia.” In Psychotherapy is Worth It: A Comprehensive Review of Its Cost-Effectiveness (ed. S. G. Lazar, pp. 31–60). Washington, DC: American Psychiatric Publishing. Rosenblatt, A. (2010). “Psychotherapy in the Treatment of Anxiety Disorders.” In Psychotherapy is Worth It: A Comprehensive Review of Its Cost-Effectiveness (ed. S. G. Lazar, pp. 103–134). Washington DC: American Psychiatric Publishing Sadler, J. Z. (2013). “Considering the Economy of DSM Alternatives.” In Making the DSM-5: Concepts and Controversies (ed. J. Paris and J. Phillips, pp. 21–38). New York: Springer. Shedler, J. (2010). “The Efficacy of Psychodynamic Psychotherapy.” American Psychologist 65: 98–109. Snell, T., Knapp, M., Healey, A., Guglani, S., Evans-Lacko, S., Fernandez, J.-L., Meltzer, H., and Ford, T. (2013). “Economic Impact of Childhood Psychiatric Disorder on Public Sector Services in Britain: Estimates from National Survey Data.” Journal of Child Psychology and Psychiatry 54: 977–985. Soeteman, D. I., Busschbach, J. J. V., Verheul, R., Hoomans, R., and Kim, J. J. (2011). “Cost-Effective Psychotherapy for Personality Disorders in the Netherlands: The Value of Further Research and Active Implementation.” Value in Health 14: 229–239. Sturm, R. (2001). “Economic Grand Rounds: The Myth of Medical Cost Offset.” Psychiatric Services 52: 738–740. Timmons, M. (2013). Moral Theory: An Introduction (2nd ed.). Lanham, MD: Rowman & Littlefield. van Ginneken, N., Tharyan, P., Lewin, S., Rao, G. N., Meera, S. M., Pian, J., Chandrashekar, S., and Patel, V. (2013). “Non-Specialist Health Worker Interventions for the Care of Mental, Neurological and Substance-Abuse Disorders in Low- and Middle-Income Countries.” Cochrane Database of Systematic Reviews 11: CD009149. doi:10.1002/14651858.CD009149.pub2 Venkatasubramanian, G. and Keshavan, M. (2016). “Biomarkers in Psychiatry: A Critique.” Annals of Neuroscience 23: 3–5.

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summary and conclusions  139 Waldinger, R. J. (2010). “Psychotherapy in the Treatment of Borderline Personality Disorder.” In Psychotherapy is Worth It: A Comprehensive Review of Its Cost-Effectiveness (ed. S.  G.  Lazar, pp. 61–86). Washington, DC: American Psychiatric Publishing. World Health Organization (2018). Mental Health Atlas 2017. Geneva: World Health Organization. Retrieved from https://apps.who.int/iris/handle/10665/272735

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Chapter 9

Ethics of Ca r e A pproach e s i n Psychother a py Anna Magdalena Elsner and Vanessa Rampton

Introduction Psychotherapy, conceived as psychological treatment, and its close relatives including psychoanalysis, counseling, family and couple therapy, have become influential ways of addressing symptoms by focusing on relationships. Psychotherapy embraces a view of human nature distinct from other areas of health or social care (Barker 2011: 32), because a core unifying theme among psychotherapies is that the feelings and attitudes therapist and patient have toward one another, and how they are expressed, are crucial for treatment and outcome (Gelso 2011: 4; Gelso and Carter 1985: 159). Indeed, it has been claimed that psychotherapy is the only medical subspecialty in which “the use of the therapeutic alliance itself is regarded as not only necessary, but as alone sufficient, for healing” (Radden and Sadler 2010: 55). While such statements are resisted by psychotherapists who prefer more measurement-­based models such as cognitive behavioral therapy, the fact remains that psychotherapy’s traditional focus on the therapeutic relationship adds “immeasurably to the patient’s vulnerability and to the responsibility imposed on the treater” (Radden 2002: 53). Care ethics is an approach to ethical problems that prioritizes and values human relations. It stresses the importance of taking into account emotions and deepening empathetic bonds in order to navigate human interdependence. It therefore has a natural affinity with psychotherapy, given that, as Liz Bondi notes, the “emotional relationship dynamics on which psychotherapies focus presuppose interdependence as a feature of human life” (Bondi 2008: 262). At the practical level, psychotherapy is a female-­dominated profession, just as caring functions have traditionally been associated with women; a recent report by the American Psychological Association calculated that there are roughly twice as many female practicing psychotherapists as male ones in the United States and that the gender gap is widening (Lin et al. 2015: 1). Specific branches of psychotherapy, such as for example, feminist, systemic, person-­centered or emotion-­focused approaches, have sought to explore emotional ­relationship dynamics by extending the therapist–patient relationship to address the complexities of

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Caring and Care Ethics: A Brief History   141 individual’s lives (see the chapter by Kramer and Elliott on emotion-­focused therapy in this volume). Efforts to include people that play important roles in the patient’s emotional relationships are exemplified by family or couple therapies, which have an obvious affinity with care ethics even if they have not been explicitly linked to that approach. Indeed, the implications of the ethics of care for psychotherapy generally remain underexamined (exceptions include Bloch and Green 2006; Robertson and Walter 2007). An analysis of these implications seems particularly relevant given that there is a topical debate within psychotherapy that opposes measurement-­based models focusing on clearly identifying problems and desirable actions/outcomes, to those who consider the therapeutic relationship itself as sufficient for healing (Leichsenring and Steinert 2017). In what follows we discuss, first, the history of caring and care ethics and, second, relevant moments in the history of psychotherapy that grapple with the reality of human relationality, before analyzing the conceptual and practical implications of bringing the two together. We claim that an ethics of care approach offers valuable insights into the unequal and emotionally complex role of psychotherapeutic relationships generally. In a context where the centrality of the psychotherapeutic alliance is contested, care ethics comes down firmly on the side of psychotherapy’s relational nature. Conversely, because psychotherapy has long been concerned with intersubjectivity, as exemplified in the concepts of transference and countertransference, it also offers valuable theoretical and practical resources for care ethics approaches.

Caring and Care Ethics: A Brief History Care ethics can be formally dated to 1982, and the publication of Carol Gilligan’s In a Different Voice: Psychological Theory and Women’s Development, as explored in further detail below. Yet the ideas of care and caring, and the ethical implications thereof, have a  long history that sheds light on present day challenges for care ethics approaches in psychotherapy. In his historical analysis of the idea of care, Warren Reich argues that it has had two principal meanings in healthcare settings:   (i)  taking care of the patient in the technical sense, that is providing competent, appropriate diagnostic or therapeutic interventions, and   (ii) caring for or about the patient, which suggests a virtue of devotion and concern for the other as a person, who is being attended to and helped in a difficult situation (Reich 1995: 361). Reich cites the early twentieth century as the moment when these two meanings of care became disconnected from one another. In the context of increasingly sophisticated techniques and scientific knowledge, physicians began “to divorce the disease from the patient,” thus marginalizing personal care in the sense of “caring for” the person (Reich 1995: 362; see also Reiser 1978: 227). In 1926, Harvard professor and physician Richard Cabot expressed an influential view whereby he acknowledged the importance of caring for “the minds, the emotions, the wills, the souls” of patients, but also the fact that doing so is impossible for

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142   Ethics of Care Approaches in Psychotherapy doctors and nurses, since “their attention is too strongly concentrated on the excessively difficult and delicate tasks of diagnosis and treatment” (Cabot 1926: 16). Cabot saw the solution as letting physicians and nurses focus on the physical body, and delegating the task of caring for the patient’s soul to ministers, theological students, friends and relatives, social workers, and psychologists (Cabot 1926: 18, 6–7). Cabot’s suggestion that physicians should be exempted from “caring for” patients was called into question by his colleague Francis Peabody. In his essay “The Care of the Patient” Peabody argued that one “of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient” (Peabody 1927: 882; our emphasis). His intervention was underpinned by his sense of the need to deal with the patient as a whole person; as he put it, the task of the doctor is to transform “that case of mitral stenosis in the second bed on the left” into the complex problem of “Henry Jones, lying awake nights while he worries about his wife and children” (Peabody 1927: 878). Peabody was therefore concerned to make physicians aware of “the commonest and simplest factors that initiate and perpetuate the functional disturbances,” including “sorrow, disappointment, anxiety, self-­distrust, thwarted ideals or ambitions in social, business or personal life, and particularly what are called maladaptations to these conditions” (Peabody 1927: 881); he singled out psychiatry as the one medical discipline sensitive to the fact that in many cases “it is not the disease but the man or the woman who needs to  be treated” (Peabody  1927: 880). Nevertheless, he stopped short of analyzing more ­specifically what the sort of personalized care he advocated would mean for mental health disciplines. Following Peabody’s intervention, the importance of caring-­as-­concern was further developed by a subsequent generation of physicians, often as a reaction to the dangers of depersonalized care in the hospital setting. This focus was associated with a concern for the patient as a person—that is, more than simply a highly complex organism—and increased attention to the moral requirements governing relations between human beings. In a widely read book published in 1970, The Patient as Person: Explorations in Medical Ethics, theologian Paul Ramsey described the physician–patient relationship as a covenant, based on “righteousness between man and man” (Ramsey 1970: xlv). The idea that caring involves an encounter with “the vulnerable humanness of the other” (Reich 1995: 366) was simultaneously expanded upon in the context of other care-­oriented professions such as nursing. Caring, in this context, was characterized as “the most demanding and deeply human aspect,” that is “the expressive art of being fully present to another person” (Davis 1981: 1). According to nursing theorist and anthropologist Madeleine Leininger, caring has a significant impact on curing, which even led her to propose that “there can be no curing without caring” (Leininger 2001: 45). Based on her work as a psychiatric nurse, Leininger developed the idea that caring is “what makes people human, gives dignity to humans, and inspires people to get well and to help others” (Leininger 2008: 1). As caring came to imply an increased sensitivity to the feelings of others, its proponents were aware of the dangers associated with excessive attachment on the part of the caregivers (see Halpern  2001). In a 1964 lecture at Harvard Medical School entitled “Caring for the  Patient,” physician Hermann Blumgart argued that “[e]motional appreciation of the patient’s feelings without becoming engulfed by them is of paramount importance” and referred to “neutral empathy” or “compassionate detachment” as a desirable safeguard

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Caring and Care Ethics: A Brief History   143 against this (Blumgart 1964: 451). A decade later, in an intervention on “ ‘Caring’ as a part of Health Care Quality,” clinician W.  W.  Menninger developed this insight by emphasizing that the physician must maintain some emotional distance from the patient, i.e. to sense the patient’s experience empathetically without becoming so involved sympathetically that the physician’s rational and effective clinical judgment is impaired by emotional involvement.  (Menninger 1975: 837)

Yet by and large the contributions that highlighted the need to care for the patient in Peabody’s sense were concerned less with the necessity of remaining emotionally detached and more with reclaiming what they felt had been lost in modern, technology-­driven health care. Menninger, for example, concluded his essay by reflecting: It may be advisable for every physician or health care provider to periodically be a patient, to reexperience that role, and to be sensitive to some of the forgotten aspects of that experience. (Menninger 1975: 837)

The appearance of Gilligan’s In a Different Voice (1982) provided a significant impetus for contemporary ethics of care by exploring care in relation to other power dynamics at work in society. Trained as a psychologist, Gilligan conducted various empirical studies on moral reasoning and reported that her female subjects were more concerned with the context of a moral dilemma and more willing than males to incorporate the viewpoint of others. As she put it, “[t]he ideal of care is thus an activity of relationship, of seeing and responding to need, taking care of the world by sustaining the web of connection so that no one is left alone” (Gilligan 1982: 62). She referred to this type of moral reasoning as an “ethic of care” and contrasted it with an ethic of justice that she associated with traditional Western approaches to normative ethics as shaped by the moral concerns of men. Crucially, Gilligan valorized what she presented as women’s moral reasoning, and portrayed care ethics as being as ­valuable as more traditional justice-­oriented moral theories. Gilligan did not aim to elaborate a comprehensive normative approach, but her empirical findings were taken up by others and her work was “followed by a torrent of feministinspired writings about personal relationships, caring and nurturing, the differences between care and justice, relational self-­identity and the importance of emotional responsiveness to others” (Friedman  2000: 209). Among them was, for example, the phenomenological description of caring by Nel Noddings, which claimed that all caring activities are characterized by a “displacement of interest from my own reality to the reality of the other” (Noddings  1984: 14). But Noddings and others also explored the wider implications of personal caring at a social and political level, which means that sometimes the ethics of care is seen as an example of a normative theory that rivals dominant ones such as deontological, consequentialist, and virtue ethics. At times, given that the ethics of care is sensitive to context, particular situations, and narratives, it is presented as a form of virtue ethics (BillerAndorno 2012: 394). Some of its proponents have gone further to argue that this approach should resist presenting itself as a moral theory, since there are no context-­independent rules for caring which is always “embodied, relational, configurational, skillful, meaningful and contextual” (Benner and Wrubel 1989: 6).

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144   Ethics of Care Approaches in Psychotherapy Despite divergences, what binds the ethics of care together is, as Marilyn Friedman puts it, “an account of a distinctive style or approach to ethical problems and concerns” (Friedman 2000: 208). Its fundamental insight is “to encourage a critical reflection of self in its embodiedness and relatedness while trying to empathically understand the individual moral world of the other” (Biller-­Andorno 2012: 395). Virginia Held, one of its main proponents, has noted that what is at stake is an “ethics of care, and not just care itself,” since “the various aspects and expressions of care and caring relations need to be subjected to moral scrutiny and evaluated, not just observed and described” (Held 2007: 539). She highlights five distinctive features of the ethics of care (Held 2007: 538ff.): first, the emphasis of the ethics of care “is on the compelling moral salience of attending to and meeting the needs of the particular others for whom we take responsibility.” Second, the epistemological focus of the ethics of care is emotions; it appreciates moral emotions (such as sympathy, empathy, sensitivity, and responsiveness) and relational capabilities that enable morally concerned persons to understand what actions are advisable in interpersonal contexts. Third, the ethics of care rejects the view that moral problems can be resolved by abstract reasoning and reliance on universal rules in favor of the particular and the actual. Fourth, the ethics of care reconceptualizes traditional public/private distinctions by emphasizing moral issues that arise in relations among the unequal and the dependent, which may be emotion-­laden and involuntary. Finally, care ethics considers persons as relational and interdependent, and therefore partly constituted by their relationships with others, in stark contrast to self-sufficient, unencumbered conceptions of persons in individualist liberalism, for example. The emphasis that care ethics places on emotions, interpersonal relationships, and valuing context-­specific interdependencies seems, at first glance, to dovetail with the aim of the psychotherapist to provide “compassionate, individualized care” (Cautin 2011: 4). Moreover, as Liz Bondi puts it, “psychotherapies constitute an arena in which emotion work is explicit and foregrounded” (Bondi 2008: 252). Yet psychotherapy has developed its own terms and concepts for theorizing the role of care in the physician–patient relationship, largely without reference to the term care itself. It is to this history that we now turn.

Caring in Psychotherapeutic Approaches and their Antecedents Early-­ to-­ mid-­ twentieth-­ century psychoanalysis was characterized by hierarchical and patriarchal perspectives rather than a relational, person-­centered approach. Yet the recognition of the importance of the therapeutic relationship, and the difficulty of defining and applying boundaries to that relationship, were already characteristic of psychoanalysis in this foundational period for psychotherapy (Zur 2007: 3). Sigmund Freud (1856–1939) captured the ambivalent concept of “transference” in his Studies on Hysteria (1895) where he described how patients project and reenact certain core attitudes and issues in their relationship with the analyst. He observed that by redirecting feelings and desires towards the analyst, the patient effectively seeks to repress or divert ideas that emerge in the course of therapy, and thereby engages in an important and necessary form of resistance to therapy, which he described in his seminal paper “Remembering,

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Caring in Psychotherapeutic Approaches and their Antecedents   145 Repeating, and Working Through” (Freud  1958 [1914]). Freud claimed that transference was constitutive of a successful psychoanalysis and went as far as to argue that “it would be senseless to try to evade it; for an analysis without transference is an impossibility” (Freud  1959 [1925]: 42). To best channel this resistance, Freud insisted on the notion of “neutrality,” and recommended “that the analysis be conducted in an atmosphere of abstinence”; that is, one in which the analyst should maintain a “relative anonymity,” which he described using metaphors such as the “blank screen,” the “mirror,” and the “surgeon” (Wolitzky 2011: 72–73). Freud recognized that, in addition to the patient, the therapist is also vulnerable to ambivalent emotions. He identified “countertransference” as the transference of unconscious emotions from the analyst to the patient. Countertransference, according to Freud, was an impediment to therapy (Freud 1957 [1910]) since it undermines any claims about the analyst being able to provide a truly blank screen onto which therapeutically valuable transference can be projected. This emphasis on distance as a therapeutic technique was not universally shared, as exemplified by Freud’s close associate Sándor Ferenczi (1873–1933), who argued that “a physician’s love heals the patient” (Holmes and Lindley 1989: 135). A contemporary view would certainly dismiss Ferenczi’s methods, which involved kissing his patients and letting them kiss him (Wolitzky  2011: 75), as unethical and transgressive. Nevertheless, Ferenczi’s concept of “mutual analysis” anticipated later shifts in psychoanalytic thinking which viewed countertransference as a positive resource that “had the effect of bringing the psychoanalyst down from some imagined pedestal to a position at the same level, or within the same field, as the patient” (Bondi 2008: 256). Feminist theorist Julia Kristeva has taken up the Freudian concepts and linked them specifically to care. She defines care as “a concern for others, and a consideration for their ‘ill-­being’” and considers “the process of transference and counter-­transference involved in the psychoanalytic cure [an] example of the economy of care” (Zournazi 2002: 65–66). The concept of countertransference remains, moreover, central to the practice of psychotherapy today, as the ability to recognize countertransference problems and deal with them is a key aspect of how therapists become aware of their own projective tendencies (Gabbard 1999: xiii; Mitchell 1993). From a slightly different angle, other post-­Freudian approaches to psychotherapy explicitly relied on “relational reworkings of analytic concepts and technique” in order to link psychotherapies more explicitly to practices of care (Botticelli 2006: 76; Aron 1996). One highly influential approach to psychotherapy, which rejected psychoanalysis and set up the caring relationship as its central feature, is the person/client-­centered tradition founded by Carl Rogers (1902–1987). Rogers emphasized that the therapist must be congruent or integrated into the relationship, a condition he describes as “genuineness.” Rogers associates this awareness or genuineness with the ability to reflect on one’s own feelings and, rather than suppress “uncaring” feelings that inevitably arise, he suggests they should be owned and thought about (see Bondi 2008: 253). Rogers further emphasized the importance of the therapist’s unconditional positive regard for patients, which implies unconditional ac­cept­ance and “caring for the client as a separate person, with permission to have his own feelings, his own experiences” (Rogers 1957: 98). Importantly, this implies accepting the client’s expression of “negative, ‘bad’, painful, fearful, defensive, abnormal feelings” (Rogers 1957: 98) as much as the good ones, something that was further explored within self-­reflective care ethics approaches. Finally, Rogers claimed that analysts must be able to identify with their clients yet avoid misunderstanding their clients’ feelings as their own, thereby acknowledging the

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146   Ethics of Care Approaches in Psychotherapy importance of protecting the emotional safety of the therapist (see also Rogers 1951, 1961; Zimring and Raskin 1992). This has a notable affinity with Gilligan’s portrayal of morally mature adults as able to achieve a self-­reflective, self-­responsible balance between care for others and care for themselves (Gilligan 1982: ch. 3). Some have argued that Rogers’s work anticipated what is called the “relational turn” that grouped together those psychotherapies focusing on the psychotherapeutic relationship itself, as opposed to those that emphasized measurement-­based behavioral therapies. The relational turn, as some have noted, was a fundamental step for assigning care a central role in psychotherapy. Analyst Sandro Botticelli, for example, observes that this has allowed therapists to think of their work as “providing care.” “Our consulting rooms,” he writes, “have become a place to which people turn to feel cared for and appreciated” (Botticelli 2006: 73–74; see also Bondi 2008: 252). The point is further developed by psychotherapist Jonathan Slavin who observed that the technical modalities that characterize the therapist–patient relationship, whether they are called transference or countertransference or something else, are but a changing vocabulary secondary to the main end of therapeutic practice, which is a “healing human relationship in and of itself ” (Slavin  1997: 813). In what follows, we examine the conceptual and practical implications of bringing together the ways in which psychotherapies and care ethics conceive of a healing relationship.

Implications of Ethics of Care Approaches for Psychotherapy Ethics Several proponents of the ethics of care have argued for extending it to the practice of psychotherapy and related disciplines (Adshead 2002; Bloch and Green 2006; Robertson and Walter 2007). Broadly speaking, these interventions highlight the limitations of ethical principlism and argue that an ethics of care approach would move caring relationships to the center of psychotherapy, and thereby engender more humane outcomes. Moreover, if, as some recent contributions in psychotherapy claim, the psychotherapeutic relationship can usefully be thought of as a caring relationship, an ethics of care provides an appropriate set of values for engaging the complex and ambivalent feelings that caregivers and recipients experience. In the following, we review the implications ethics of care approaches have for psychotherapeutic practice, focusing specifically on four key aspects, namely the role of psychotherapy and its wider social and political implications, as well as conceptions of personhood, autonomy, and boundaries in the therapeutic relationship.

Society and Politics In considering how a care ethics orientation might be usefully applied to psychotherapy it is necessary to acknowledge that care ethics has sometimes been portrayed as a specifically feminine perspective on ethics, based on the practical experience of care work—e.g., ­mothering—undertaken by women (Ruddick 1989). Virginia Held has observed that the

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Society and Politics   147 ethics of care “builds relations of care and concern and mutual responsiveness to need on both the personal and wider social levels” (Held  2006: 43). Care ethics’ prioritizing of ­relational dynamics as they are experienced within the immediate family, friendships, and social groups are therefore considered the foundations for the establishment of a “caring society,” which would regard “the tasks of bringing up children, educating its members, meeting the needs of all” as foundational for its success (Held 2007: 550). Crucially, “a­­caring society would attend to the health of the social relations between its members” (Held 2006: 136), in which mental health plays an important part. As Held and others have noted, the social changes a focus on care requires are profound, also because of their inherently political implications. The observation by political theorist Joan Tronto that “caring activities are devalued, underpaid, and disproportionately occupied by the relatively powerless in society” (Tronto 1993: 113) still holds today. Like many other forms of care work, practitioners of psychotherapies are numerically dominated by women, particularly outside the field of psychiatry where the gender gap is least pronounced (Lin et al. 2015; Pelling et al. 2006). In terms of salary, psychotherapists and related professions—marriage and family therapists ($50,090 median pay per year), psychologists ($79,010), mental health counselors ($44,630)—earn far less than related medical specialties such as psychiatrists ($220,380), who themselves have small revenues compared to other medical professions (US Bureau of Labor Statistics 2018). This political and economic reality entails practical obstacles for a care-­based approach to mental health because, as Botticelli notes: [t]o the extent that the work we perform increasingly is needed in this more “nurturant” form, it becomes susceptible to the devaluation to which such work has perennially been subject. This devaluation has everything to do with gender: the low value placed on care work in our society goes hand in hand with the fact that traditionally women do it. Among the consequences for psychoanalysis: reduced reimbursement rates, fewer men entering the profession, lower “prestige” for the field within the larger culture.  (Botticelli 2006: 74)

The psychoanalyst Jessica Benjamin has described this problem by highlighting what she refers to as a seeming opposition between “inspired healing and professional technique” (Benjamin 1997: 794). In her assessment, this is rooted in the fact that many female analysts feel uncomfortable taking on the responsibility for theoretical legitimation, seeing as they are far more “comfortable with their stance as empathic, reparative clinicians—embracing happily the ‘ethic of care’ ” (Benjamin 1997: 795). This perceived division between caring and scientific rigor, which continues to inform contemporary divides between those committed to the therapeutic alliance and those who favor measurement-­based therapies, has deep roots in the history of psychotherapy, as intimated above. Louis Breger, in his revisionist biography of Freud, observed that Freud’s development of psychoanalysis was responsible for attempting to fit its fundamentally practical focus on caring into the more formal structures of a respected scientific discipline (Breger 2000). In Breger’s account, Freud was loath to reduce psychoanalysis to caregiving and thus resisted the—empirically compelling—evidence that his treatments had the most curative value when patients felt liked, valued, and appreciated rather than when analysts used, for example, the methods of abstinence and blank slate Freud prescribed. Botticelli argues that this is why “care has been undertheorized in psychoanalysis,” namely because it “seems at odds with the rigors of theory and technique” (Botticelli 2006: 75). As self-­reflective care ethics provides valuable theoretical resources,

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148   Ethics of Care Approaches in Psychotherapy and care ethics-­embodied therapies are increasingly subjected to scientific testing of efficacy, it seems increasingly likely that this divide can be bridged.

Personhood Care ethics reinforces a generalized premise among psychotherapies concerning “a holistic conception of the person, in the sense that a person is understood as an embodied psychosocial whole embedded in a social and relational nexus” (Radden 2002: 54). Its conception of the moral agent is able “to capture significant features of man’s interaction in general, such as reciprocity, dependency, connectedness and asymmetry” (Pettersen  2011: 52). Assigning caring relations a central rather than derivative role is, therefore, one way to acknowledge the importance of attachments and human interdependence within the psychotherapeutic relationship (Fry  1989: 20–21). More specifically, by foregrounding the importance of relationships, an ethics of care approach in psychotherapy seems particularly pertinent to feminist, family, and systemic forms of psychotherapy, as it encourages the view that relationships are both part of the problem and crucial for treatment. In Pettersen’s assessment, this model of a related moral agent enables “care ethicists [to] become analytically equipped to address a wide variety of relationships and the type of harm some may inflict” (Pettersen 2011: 54). As Bondi highlights, such an approach seems uniquely positioned to assess the emotional dynamics at stake in the psychotherapeutic encounter, because rather than demanding of care-­givers specific kinds of feelings towards care recipients, such as love or filial piety, psychotherapeutic approaches call instead for the capacity and willingness to acknowledge and tolerate the full range of feelings caring and being cared for may stimulate, at the same time maintaining an underlying respect for the care recipient, a respect expressed in part through bearing witness to their experience.  (Bondi 2008: 260)

Acknowledging that psychotherapists may experience a large range of feelings towards their patients seems particularly relevant, especially since they might be confronted with patients who refuse treatment even if they would find it helpful. Since the concept of care is particularistic, in the sense that it is “always specific and relational,” as Benner and Wrubel (1989: 3) put it, it has also been accused of failing to provide “any real guide to action in a clinical setting” (Robertson and Walter 2007: 210). Others have argued that care remains ambiguous and “hopelessly vague” (Allmark 2002: 63), and by positing that care itself is constitutive of a moral good, the approach runs the risk that the focus on caring no longer allows for the critical assessment of the object of care. Yet care ethics’ attempt to act as “a template for acknowledging the interests of all affected” can also be understood as a way to deal with the complexities of human relationality in a constructive way that acknowledges the drawbacks of “caring too much” (Pettersen 2011: 57). Emphasis on a web of relations calls for a more pluralistic and holistic view of situations than other ethical approaches; the value of care ethics may therefore lie in “constraining, or perhaps humanizing, more utilitarian or principlist based calculations of ethical action” (Robertson and Walter 2007: 210).

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Boundaries   149

Autonomy By drawing attention to the value of human relations, care ethics questions the central role the concept of individual autonomy has held in other moral theories. This critique of a normative concept associated with independence and self-­sufficiency might seem fundamentally at odds with the goals of psychotherapy, in so far as psychotherapy not only aims to respect the autonomy of patients, but the “promotion of [their] autonomy” and “developing [autonomous] functioning” (Thompson 1990: 13). Yet care ethics does not reject the notion of autonomy altogether, rather it relies on a relational conception which highlights the social, emotional, and embodied aspects of the concept (Mackenzie and Stoljar 2000; Osuji 2018). Care ethics does not “see the person making moral decisions as a radically autonomous, self-­legislating individual. Rather she is tied to others” (Allmark 2002: 64). With its assumption of human interdependency, care ethics is, as Verkerk puts it, “more concerned about the dangers of abandonment than the dangers of interference” (Verkerk 2001: 291). This perspective might prove particularly relevant to psychotherapy since by “developing a more relational model of autonomy, interventions in care can be shown to be in the interest of patients, that is, they can be seen as interventions for attaining autonomy instead of threatening it” (Verkerk 2001: 293). For this reason, Bondi has emphasized the advantages of working with a notion of relational autonomy in psychotherapies, which respects the autonomy of those seeking help and yet “presuppose[s] interdependence as a feature of human life” (Bondi 2008: 262). In this sense, care ethics leaves open the possibility of more paternalistic interventions because they may be required by the situations of interdependence and mutual support that define our lives. In Verkerk’s analysis, a care ethics perspective offers several distinct arguments for the involuntary treatment of mental patients, what practitioners in social psychiatric care have termed “compassionate interference” (Verkerk 2001: 292). First, the ethics of care is more directed to how people “can relate to each other, rather than how they can be left free” (Verkerk 2001: 293). Second, the care perspective stresses the idea of responsibilities rather than rights, and the therapeutic relationship is one “in which responsibilities towards each other are set,” as opposed to rights of non-­interference, for example. Finally, a relational model of autonomy can show that interventions in care are “in the interest of patients, that is, they can be seen as interventions for attaining autonomy, instead of threatening autonomy” (Verkerk 2001: 293). While more restrictive interventions fall into the domain of psychiatry rather than psychotherapy, a care ethics conception of relational autonomy highlights why the importance of such interventions is always to allow patients to “be helped in caring and committed relationships to regain their self-­ esteem” (Verkerk 2001: 293). For psychotherapists, caring may at times involve breaching confidentiality and advocating involuntary treatment on patients’ behalf.

Boundaries Given care ethics’ focus on acceptance and emotional availability, maintaining boundaries and preventing boundary crossings and violations plays a crucial role in its application in psychotherapy. Boundary violations, which are often preceded by boundary crossings

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150   Ethics of Care Approaches in Psychotherapy (Gutheil and Gabbard 1993), always “represent a failure to regulate the space between the patient and the therapist, so that they are either too close and enmeshed or too far away and distant” (Adshead 2016: 455). Paying close attention to boundaries as structuring and maintaining the therapeutic relationship seems particularly vital in a care ethics framework, given its emphasis on non-­verbal forms of communication, such as “touch, movement, facial expression, tone of voice, quality and pace of non-­verbal utterances, what is not said and so on” (Bondi 2008: 260). It has been argued, however, that an ethics of care might be able to integrate the regulation of boundaries rather than needing to formalize them as rules. By “including attention to both professional duties of care and patient rights,” it might be able to “offer a more coherent justification for prohibiting therapist–patient sexual relationships,” for example, than one informed by principlism (Adshead  2002: 59). An ethics of care approach highlights that the therapist must “understand how her own relational needs may have caused her to come to take action which was ethically unjustifiable” (Adshead 2002: 59), and this awareness is necessary for managing the aftermath of such an event in a constructive way. In this sense, care ethics might provide a framework for dealing effectively with mistakes such as boundary violations, as it requires both patient and therapist to reflect on how they “should” behave in the context of an ongoing relationship, which in Adshead’s estimation is “the very substance of a notion of the duty of care” (Adshead 2002: 59) This insight is compatible with the notion that caring for others can entail neglect and even harm of the self. As Kottler remarks: “[t]he experience of any practitioner would attest to the emotional as well as intellectual strains of living constantly with clients’ crises, confusion, and intense suffering” (Kottler  1986: 66). This might even be exacerbated by the requirements of professionalism and confidentiality, as even the best clinical detachment might not be able to fully protect therapists from feeling overwhelmed and exhausted by their patients’ suffering. If a care ethics approach enables us to understand “caring” as a reciprocal, rather than one-­sided, activity then it can make a real contribution to the ethics of psychotherapy since it allows us to account for the fact that even within the asymmetrical relationship between psychotherapist and patient, the seemingly dominant figure of therapist is also vulnerable and may need to seek professional help her/himself.

Conclusion Jennifer Radden has observed that the “uniqueness of psychiatry calls for a unique ethics” (Radden 2002: 53). As a perspective that highlights the limitations of abstract moral theories and instead valorizes attentiveness, empathy, and concern, and specifically encourages listening and talking to the patient, the ethics of care could be said to offer such an approach. Its emphasis on communication skills, emotional sensitivity, and the moral weight of personal relationships all have their place within contemporary psychotherapy, particularly because both fields understand and valorize human relationships as a key part of healing. Yet recourse to the ethics of care provides no straightforward answers to some of the fundamental challenges in psychotherapy ethics. This is compounded by the fact that its focus on caring cannot function as a comprehensive normative theory. Not only is it

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Conclusion   151 difficult to allocate care as a limited resource, it can be easily manipulated, and it does not ­provide tools for assessing the moral weight of that about which we care (Card  1990; Houston 1990). Care ethics can, however, provide an analytical framework for reflecting on the nature of the therapeutic relationship, as well as the role of psychotherapy within the healthcare system more broadly. Conversely, psychotherapy can help care ethics address some of its unanswered questions, including the fact that sharing the feelings of the patient and acknowledging one’s own vulnerability always contain the threat of escaping from the carer’s control.

Acknowledgments The authors would like to thank Mary Bartram for her helpful comments on the chapter.

References Adshead, G. (2002). “A Different Voice in Psychiatric Ethics.” In Healthcare Ethics and Human Values: An Introductory Text with Readings and Case Studies (ed. K. W. M. Fulford, D. L. Dickenson, and T. H. Murray, pp. 56–62). Malden, MA: Blackwell Publishers. Adshead, G. (2016). “Ethics and Boundaries.” In Oxford Specialist Handbooks: Medical Psychotherapy (ed. J. Yakeley, J. Johnston, G. Adshead, and L. Allison, pp. 441–460). Oxford: Oxford University Press. Allmark, P. (2002). “Can There Be an Ethics of Care?” In Healthcare Ethics and Human Values: An Introductory Text with Readings and Case Studies (ed. K.  W.  M.  Fulford, D.  L.  Dickenson, and T. H. Murray, pp. 63–69). Malden, MA: Blackwell Publishers. Aron, L. (1996). A Meeting of Minds: Mutuality in Psychoanalysis. Hillsdale, NJ: The Analytic Press. Barker, P. (ed.) (2011). Mental Health Ethics: The Human Context. New York: Routledge. Benjamin, J. (1997). “Psychoanalysis as a Vocation.” Psychoanalytic Dialogues 7: 781–802. Benner, P. and Wrubel, J. (1989). The Primacy of Caring: Stress and Coping in Health and Illness. Menlo Park, CA: Addison-Wesley. Biller-Andorno,  N. (2012). “Care, Ethics of.” In Encyclopedia of Applied Ethics (2nd ed., vol. 1; ed. R. Chadwick, pp. 390–396). San Diego, CA: Academic Press. Bloch, S. and Green, S. A. (2006). “An Ethical Framework for Psychiatry.” British Journal of Psychiatry 188: 7–12. Blumgart, H. L. (1964). “Caring for the Patient.” New England Journal of Medicine 270: 449–456. Bondi, L. (2008). “On the Relational Dynamics of Caring: A Psychotherapeutic Approach to Emotional and Power Dimensions of Women’s Care Work.” Gender, Place and Culture 15: 249–265. Botticelli, S. (2006). “Globalization, Psychoanalysis, and the Provision of Care: Roundtable on Global Woman.” Studies in Gender and Sexuality 7: 71–80. Breger, L. (2000). Freud: Darkness in the Midst of Vision. Hoboken, NJ: Wiley. Cabot, R. C. (1926). Adventures on the Borderlands of Ethics. New York: Harper & Brothers. Card, C. (1990). “Caring and Evil.” Hypatia 5: 101–108. Cautin, R. L. (2011). “A Century of Psychotherapy, 1860–1960.” In History of Psychotherapy: Continuity and Change (2nd ed.; ed. J. C. Norcross, G. R. VandenBos, and D. K. Freedheim, pp. 3–38). Washington, DC: American Psychological Association. Davis, A. J. (1981). “Compassion, Suffering, Morality: Ethical Dilemmas in Caring.” Nursing Law and Ethics 2: 1–8. Freud, S. (1957 [1910]). “The Future Prospects of Psycho-Analytic Therapy.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 11 (1910): Five Lectures on Psycho-Analysis, Leonardo da Vinci and Other Works (ed. J. Strachey et al., pp. 139–152). London: Hogarth.

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152   Ethics of Care Approaches in Psychotherapy Freud, S. (1958 [1914]). “Remembering, Repeating and Working-Through (Further Recommendations on the Technique of Psycho-Analysis II).” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 12 (1911–1913): The Case of Schreber, Papers on Technique and Other Works (ed. J. Strachey et al., pp. 145–156). London: Hogarth. Freud, S. (1959 [1925]). “An Autobiographical Study.” In The Standard Edition of the Complete ­Psychological Works of Sigmund Freud, vol. 20 (1925–1926): An Autobiographical Study, Inhibitions, Symptoms and Anxiety, The Question of Lay Analysis and Other Works (ed. J. Strachey et al., pp. 1–74). London: Hogarth. Friedman, M. (2000). “Feminism in Ethics: Conceptions of Autonomy.” In The Cambridge Companion to Feminism in Philosophy (ed. M. Fricker and J. Hornsby, pp. 205–224). Cambridge: Cambridge University Press. Fry, S. T. (1989). “Toward a Theory of Nursing Ethics.” Advances in Nursing Science 11: 9–22. Gabbard, G.  O. (ed.) (1999). Countertransference Issues in Psychiatric Treatment. Washington, DC: American Psychiatric Association. Gelso, C. (2011). The Real Relationship in Psychotherapy: The Hidden Foundations of Change. Washington, DC: American Psychological Association. Gelso, C. and Carter, J. A. (1985). “The Relationship in Counseling and Psychotherapy: Components, Consequences, and Theoretical Antecedents.” The Counseling Psychologist 13: 155–243. Gilligan, C. (1982). In a Different Voice: Psychological Theory and Women’s Development. Cambridge, MA: Harvard University Press. Gutheil, T. G. and Gabbard G. O. (1993). “The Concept of Boundaries in Clinical Practice: Theoretical and Risk-Management Dimensions.” The American Journal of Psychiatry 150: 188–196. Halpern, J. (2001). From Detached Concern to Empathy: Humanizing Medical Practice. Oxford: Oxford University Press. Held, V. (2006). The Ethics of Care: Personal, Political, and Global. Oxford: Oxford University Press. Held, V. (2007). “The Ethics of Care.” In The Oxford Handbook of Ethical Theory (ed. D.  Copp, pp. 537–566). Oxford: Oxford University Press. Holmes, J. and Lindley, R. (1989). The Values of Psychotherapy. Oxford: Oxford University Press. Houston, B. (1990). “Caring and Exploitation.” Hypatia 5: 115–119. Kottler, J. (1986). On Being a Therapist. San Francisco, CA: Jossey-Bass. Leichsenring, F. and Steinert, C. (2017). “Is Cognitive Behavioral Therapy the Gold Standard for ­Psychotherapy? The Need for Plurality in Treatment and Research.” JAMA 318: 1323–1324. Leininger, M. (2001). Culture Care Diversity and Universality: A Theory of Nursing. New York: National League for Nursing Press. Leininger, M. (2008). “Overview of Leininger’s Theory of Culture Care Diversity and Universality.” Retrieved from http://www.madeleine-leininger.com/cc/overview.pdf Lin, L., Stamm, K., and Christidis, P. (2015). Demographics of the U.S. Psychology Workforce: Findings from the American Community Survey. Washington, DC: American Psychological Association. Mackenzie, C. and Stoljar, N. (eds.) (2000). Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self. New York: Oxford University Press. Menninger, W. W. (1975). “ ‘Caring’ as Part of Health Care Quality.” JAMA 234: 836–837. Mitchell, S. (1993). Hope and Dread in Psychoanalysis. New York: Basic Books. Noddings, N. (1984). Caring: A Feminine Approach to Ethics and Moral Education. Berkeley, CA: University of California Press. Osuji, P. I. (2018). “Relational Autonomy in Informed Consent (RAIC) as an Ethics of Care Approach to the Concept of Informed Consent.” Medicine, Health Care and Philosophy 21: 101–111. Peabody, F. W. (1927). “The Care of the Patient.” JAMA 88: 877–882. Pelling, N., Brear, P., and Lau, M. (2006). “A Survey of Advertised Australian Counsellors.” International Journal of Psychology 41: 204–215. Pettersen, T. (2011). “The Ethics of Care: Normative Structures and Empirical Implications.” Health Care Analysis 19: 51–64.

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Conclusion   153 Radden, J. (2002). “Notes Towards a Professional Ethics for Psychiatry.” Australian & New Zealand Journal of Psychiatry 36: 52–59. Radden, J. and Sadler, J. (2010). The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice. Oxford: Oxford University Press. Ramsey, P. (1970). The Patient as Person: Explorations in Medical Ethics. New Haven, CT: Yale University Press. Reich, W.  T. (1995). “Care: I, II and III.” In Encyclopedia of Bioethics (2nd ed.; ed. W.  T.  Reich, pp. 319–344). New York: Simon & Schuster. Reiser, S. J. (1978). Medicine and the Reign of Technology. Cambridge: Cambridge University Press. Robertson, M. and Walter, G. (2007). “Overview of Psychiatric Ethics II: Virtue Ethics and the Ethics of Care.” Australasian Psychiatry 15: 207–211. Rogers, C. R. (1951). Client-Centred Therapy: Its Current Practice, Implications, and Theory. Boston, MA: Houghton Mifflin. Rogers, C. R. (1957). “The Necessary and Sufficient Conditions of Therapeutic Personality Change.” Journal of Consulting Psychology 21: 95–103. Rogers, C. R. (1961). On Becoming a Person. Boston, MA: Houghton Mifflin. Ruddick, S. (1989). Maternal Thinking: Toward a Politics of Peace. New York: Ballantine Books. Slavin, J. H. (1997). “Models of Learning and Psychoanalytic Traditions: Can Reform Be Sustained in Psychoanalytic Training?” Psychoanalytic Dialogues 7: 803–817. Thompson, A. (1990). Guide to Ethical Practice in Psychotherapy. New York: John Wiley & Sons. Tronto, J. (1993). Moral Boundaries: A Political Argument for an Ethic of Care. New York and London: Routledge. US Bureau of Labor Statistics (2018). Office of Occupational Statistics and Employment Projections. Retrieved from https://www.bls.gov/ooh/life-physical-and-social-science/home.htm Verkerk, M. A. (2001). “The Care Perspective and Autonomy.” Medicine, Health Care and Philosophy 4: 289–294. Wolitzky, D. (2011). “Psychoanalytic Theories of Psychotherapy.” In History of Psychotherapy: Continuity and Change (2nd ed.; ed. J. C. Norcross, G. R. VandenBos, and D. K. Freedheim, pp. 65–100). Washington, DC: American Psychological Association. Zimring, F. M., and Raskin, N. J. (1992). “Carl Rogers and Client/Person-Centred Therapy.” In History of Psychotherapy: A Century of Change (ed. D. K. Freedheim, pp. 629–656). Washington, DC: American Psychological Association. Zournazi, M. (2002). “Joyful Revolt: A Conversation with Julia Kristeva.” In Hope: New Philosophies for Change (ed. M. Zournazi, pp. 64–77). Annandale: Pluto Press Australia. Zur, O. (2007). Boundaries in Psychotherapy: Ethical and Clinical Explorations. Washington, DC: American Psychological Association.

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Chapter 10

Legitim ate a n d Illegiti m ate Im position of Ther a pists’ Va lu e s on Patien ts Susana Fehr Lampley AND John Z. Sadler

Introduction The notion that psychotherapists should not impose their values on their patients is a ­common truism in professional meetings, clinical supervision, ethics guidelines, and the clinical literature (Tjeltveit 1986). However, other than providing methods for discussing values in therapy, comparatively little has been written about how, exactly, not to impose one’s values on patients (Kocet and Herlihy 2014). For this chapter, we would like to sketch an approach to thinking about and managing therapists’ own value commitments, ethical and otherwise, that addresses more directly the issue of imposing values, and how to evaluate justified and unjustified impositions of values in therapy. First, we describe what we mean by “values,” how one can identify one’s own values, and how values manifest into clinical discourse. As a second step, we describe what it means to “impose” values on a psychotherapy patient. In a third section, we take a contrarian viewpoint regarding the psychotherapist truism of not imposing values on one’s patients: we present arguments that defend the idea that psychotherapists impose values on their patients frequently, often appropriately, and indeed, inevitably. The inevitability of imposing values on patients then frames the core ethical questions for us: Which values, and in what contexts of practice, is it justifiable for therapists to impose? With this understanding, we suggest there is no “general rule” to discourage imposition of values on patients; some impositions are practice conventions, others are consented to in early phases of therapy, others are negotiated in the course of therapy, leaving open and flexible whether or not they

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introduction   155 are “imposed” by therapists, and still others are frankly forbidden and/or unethical. In the fourth and most substantive section, we present a variety of brief case vignettes which illustrate an exemplar range of clinical psychotherapy situations where therapists may find themselves imposing their values on patients. We show that some kinds of values embedded in psychotherapist conduct are unambiguously appropriate, and indeed, often required to conduct therapy. Other kinds of values, in contrast, are unambiguously inappropriate and should never be imposed on patients. Still other kinds of values embedded in psychotherapist conduct fall into context-­dependent assessments, where ethical justification depends on particular case details, circumstances, and the interplay of other value considerations. Some of these situations may rise to the level of a true ethical dilemma, where action in either direction is morally defensible, and the interplay of values result in contradictory actions and are indecisive. For all of our cases, we try to provide some management guidance, when feasible, and also situate our analyses in sample citations of existing literature and professional ethics guidelines and policy. Our examples are not intended to be comprehensive, or detailed in discussion; our intention is to provide an introductory overview to the issues involved when “imposing values.” Our case sample discussions have several functions: (a) to provide rough guidance about how to analyze one’s own unique cases, (b) to 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) to provide sample references from the literature illustrating particular values-­ imposition (V-­ I) discussions and policies. Our conclusions emphasize the limitations of this exploratory and preliminary work, and we point to areas where additional analysis and empirical work would be of benefit for clarifying ambiguities of practice. We make several assumptions in developing our work and in taming the wild complexities involved. First, we assume that the psychotherapists considered in our cases are well-meaning, conscientious, and competent clinicians, unless indicated otherwise. Our exemplar clinician is not impaired professionally by significant psychopathology or a corrupt morality. Moreover, we assume that the contexts of practice are conducive to the ethical and professionally standard conduct of psychotherapy, and that our exemplar clinician is not hampered by corrupted business, reimbursement, facilities, or other extraneous factors that render adequate care difficult-­to-­impossible. We assume adequate, not exceptional or superlative care. These assumptions are required for our analysis, because ethical judgments are always already complex. Considering all, or even most of the variations of corrupted clinical and nonclinical practices would make this chapter unfeasible to write. We also, by and large, eschew commitments to this or that psychotherapy modality, while recognizing that ethical justification for values-­imposition (V-­I) varies across different modalities. For example, what might be an inappropriate directive for a patient in psychoanalysis may be the very stuff of treatment for a couple in emotion-­focused therapy. Moreover, with each of our sample cases, we provide one or more references that address the issue at hand. These references are not intended to close the discussion regarding the appropriateness of the particular V-­I in mind, but rather to show that the position we propose regarding appropriateness has at least some support in the literature. That said, none of our claims about the appropriateness of a particular case scenario are intended to be conclusive, but rather pose a challenge to the reader and the literature to consider the appropriateness question more. We don’t claim our sample case discussions to be conclusive, only introductory.

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156   Legitimate and Illegitimate Imposition of VALUES With all this said, we also write our cases with real people in mind, who are subject, as we all are, to non-­therapeutic emotions, motivations, and reactions to patients.

What Do We Mean by Values? Sadler (1997, 2002, 2005; see also Sadler et al. 2015) in his prior work on the values involved in psychiatric diagnosis and classification provided an operational definition of values which enabled users to search or “interrogate” texts and discourses for particular kinds of values. Through the identification of these values, they could then be considered explicitly, instead of implicitly or not at all. The definition offered was “values are attitudes or dispositions to act which are action-­guiding and subject to praise or blame” (Sadler 1997: 545; see also Sadler 2005). As attitudes and dispositions, values influence our actions, but do not determine our actions, which are always influenced by many other factors, such as competence, opportunity, or environmental constraints. For example, I may prefer to work with patients in psychotherapy (I value psychotherapy practice) but will use medications when indicated (patient-­centered treatment is also a value). Values may manifest in terms of positive or negative words, or terms, like good, beautiful, negligent, dubious, or elegant. For our discussion in this chapter, we will call attention to words or phrases as values by italicizing them as we did in the previous sentence. Values also manifest in the meanings of sentences, even those without a “value term”: “John will do anything to get a grant.” In this example, the sentence does not have a word conveying value, but in ordinary usage, this sentence condemns John as a ruthless, unethical grant-­seeker (see Sadler 1997 and 2005 for detailed discussions). Whether positive or negative, we praise (applaud) or blame (condemn) particular values in practice. Examining texts or discourses for meanings that are covered by this definition of values then becomes the tool for considering the complex interplay of values in human relations, including psychotherapy.

The Imposition of Values on Patients: Why Inevitable? We have suggested, for brevity’s sake, to condense the idea of values-­imposition into abbreviation: V-­I. What does it mean to “impose” one’s values on a patient? To impose values on a patient, for our purposes, implies that the therapist makes an implicit or explicit demand or requirement of the patient. As a therapist’s demand or requirement, an imposition is one-­sided, by the therapist, for the purposes of this chapter’s discussion. What kind of demand depends upon the situation. A therapist may require that the patient arrive on time, or be subject to some consequence—a V-­I that demands respect for the value of promptness and the avoidance of the value of tardiness. A family therapist may demand that all members of the nuclear family attend therapy sessions. Here the V-­I involves a particular attendance requirement which the therapist may assert for practical reasons. For example, the therapist may believe that this attendance requirement is required to respect the value of efficacy of the therapy.

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values appropriate and inappropriate   157 By examining the first example, about a V-­I for promptness in therapy, the reader may now anticipate our main argument about why the imposition of values by therapists on patients is inevitable. A therapist who has no reliable schedule of appointments will be unable to practice therapy in any feasible way. Similarly, a therapist in a fee-­for-­service practice setting may impose fees as a condition for being able to make a living as a therapist. The V-­I of fees can be understood as imposing the values of a bilateral trading of benefits—fee (benefit for therapist) for service (benefit to patient). This bilateral symmetry of benefits illustrates that the V-­I on the part of the therapist doesn’t necessarily mean that the V-­I is burdensome to the patient, or the patient receives no corresponding value. As we will see from examples to follow, not all V-­Is on the part of therapists on patients have this powerful feature of feasibility values. For example, the family therapist requiring participation by all members of a nuclear family is another example of a V-­I.  However, compared to the transparent feasibility value of promptness and trading benefits, the value of insisting all members of the family attend is not as well established, and may need to be established by scientific evidence to be justified ethically. We will provide a few other examples of V-­I which are required for the feasibility of psychotherapy practice, but only a few in that these examples have less clinical and ethical interest than examples which depict inappropriate and ambiguous impositions of psychotherapist values on patients. With this orienting discussion, we proceed to discussing particular cases.

Values Appropriate and Inappropriate We begin by addressing what we think are clear-­cut cases of appropriate and inappropriate V-­Is. Regarding our cases, we group them initially by their level of appropriateness, which follow below.

Appropriate I-­V Values/Situations Fees and Appointments We have already mentioned the practical requirement for these arrangements in typical psychotherapy practices. However, for the V-­I of fees and appointments to be justifiable regarding patients, a management endeavor is required, namely, obtaining informed consent from patients before therapy starts, either over a telephone encounter or a first session (see also Chapter 17 by McKean, Trachsel, and Croarkin on informed consent in psychotherapy, in this volume). This consent is often taken for granted as simply the way a therapist does business; and this taken-­for-­grantedness obscures the recognition that being paid for service is a value the therapist imposes, in addition to the practice of agreeing to an appointment time is also a value imposed by the therapist. Associated values, for example, a reasonable fee may also apply here. For more discussion of professional ethics standards concerning fees and appointments, see the American Association for Marriage and Family Therapy (2012 and  2015), the American Counseling Association (2014), the American Psychological Association (2016), and the American Psychiatric Association (2014).

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Practice Specializing in Feminist Therapy This case scenario concerns a therapist whose practice is specializing in feminist therapy. We should take care here to note that the therapist is specializing in feminist therapy; we don’t use the more restrictive term “limited to.” In the latter case, “limited to” means the therapist is imposing the tenets of feminist therapy on all patients, irrespective of indication, and implying that this is not negotiable. We think this would impose an inappropriate burden on the lay potential client, who may or may not know what she is getting into and what potentially helpful interventions will not be offered. However, in the case of a therapist having a specialization, this would be an appropriate V-­I depending on some considerations to follow. Therapists with specialties are very common, but the specialty should not mean that clients falling outside of that specialty “need not apply,” but simply that the therapist has a particular expertise. Like with fees and appointments, a particular management technique is required: the provision of informed consent. In this case, the therapist should disclose, probably in practice-­information materials (business cards, ads, etc.), in the telephone screening interview, and certainly the first session, the therapist’s focus on feminist therapy, so that potential patients can ask questions about and decide if feminist therapy is for “them.” We chose feminist therapy as an example, but most, perhaps all, other psychotherapies would be equally applicable, e.g. cognitive-­behavioral therapy, family therapy, psychodynamic therapy, etc. Multiple specialized therapies can be examples which are equally suitable. In the informed consent context for a specialized therapy, typical disclosures include the predominant values or goals of the therapy, methods of conceptualizing mental health problems, and expectations directed to the patient’s participation, techniques, and alternatives. More detailed discussions of this topic can be found in this volume (see Chapter 17 on informed consent in psychotherapy, and Chapter 19 on evidence-­based and non-evidence-­based psychotherapy; see also Brown  1991; Evans et al.  2005; Feminist Therapy Institute 2008).

Practice Specializes in Christian Therapy We decided to treat this as a unique example of V-­I, in that it differs from our prior feministtherapy example in that the therapy included tenets of the Christian religion in their varieties. Rather than a scientific/theoretical orientation, Christian therapy is offered to fellow religious believers, with associated values of that religion and its varieties. Like with specialized therapies, “Christian therapy” to be an acceptable V-­I for patients must have an appropriate management technique attached—informed consent as before. In this example, the specialty of Christian therapy doesn’t necessary restrict techniques or modalities of therapy, so in some ways this “specialty” is more flexible than the feminist-­therapy example. Note also, that the therapist “specializes” in Christian therapy, but does not state that the practice is “restricted to” Christian therapy. The latter, as will be discussed later, would potentially be unethical on the basis of discrimination on the basis of religion—that is, if Muslims, Jews, and Buddhists need not apply. Both of the above examples of specialized and Christian therapy raise questions about the disclosure, in the informed consent process, of the evidence base for the respective therapy approach; this may bear on the appropriateness of imposing the specialty to the particular therapy. However, as Jens Gaab has pointed out, this is an appropriate V-­I only

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values appropriate and inappropriate   159 insofar as referral to a compatible therapist is a real possibility in the community. This ­question is discussed further in Blease et al. (2016), and in the Chapter 19 in this volume.

Couple Therapist Privately Advises Batteree to Seek Shelter This example refers to the situation where a couples/marital therapist discovers, one way or another, that a member of the couple is violently abusive, and protective action is needed regarding the other member of the couple, the potential or ongoing victim of the abuse— the “batteree.” This situation is familiar to couple/marital therapists and is a common ethical challenge posed to them (Willbach 1989). In contrast to our earlier examples of “appropriate” V-­I, this example poses not a routine values-­imposition (as with discussing fees and appointment times, or style of therapy), but instead an exceptional moment arising in the context of a therapy already initiated and ongoing. One or more management techniques are needed. Some couple therapists may incorporate this contingency into their informed consent, initial-­evaluation discussion, e.g., “If one or another of you (the couple) becomes at risk for being violent, we reserve the right to offer protective action, even privately, for the potential victim.” The context of this informed-­consent discussion might play out in a clinic which specializes in working with domestic-­violent individuals and couples. However, in ordinary marital/couple therapy practice, this kind of pre-­emptive discussion is often overlooked, sometimes with intent, because therapists might be concerned that such a warning may be off-­putting or alienating for the majority of non-­violent couples which constitute their practice. Here the professional values of preserving safety and professional discretion come into consideration, and which of these two values prevails depends upon the context of practices and circumstantial details. Our original case, however, framed at the beginning of this subsection, notes that the potential for violence has arisen in the context of ongoing marital therapy. So, the values/ ethics calculus at work in this context concerns the appropriateness of imposing safety values over completing therapy values like neutrality (Aldarondo and Straus 1994), and the interest in preserving the therapy project in the face of domestic violence. The consensus of the domestic-­violence therapy community appears to be that preserving safety for therapy participants is a prevailing value (e.g., APA 2014, 2015; American Psychoanalytic Association (ApsaA)  2018; London  1986). In this sense, we offer this example as an uncontroversial example of an appropriate V-­I of safety values over other therapy values.

Therapist Wants to Practice EBP (Evidence-­Based Practice) with Alternative Treatment-­Seeker In this clinical situation, a therapist wants to impose the values of evidence-­based practice (Barnett and Shale 2013) on a patient who is requesting an alternative, presumably nonevidence-­based practice. Like with the specialized-­therapies’ examples, this situation, to be acceptable ethically, requires an informed-­consent management technique. The therapist’s insistence on EBP would need to be negotiated with such a patient at the beginning of the treatment relationship, so that the patient has the opportunity to decide for him- or herself to submit to the therapist’s recommendation or seek treatment elsewhere. With these precautions in place, the imposition of EBP values would be appropriate. The ethics of EBP is discussed in more detail in Chapter 19 in this volume.

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Therapist Treating a Family Discourages Spankings In this situation, a therapist, during a course of family therapy, discourages spanking as a technique of parental discipline for a young child. The therapist’s judgment is based upon her study of the science on safety and utility of spankings, which is prevailingly critical of this parental practice (Miller-­Perrin and Rush 2018). Moreover, spankings may be illegal or sanctioned in some countries or jurisdictions. The therapist aims to help the family find safer and more effective disciplinary interventions. The values carried by such therapists are complex, for example, scientific values, values around humane kindness, practical values like efficacy, and perhaps protective values regarding the child. In contrast, the parents’ values may be entangled with loyalty to family-­of-­origin based practices (e.g., “spare the rod and spoil the child”), religious practices, and perhaps suspicious mistrust of secular psychological claims. In contrast to prior examples, this example addresses differential weighting of values held by the therapist. While the therapist may wish to not offend or challenge the parents, or may be tempted to seek some sort of compromise regarding disciplinary practices, she may decide that the value of safety and efficacy are too important to outweigh the values pointing toward accommodating the parents’ wishes. This weighing of values is often referred to as seeking a favorable risk–benefit ratio, ratio here being a qualitative, metaphorical sense, not an actually weighting of quantitative values. Here, the benefit of avoiding spankings outweighs the risk of accommodating to ongoing spankings. So, the therapist’s strong statement against spankings and in favor of alternatives is justified ethically.

Therapist Uses Motivational Interviewing to Promote a Denying Alcoholic Patient to Address Problem Drinking While this example resembles the prior one in eliciting considerations of risk–benefit, significantly more management considerations are needed to make the V-­I ethically justifiable. First, perhaps some more details of this clinical context should be spelled out. In this clinical context, the therapist’s diagnosis of alcohol dependence arises in the course of treatment for other complaints, such as (for example) “anxiety,” where the patient minimized alcohol use in the evaluation phase of the clinical encounter and only later in treatment did a pattern of self-­destructive alcohol use become evident to both therapist and patient. The point of motivational interviewing is to explore the ambivalence around sobriety and recovery in order for the patient to choose to pursue sobriety as a primary goal. The example is distinctive in our discussion so far because the therapist, through the use of motivational interviewing (Miller and Rollnick 2012), is in effect attempting to shift the direction of the therapy away from the patient’s stated primary objective (reducing anxiety), towards what the therapist believes should be the primary objective, which is sobriety. In this framework, the patient’s objective of reducing anxiety would presumably fall to a secondary objective, with the presumption that sobriety will assist in anxiety management, or at minimum, clarify an underlying primary anxiety disorder diagnosis. At first glance, this seems an ethically tall order, raising the question of the amount, kind, and quality of informed consent, the possibility for “manipulating” the patient, and more literally imposing the value of sobriety on the patient, which may be a secondary interest (as a value) or even an anti-­value (e.g., the patient wants to maintain “social” drinking). What makes this example distinctive is that at least two value-­conflicts have arisen: (1) the therapist and patient have different priorities about what the role of alcohol should be in the

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values appropriate and inappropriate   161 patient’s life; and (2) the therapist believes that the first step in the goal of overcoming the patient’s anxiety involves at least a reduction or elimination of alcohol use, while the patient may have differing views, such as “I won’t need to drink once I have my anxiety controlled.” We believe that these concerns are typically played out in the ongoing consent-­oriented treatment negotiation; motivational interviewing is transparent in its emphasis on exploring all sides of an issue with the patient, and assessing the patient’s readiness for change. This transparency dilutes the potential for “manipulation.” Moreover, while an alcoholic individual may present with a desire to moderate but not stop drinking, s(he) may also have tacit values supporting sobriety. If so, these too would emerge in the ongoing treatment negotiation and so diminish the values-­conflict between patient and therapist. So, for this example we would conclude that this V-­I is ethically acceptable.

Therapist Refuses to Remove Accurate Diagnosis from Medical Record For this example, we have specified “accurate diagnosis” to specify the situation of a disputed diagnosis with a patient and to rule out simply mistaken or provisional diagnoses. (For the latter cases, we would agree with the patient that removing mistaken or provisional diagnoses is appropriate.) A typical example of this kind of case would be a patient who insists on the therapist removing the diagnosis of narcissistic personality disorder from the record, and the therapist refusing. However, for this example of an appropriate V-­I, several reasons should be mentioned. As enshrined in the US Federal HIPAA confidentiality and privacy guidelines (AHIMA  2004; https://www.hhs.gov/hipaa/for-­professionals/privacy/ laws-­regulations/index.html), the medical record is the property of the clinician and/or healthcare system. Patients are entitled to a copy of their own medical record, and may request a change to the medical record, but clinicians are not obligated to make the change. Aside from regulatory guidelines, the ethics of medical records are built upon the foundation of accurate information in order to pursue the therapeutic ends of clinical care (Pope 2015). In this sense, the prevailing value is beneficence, supplemented by other values such as information ownership by the clinician, meaningful information-­sharing with other treating clinicians, and clinician self-­interest in documenting care in case of lawsuits or other care disputes. In this setting, the patient’s autonomy interest and concerns about stigma should be, of course, discussed and possibly, managed. Moreover, while we defend the V-­I of not changing the medical record, this does not imply that the therapist is forbidden to change the record; some therapists, for their own reasons, may elect to cooperate with the patient’s request.

Inappropriate I-­V Values/Situations Having considered some examples of cases where imposition of values is appropriate to therapy, we now turn to the opposite condition where values impositions would be inappropriate.

Therapist Practices Conversion Therapy (Homosexuality to Heterosexuality) At first consideration, this V-­I case resembles prior cases of religion- or ideologicallydefined therapies. In this case, however, conversion or reparation therapy is aimed at a

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162   Legitimate and Illegitimate Imposition of VALUES ­ articular condition of alleged “psychopathology”—homosexuality—and aims to convert p or repair the patient to heterosexuality (Haldeman  1994). The prior cases of religion- or ideologically-­defined therapies, in contrast, are aimed at treating conventional forms of psychopathology and problems in living as mainstream therapies do. So, what is the significance of heteronormative values being perpetrated upon participating homosexual patients? The American Psychological Association responses to this center around two main points: (1) homosexuality is not a mental disorder, and therefore does not require treatment (APA 2009); (2) these therapies pose an offense against values of toleration of diversity, non-discrimination, and the promotion of healthy adaptation and self-­acceptance of sexual orientation (APA 2009). Other harm-­inducing considerations, such as perpetuating stigma and damaging the professional image of mental health care, also contribute to the V-­I here.

Therapist Has a Practice Restricted to the Care of Aryans This provocative example of an inappropriate V-­I also, at first glance, resembles other, acceptable, V-­Is having to do with imposing explicitly ideological therapies, or therapies aimed at specific populations of patients, such as victims of domestic violence or traumatized war veterans. What is distinctive here is the reference to “Aryans,” linking this example of a restricted practice to Nazi ideology, where white Aryans are considered morally, physically, and intellectually superior to other races or ethnicities (Bialas and Fritze 2014). In our view, what makes this example distinctive from the other special-­population therapies, is the nested view of moral inferiority in other races and the moral superiority of Aryans. A second significant factor in this example pertains to the use of “restricted” in the practice, meaning that other ethnicities or races are excluded systematically, placing this example as blatant racial discrimination. Alexander (1992) in his complex and detailed analysis of morally acceptable and morally unacceptable forms of discrimination, argues that the most egregious examples of morally unacceptable discrimination are those where the discriminator bases judgments and actions on beliefs or assumptions of lesser moral worth of those discriminated against. In other words, Alexander argues that the clearest examples of objectionable discrimination contradict the moral principle of equal moral worth of people, a principle embedded in the US Constitution and Bill of Rights.

“Dubious” and “It Depends” Appropriateness of Imposing Values by Therapists In this section, we now turn to more complicated and complex examples of valuesimpositions by therapists on patients. We explain the two categorizations briefly here “Dubious” (D) and “It Depends” (ID) V-­Is. These abstract sketches of D and ID cases will then be particularized with examples to follow. Dubious (D) case examples represent situations where, regardless of the contextual details of the case, the case poses a persistent conflict of values where the values-­imposition has strong moral/ethical arguments for both appropriate and inappropriate judgments of the values-­imposition. Some D cases may rise to the level of a true ethical dilemma, where

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values appropriate and inappropriate   163 no resolution of the conflicting values is evident. Other D cases may reflect a conflict of ethical values involved in the values-­imposition, where even a strong ethical argument in favor of one, or another, professionally-­accepted action leaves the practitioner with residual moral discomfort. “It Depends” (ID) cases represent situations where contextual factors are crucial in determining if the values-­imposition is appropriate or inappropriate. Stated differently, our brief case examples, when specified with more detailed case context and circumstances, lead to ethically justified conclusions of appropriateness or inappropriateness. In ID cases, different sets of contextual and circumstantial details may lead to different conclusions regarding appropriateness of the values-­imposition. Now let us consider some examples.

Dubious V-­I Cases Military Therapist Imposes Return-­to-­Duty Date (or Commanding Officer Forces) on a Persistently Ill Soldier In this case, an officer with mental-­health credentials and duty (e.g., psychiatrist, psychologist) is involved in treating a fellow soldier who has war-­related post-­traumatic stress disorder. The therapist/officer receives an instruction either explicitly from a commanding officer, or implicitly through military duty requirements, to return an insufficiently-­recovered soldier to duty by a particular date. The return-­to-­duty stands as the dubious V-­I on the patient/ soldier (Orme and Doerman 2001). In this case, the case essentials provide for a dual-­agency conflict: the therapist has duties to both military service and the command hierarchy, as well as clinical/ethical duties to the patient (Howe 1986). No readily-­identifiable contextual factors resolve the agency conflict of the military therapist. Even if the therapist is the commanding officer, s(he) is faced by the duty to the military-­service ethic; accentuated in the context of a war-­zone ethic where even a clinically-­compromised soldier could save lives (Camp 1993). This case of V-­I is further complicated by the interest of the impaired soldier, who may, for example, wish to return to the unit more quickly out of unit loyalty, further adding to the complex values pointing in opposing directions.

Therapist Supports BIID Treatment by Affirming Amputation Body Integrity Identity Disorder (BIID) is a condition whose very definition is under debate. Current formulations describe it as a condition in which “individuals perceive a mis-­match between their internal body scheme and physical body shape, resulting in an absolute desire to be either amputated or paralyzed” (Blom et al. 2016). BIID is sometimes dubbed “xenomelia” defined as “a rare condition characterized by the persistent and compulsive desire for the amputation of one or more physically healthy limbs” (Hänggi et al. 2017). BIID is sometimes construed for another, possibly related, condition, “apotemnophilia,” which is an eroticized version of the desire to amputate one or another limbs. That is, the desire for amputation is erotic in content (Bottini et al. 2015). As might be suspected from the disagreements about nomenclature, the conditions are poorly understood, and particularly so when considering the realm of treatment for this condition. Some authors hypothesize the conditions represent neuropsychiatric abnormalities in the brain

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164   Legitimate and Illegitimate Imposition of VALUES (Craimer  2009), while others argue for learned or developmentally-­acquired etiologies (Jotkowitz and Zivotofsky 2009). Accordingly, the former aim for treatments directed at the brain pathology, while others, sometimes analogizing the condition to transgender conditions, recommend surgical removal of the offending limb(s) as treatment. Hence, we present the V-­I case of a patient who seeks assistance for BIID, with a therapist who believes, justified or not, that surgical amputation is the appropriate treatment. Rather than exploring the psychological territory and ambivalence about treatments with the patient, the therapist embarks upon a project to ready the patient for surgical treatment, taking care to address related psychopathology, if any. So, the values-­imposition here is based upon uncertain clinical/scientific knowledge at best, and with the current state of knowledge, the ethicallycorrect path to take is ambiguous. In our view, to advocate pre-­emptively for one or another viewpoint vis-­à-­vis surgery is a good example of a dubious V-­I. Dubious because the right decision is not discernible or feasible given the current state of knowledge.

“It Depends” V-­I Cases For our first set of discussions around “it depends” V-­I cases, we consider the common situation of a psychotherapist in the position of treating another psychotherapist. (Readers may want to consult Doyle’s Chapter 23 in this volume, “Dual and Multiple Relationships in Psychotherapy,” and Franke’s and Riecher-­Rössler’s Chapter 64, “Professional Competence Problems and Handling of Professional Misconduct.”) The latter, the “therapist-­patient” we will call for simplicity the “T-­P.” In both case contexts the situation of the therapist and T-­P is the same: In the course of therapy, the male T-­P reveals several sexual affairs with active patients/former patients. The V-­I question is whether the therapist should impose the value of protecting third parties (the T-­P’s patients) through reporting the boundary violations to institutions (licensing boards, professional societies, healthcare systems) or imposing this value through other mechanisms. We provide two prototypical contexts where a therapist might consider imposing certain values upon the T-­P, because as we’ll see, the contexts make a difference in how the ethics issue of values-­imposition should be handled.

Boundary-­Violating T-­P in the Context of a Private, Self-­Referred Therapy Relationship For this context, the T-­P is self-­referred for assistance of a general complaint, such as anxiety or depression, and in the course of therapy reveals to the therapist that the T-­P has had “a few” sexual relationships with active and former patients. In this context, the treating therapist has no reporting obligation, implied or explicit, to an institution (training program, practice group, healthcare organization) that referred the T-­P for treatment of impairment. The treatment relationship is private and bound by standard confidentiality ethics (see also Maatz, Scheller, and Hoff, Chapter 22 in this volume). However, most professional ethics guidelines promote the idea of reporting impaired/incompetent colleagues (e.g., APA 2015), but often don’t specify the question of reporting impaired T-­Ps. The therapist, however, has a duty in the professional–patient relationship, but does not have a duty to the public, or the T-­P’s patients, not even of a secondary nature, as would be the case of a supervisor of

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values appropriate and inappropriate   165 T-­P. Moreover, the literature of “wounded healers” and impaired clinicians emphasize the shame and guilt characteristic of these conditions, rendering the T-­P particularly vulnerable (Zerubavel and Wright 2012). These considerations support the idea of not reporting, and conducting treatment as usual. From a consequentialist ethics perspective, the situation poses thorny problems. The public, of course, deserves to be protected from impaired clinicians. However, it’s unclear what the calculus of consequences would conclude when comparing outcomes for self-­referred, voluntary care, versus career-­damaging sanctioned care from professional licensing boards. The science for this is not available. The therapist reporting the T-­P, however, may significantly damage the treatment relationship and trust, undermining treatment in the present, and possibly in the future. Our net conclusion here is that the therapist should not report the T-­P. We mentioned alternative mechanisms in the situation. A prevailing V-­I consideration, and non-­controversial, would be that the therapist would ultimately aim to reduce the boundary violations and related goals, such as having the T-­P terminate boundary transgressions, and refer his violated patients to other therapists. We think this V-­I would be appropriate, as woven skillfully into an overall treatment arc of negotiated goals and foci of care. One alternative response from the therapist might be a V-­I to push the T-­P to self-­refer to the appropriate regulatory body, such as a licensing board. Again, from the consequentialist perspective, the foreseeable outcomes here would be complex. First, we should consider that the board is ultimately accountable not to the T-­P but the public at large; interests of the board in the practitioner’s welfare may be of secondary interest at best. If this is true, then the practitioner faces significant risk of substantive harm, materially as well as psychologically, in face of the pre-­existing vulnerability of the wounded healer. Certainly, the regulatory body may not just encourage, but require, steps we’ve already acknowledged above, such as terminating violating relationships and referring the patients elsewhere. However, the consequences of self-­disclosure to the board could include loss or suspension of licensure, a requirement for supervision of the offender, education requirements, and/or therapy. Without great confidence of a better outcome through the board route, even encouraging the V-­I to self-­report seems ethically unwarranted on the part of the private therapist. (We should acknowledge that some states or jurisdictions may have regulatory or legal requirements for reporting, which would be a powerful incentive for the therapist to report, if present.)

Boundary-­Violating T-­P in the Context of a Training-­Program/ Institutional Referral This case context involves the situation where the T-­P has been referred, presumably through being caught, of a sexual boundary violation while working in a training and/or institutional setting. Here the T-­P has been referred to the therapist with an explicit directive from the program to address the T-­P’s mental health needs, and specifically those involved in transgressions. So, in this context, the therapist is the agent of two interests—one being the T-­P’s, and the other, the training program/institution. In this setting, the treatment arrangement has some stipulated, explicit, and likely written-­out, reporting requirement, mutually agreed-­upon by the therapist and the T-­P. The “consent” of the T-­P might be characterized as fragile, in that the consequences of non-­consent might be so severe that not consenting would be devastating professionally (e.g., dismissal from the training program,

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166   Legitimate and Illegitimate Imposition of VALUES loss of healthcare system privileges, loss of job). In this context we could say that the therapist is the “agent” of two masters—the patient and the institution. The latter master, the institution, has a stipulated, restricted authority for treatment information and adherence, and the T-­P has the remaining authority in the treatment relationship. The values-­imposition, in this context, is the therapist’s agreement to participate in treating and reporting about the T-­P under this contractual or mutually agreed-­upon arrangement. In some ways, this case context is less ethically complex for the therapist, because the risk of harms to the T-­P shifts away from the therapist’s actions and decisions. Decisions for reporting are shifted away from the therapist and transferred to the training program/institution, which should have administrative structures and policies for addressing clinician impairment. Moreover, the strong arm of terminating and referring violating relationships has shifted away from the therapist and into the training program/institution. The therapist, however, may still find herself in the position of being the reminder of the T-­P of the goal of adequate professional conduct, given the likely ambivalence the T-­P may feel about the fragile and coercive elements of his treatment and consent for reporting. The therapist’s V-­I of being the “reminder” of treatment goals we would endorse as justifiable, with some reservations perhaps about the fragile nature of the consent.

Therapist Recommends a Mode of Therapy (e.g., Psychodynamic, CBT, Medications) This situation is likely so common as to be ubiquitous in psychotherapy practice. What makes the recommendation of a mode of therapy a V-­I issue is that therapists are seldom trained and competent in all prevailing modes of psychotherapy. For this discussion, we make three broad assumptions. For the purposes of this analysis we assume that the prevailing or dominant modes or methods of Western psychotherapy are supportive, psychodynamic/ psychoanalytic, cognitive-­behavioral therapy (CBT), group therapy, and family/systems therapy. Moreover, while many therapists, such as psychologists and psychiatrists, are exposed to these five modalities/formats in their training, we are assuming that few therapists go on to practice these modalities in approximately equal frequencies—that is, few to none carry 20 percent of their cases in each modality. The third assumption is that most therapists end up practicing one or two of these modalities and eschew the others, with infrequent exceptions. We could not find empirical studies that either confirm or refute these assumptions. Under these assumptions then, we believe a fair conclusion is that most therapists do not provide psychotherapy by pure indication—the mode of therapy either empirically (through clinical research studies) or theoretically most appropriate (as in multi-­modal and related therapies) to the patient’s personhood and condition—but rather provide therapy which the therapist feels most comfortable and competent in providing. In this instance, which we suspect is very common, the therapist is imposing the values of her preferred mode of therapy on the patient. The matter relates to the issue of informed consent in psychotherapy, which is taken up in the chapter by McKean, Trachsel, and Croarkin in this volume. Here, consent relates to disclosing of alternative therapies instead of the therapist’s preferred modality, potential referral elsewhere to therapists that practice the best-­indicated therapy, and explaining the

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values appropriate and inappropriate   167 risks/benefits of proposed and alternative psychotherapy modalities, if known. We also suspect these practices of disclosure, referral to other therapists on the basis of indication for therapy modality, and explaining risk/benefits, are also uncommon, or at least not ­universally practiced. So, the core V-­I we examine in this “it depends” example is that of the therapist imposing her own preferred mode of therapy on the patient. What might be the factors to consider in the ethical justification of this, presumably common, practice? We can identify quite a few: (a) Comparative evidence-­base for each modality. Each modality may have a stronger, or weaker, evidence base across all psychiatric conditions—what we might call the “global” evidence base. Presumably, therapists should recommend therapies with a stronger global evidence base over weaker. However, other factors may supervene as considerations in treatment selection, see Chapter 24 by Sadler (treatment selection) and Chapter 19 by Phillips and Sadler in this volume for more discussion. (b) Comparative indication of a modality for a given clinical problem (diagnosis, symptom). Readers of the psychotherapy clinical research literature will recognize that some conditions, such as a DSM-­based major depressive disorder, have more psychotherapy research studies built around that condition, than other DSM diagnoses/ conditions. Similarly, some psychotherapies, such as CBT, have a stronger research base for phobic disorders, than say, for example, schizophrenia. Presumably, therapists should recommend therapies with a strong research base for their patient’s diagnosis or symptom. (c) Patient preferences, if any. The ethics of informed consent would imply that patients themselves should have some input about what therapy is administered with them. Presumably, therapists would want to respect patient preferences and values, consistent with evidence-­based practice (APA Presidential Task Force 2006). (d) Therapist competence in a particular therapy modality. (e) Possible indications for medication treatment or evaluation for underlying medical conditions. Patients, particularly those who self-­refer for psychotherapy, may seek treatment for a condition which they don’t understand fully. Coming to a mental health professional means that some burden of responsibility is borne by the clinician to assure that potential complicating or even defining conditions of the patient’s case are addressed. This could include, for example, a depressed patient needing medication in addition to psychotherapy, or even a patient with the fatigue and disinterest in life from undiagnosed hypothyroidism requiring medical treatment instead of psychotherapy. Presumably therapists would advocate for effective and comprehensive diagnosis and treatment for their patients. (f) Self-­interest, financial or otherwise, of the therapist. Therapists may be tempted to offer their preferred modality to patients even when other factors weigh against it. Doctor M may need to fill up his schedule for income purposes, and may ignore referring patients elsewhere, even when a more effective or empirically-­validated treatment is known and available from other clinicians. Presumably, therapists would set aside such self-­interest in recommending care to a patient. However, to assume that therapists’ self-­interests are always set aside would be naïve.

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168   Legitimate and Illegitimate Imposition of VALUES (g) Risk to patient. Some therapies may pose greater risks to the patient. For example, while response-­inhibiting exposure therapies have a strong evidence base for obsessive-compulsive disorder, the treatment is anxiety-­provoking and often unpleasant for the patient. Presumably therapists would consider risks of the preferred modality in ­recommending such. (h) “Therapy X is what I do.” Some therapists may address some of these V-­I concerns about simply informing the patient, even before an appointment, that a particular therapy modality is what the therapist practices, letting the patient decide if therapy X is for her. At first examination, this approach is appealing, through preserving both the therapist’s preference and the patient’s choice—to take it or leave it. However, what knowledge the patient bases her decision upon is uncertain, and we might suspect that a symptomatic, vulnerable, and distressed patient may be all too willing to accede to what a potential caregiver offers. Stated differently, while the patient may consent to the “therapy I do,” the element of being informed before consenting may be absent with this therapist posture. With a true informed consent process, therapists have some responsibility to disclose alternative treatments, including those they do not perform themselves. (i) The relative risk of a therapist incompetently practicing a non-­preferred therapy with a patient who has a strong indication for the non-­preferred therapy. So how might therapists assess the ethical appropriateness of imposing their preferred therapy on each of their unique patients? We argue that no standard set of rules can be applied here. Given these (only) nine factors to consider about assessing the appropriateness of imposing one’s preferred therapy modality, and ignoring interactions and weighting among the factors, we calculate over 362,000 permutations of these factors, making a case-­by-­case calculus of appropriateness of the V-­I impossible for ordinary clinicians without supercomputers—that is, all clinicians. It depends, indeed! However, some examples of clearly inappropriate versions of this situation can be mentioned. A therapist who practices a one-­size-­fits-­all therapy with all patients is not just on feeble ethical ground, but is not likely to retain many patients. A therapist is in the wrong when routinely ignoring the potential for severe mental disorders and medical diseases contributing to a patient’s ills. A therapist is wrong in exploiting dependent patients solely for the fees generated. A therapist is unethical when persisting in a given therapy modality despite unremitting worsening of the patient’s status. Other examples are, of course, possible, and often addressed in ethics guidance promulgated by professional associations. In another chapter (24) in this volume, Sadler discusses the ethics of psychotherapy treatment selection in explicit detail. Encountering a similar, dizzying number of factors encountered in this brief discussion, Sadler appeals to a virtue ethics approach in psychotherapy modality and format selection. Virtue ethics refers to the idea that good practice results when clinicians develop and cultivate ethically-­positive character traits—virtues. The clinician virtues relevant to virtuous psychotherapy modality/format selection are: humility, phronesis or practical wisdom, self-­knowledge, perseverance/flexibility, empathy, integrity, and unselfing. The application of these virtues is considered in more detail in Laney and Brenner’s chapter (11) in this handbook, and interested readers may want to consider this section’s examples in light of that chapter.

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values appropriate and inappropriate   169

The Training Director Tells You You Don’t Have Enough (Psychotherapy) Experience with a Particular Psychotherapy Modality to Graduate/ Qualify/Satisfy Requirements Many, perhaps most, training programs in clinical psychology, clinical social work, and psychiatry typically require a targeted amount of cases and supervision in two or more of the prevailing psychotherapy modalities (see, for instance, the US ACGME RRC Requirements for Psychiatry [PR IV.B.1.(b).(1).(b).(ix)] (2019), https://www.acgme.org/ Specialties/Program-­Requirements-­and-­FAQs-­and-­Applications/pfcatid/21/Psychiatry). This training requirement then sets the stage for the likelihood for a trainee to have a values conflict between the patient’s indication for a particular modality, and the trainee’s need to fulfill a psychotherapy modality training requirement. For example, a patient whose depression indicates CBT as the preferred modality may be assigned to a resident who needs a patient for psychodynamic therapy. To treat such a patient with the latter then constitutes a V-­I. (Another way of conceptualizing this ethical conflict is as a conflict of interest. In this case, the primary interest, the patient’s welfare, is competing with the secondary interest, the trainee’s requirement.) Granted, training programs with an overabundance of patients needing any and all psychotherapy modalities may exist, but we have found this values conflict is common in programs without an overabundance of patient/clients. The “it depends” quality of such a case disappears most obviously with the occasion that the therapist’s training need happens to be aligned with the patient’s therapy indication; here the patient and therapist interests are aligned. In this situation, proceeding with the therapy is appropriate. However, what about the case of a mismatch of training need and patient indication? For this case “it depends” applies as well, but the situation we would identify as ethically problematic from the beginning. However, mitigating factors may apply to this V-­I which we considered in the section above, which may make the conflict of interest more acceptable. These mitigating factors might include: the trainee may charge reduced fees; the trainee is likely supervised by an experienced senior clinician, conferring additional benefit to the patient, empirical research on psychotherapists challenges the assumption that increased experience is a reliably positive predictor of outcome (Goldberg et al. 2016), and likely other factors. Here we again appeal to a virtues approach in addressing this issue. Moreover, we would also call out for psychotherapy training programs to address this problem through administrative structures or other means.

Therapist Recommends Divorce to a Patient On the face of it, this case situation seems an unlikely candidate for the “it depends” section, and more appropriate for the “inappropriate V-­I” section. However, the literature as well as professional guidance point to some situations where advice to divorce is supported. We found two studies that conducted surveys of therapists’ attitudes toward recommending divorce in therapy. In the older study, Brock and Coufal (1994) conducted a survey of members of the American Association for Marriage and Family Therapy (AAMFT) and their practices concerning recommending divorce, staying married, or staying neutral around the issue. In their national sample of AAMFT members, 17.6 percent of respondents “at least sometimes” encouraged divorce. In contrast, 49 percent “at least sometimes” recommended staying in the marriage, and 57 percent of those thought that this recommendation was

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170   Legitimate and Illegitimate Imposition of VALUES ethical “at least sometimes.” Five years later, Wall et al. (1999) explored the attitudes of 1,035 self-­identified marriage and family therapists in the United States. The investigators framed the question of therapist recommendation for divorce more precisely: 2.4 percent of the respondents endorsed recommending divorce “when it is psychologically best for the individuals” versus “I am committed to preserving marriage and avoiding divorces whenever possible,” while 37.2 percent endorsed neutrality (Wall et al. 1999: 43). The underlying message here is that therapists find that in some cases, recommending divorce is warranted, and perhaps, in more select cases, even ethically desirable. So, what might be the (ethical) rationales for recommending divorce? The 2015 edition of the AAMFT Code of Ethics provides a partial answer: in section 1.8 “Marriage and family therapists respect the rights of clients to make decisions and help them to understand the ­consequences of these decisions. Therapists clearly advise clients that clients have the responsibility to make decisions regarding relationships such as cohabitation, marriage, divorce, separation, reconciliation, custody, and visitation” (AAMFT 2015: 4). Here the therapist role is the facilitator, not the decider. Margolin et al. (2015: 1312) provide the general guidance that “The therapist’s job is to help the couple work through these [relationship] issues, not for the therapist to provide opinions on who is right.” The authors go on to recognize the potential for therapists to impose their own values: “Thus, therapists must be mindful of their own values regarding divorce versus ‘saving relationships’. ” They continue: The therapist may have specific recommendations about avoiding high levels of hostility in front of the children or, when possible, minimizing instability for the children . . . However, unless the situation poses clear risk to a family member, the therapist’s role is to establish an environment in which each partner can fully consider and articulate her or his thoughts about benefits and losses related to maintaining versus ending the marriage. (Margolin et al. 2015: 1312)

The stipulation “unless the situation poses clear risk to a family member” seems here to open up the possibility that divorce could be recommended in the case of high-­risk situations for family members. While not explicitly referring to domestic violence situations, we suspect that such situations may well refer to intractable violence, typically by a male, posing unacceptable risks to women and children in the family and might well provide the space for a therapist to recommend divorce to promote the ongoing safety of other family members (Avis  1992). That the value of safety of family members, particularly children, might trump the values of therapist neutrality and the sanctity of marriage is a credible ethical argument, in our view. However, this viewpoint may not be shared by all therapists. Indeed, as Margolin et al. (2015) warn, therapists should be careful to examine their own values and patterns of their practices before recommending divorce.

Therapist Recommends Sexual Surrogacy Therapy for a Client with a Sexual Disorder This case situation is another which might well appear to be better suited to the V-­I inappropriate category. Consider the 2016 edition of the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct in Section 10.05, where a simple sentence, without qualifiers, reads: “Psychologists do not engage in sexual intimacies with

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values appropriate and inappropriate   171 current therapy clients/patients.” In the 2015 publication of the American Psychiatric Association, APA Commentary on Ethics in Practice, Topic 3.2.6 boldly states: “Sexual behavior with patients is unethical.” These strong statements against therapist–patient sexual contact seem to leave little room for so-­called “sexual surrogacy therapy.” What is sexual surrogacy therapy? Rosenbaum et al. (2014: 324) explain: “Masters and Johnson [1970] introduced the concept of surrogate partners and defined their role as partners for the duration of [sex] therapy that put the therapist’s instructions into practice and acts to model sexual comfort and confidence for the client.” Freckelton (2013: 644) explains the role of sexual surrogacy: “sexual surrogate partners . . . provid[e] assistance under the supervision of a therapist (a psychiatrist, psychologist, psychotherapist, sex therapist or sexologist) to persons with impairments and limitations in their capacity for sexual experience and expression.” Sympathetically drawn in the 2012 Ben Lewin film The Sessions, sexual surrogacy therapy remains controversial and seemingly forbidden by two mainstays of organized mental health. (We choose “seemingly” here for reasons described below.) The practice persists despite these statements. Note that the above definitional statements do not condone direct participation by a psychologist/psychiatrist/sex therapist in sexual surrogacy, but rather specify that the sexual surrogate partner is under the supervision of a degreed mental health professional. While this could be construed as a hedging technicality to avoid censure from both APAs in the United States, it does support the idea that psychiatrist/psychologist should eschew direct sexual contact in the context of a sex-­therapy treatment plan in which the sexual surrogate is a component, making sexual surrogacy treatments a threeperson endeavor. Also notable are international ethics guidelines from the World Association for Sexual Health, who offer both “guiding ethical principles” as an online document (http://176.32.230.27/worldsexology.org/wp-­content/uploads/2013/08/guiding-ethicalprinciples.pdf) and specific ethics guidelines for “sexual counselling and sexual ­psychotherapy” (http://176.32.230.27/worldsexology.org/wp-­content/uploads/2013/08/standards-­of-­sexual­psychotherapy.pdf). Neither of these documents makes specific comments about sexual surrogacy in sexual medicine; neither excluding or including such practices. Emerging from the International Society of Sexual Medicine’s (https://www.issm.info/) affiliated journal, Rosenbaum et al. (2014) provide an article intended as continuing medical education which describes the author’s clinic in Israel which provides sexual surrogacy as a treatment component. The article details the ethical precautions the clinic takes in avoiding exploitation of clients. Driven by a post-­Holocaust orientation on growth of families and rehabilitation of sexually disabled combat veterans, the author notes sexual surrogacy has been a part of Israeli sexual rehabilitation since the 1980s. Rosenbaum’s clinic operates within the ethics guidelines of the International Professional Surrogates Association, whose code of ethics is online (http://www.surrogatetherapy.org/ipsa/code-­of-­ethics/). The ethics code is extensive, and readers can review the entire document through the link. The most pertinent features for our purposes here, include (1) a requirement for the therapeutic triangle, consisting of client, surrogate, and supervising therapist; (2) the prevailing value is the client’s welfare; (3) full informed consent with the client; (4) a requirement for a temporary therapeutic relationship with the surrogate; (5) a requirement for the supervising therapist for a professional degree, certificate license, or accreditation; (6) that termination is a joint decision by all three parties; (7) the surrogate’s responsibility for communicable disease and cautions against conception; (8) a requirement for the surrogate to “maintain[ing] independent, personally fulfilling social and sexual relationships.” The Code also includes

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172   Legitimate and Illegitimate Imposition of VALUES standard psychotherapy requirements for confidentiality, privacy, and the like. With the exception of a recommendation for a grievance process, we assess this ethics code as thorough in the protection of clients. In the context of a suitably funded, professionally conscientious sexual medicine clinic as described by Rosenbaum, we would argue that such practices might well be the exception to the proscriptions against sexual surrogacy identified in other mental health ethics guidelines. Hence our placement of sexual surrogacy into the “it depends” V-­I category.

Therapist Arranges Involuntary Treatment of Suicidal Patient Here is a case which, at first consideration, might seem a transparently appropriate V-­I, in that the intention of seeking involuntary hospitalization of a patient is to save a life. However, in this case the example serves as an “it depends” example instead. The reasons for this, on brief reflection, are straightforward. First, not everyone agrees that involuntary treatment for suicidality is a humane response (Lay et al. 2011). Second, research on the safety and efficacy of involuntary hospitalization and treatment is unsettled at best (e.g., de Jong et al. 2016, 2019; Kallert 2008; Kisely et al. 2017). Third, the decision for involuntary hospitalization is a complex clinical judgment, ethically rich, which includes a range of decisions which are individually subject to question. For example, is the involuntary hospitalization a  compensation for insufficient outpatient support? Might the patient’s refusal reflect impaired decision-­making capacity? Is the clinician making an involuntary hospitalization recommendation in order to assuage his/her own anxiety about patient safety? Is the assessment of suicide risk adequate and informed? Such complexity of judgment leaves the ethics of involuntary hospitalization an “it depends” situation.

Therapist Wants to Transition to New Therapy Approach Psychotherapists competent in more than one format or modality of psychotherapy may consider transitioning a patient from one format/modality to another format/modality of therapy. This in itself may not represent a values-­imposition at all, if the transition has appropriate clinical indications and is discussed with and consented to by the patient. However, on occasion therapists may develop an enthusiasm for one mode of therapy and attempt to persuade a patient to “convert” to this modality. Phillips and Sadler, in Chapter 19 of this handbook, describes such cases, their example being a patient who had a successful and satisfying experience with psychodynamic therapy, and a new therapist encourages the patient to transition to CBT because of a “stronger evidence base.” Other contexts where transitions to a new therapy modality are encouraged by therapists might be when a therapist learns a new mode of therapy, for example, Eye Movement Desensitization and Reprocessing (EMDR; Davidson and Parker 2001). In this context, therapists may be eager to “try out” their new skills on existing patients, and thus potentially inappropriately impose this on existing patients. However, what makes this temptation an “it depends” situation depends on a fair assessment of the clinical indication to the transitioned-­to therapy, in this case, EMDR. The technique may, for instance, be applied in a patient with complex psychological trauma as an adjunct to other forms of therapy, with appropriate informed-­consent precautions. However, without justifiable clinical indications, or perhaps, an impasse with the prior course of therapy, suggesting EMDR would be an inappropriate imposition of therapist values (interest in trying out EMDR).

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Summary/Conclusions   173

Therapist Imposes Limits on After-­Hours Phone Calls We conclude our series of cases examining V-­I on the part of therapists with this very common practice (Sandberg et al. 2002). The clinical problem of frequent after-­hours phone calls can range from calls from needy patients requesting reassurance, to patients attempting to process overwhelming affects in the moment, to frank stalking and harassment behaviors. The typical justification for setting limits on after-­hours calls is to reserve clinical material for the actual psychotherapy session, along with the requirement for reasonable therapist self-­care in off hours. However common this practice is, it often is a source of worry and reflection on the part of therapists, most typically out of concerns for excluding a potentially life-­saving therapist contact with a suicidal patient. For this reason, therapists’ practice may have general principles about limit-­setting for phone calls, but often exceptions are made. A complete discussion of this complex clinical situation cannot be done here, but we can supply a few ethics-­relevant stipulations. Limit-­setting for phone calls should be discussed with the patient in advance, including the rationale for the limit-­setting. Alternative sources of support or treatment should be recommended in the context of after-­hours care. Therapists should ask themselves whether rigid adherence to limit-­setting parameters are simply serving therapist’s self-­interest, or instead, flexibly merging therapist self-­care into patient therapeutic needs (Murphy and Guze  1960). If limit-­setting is prevailingly oriented to therapists’ convenience, then this would constitute an inappropriate V-­I on the patient.

Summary/Conclusions Rather than something that should be avoided always, imposition of some kinds of values on patients often sets feasibility conditions for conducting psychotherapy. Instead, therapists should be aware of the values and interests that are overt in their practices, as well as the values and interests that “sneak” into clinical practice, and be ready to evaluate their appropriateness to the clinical situation. We have provided a number of illustrative examples of generic case situations where the impositions of values are unambiguously appropriate, unambiguously inappropriate, and the tougher “dubious” and “it depends” conditions. We have cited samples of relevant literature to support our very brief analyses, but each case is far from a comprehensive ethics treatment of the case situation. Indeed, we think that each of our illustrative case situations warrants an article-­length analysis on its own. We have not, of course, come close to addressing the myriad possibilities of value-­impositions encountered in the complex practice of psychotherapy. We hope our exemplar cases will stimulate practitioner interest in this arena, and provoke ongoing debate and analysis in the professional literature on this neglected ethics issue.

References Aldarondo, E. and Straus, M. A. (1994). “Screening for Physical Violence in Couple Therapy: Methodological, Practical, and Ethical Considerations.” Family Process 33: 425–439. Alexander, L. (1992). “What Makes Wrongful Discrimination Wrong? Biases, Preferences, Stereotypes, and Proxies.” University of Pennsylvania Law Review 141: 149–219.

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174   Legitimate and Illegitimate Imposition of VALUES American Association for Marriage and Family Therapy (2012). Code of Ethics. Alexandria, VA: Author. American Association for Marriage and Family Therapy (2015). Code of Ethics. Alexandria, VA: Author. American Counseling Association (2014). Code of Ethics. Washington, DC: Author. American Health Information Management Association (2004). Code of Ethics. Washington, DC: NASW Press. American Psychiatric Association (2014). Opinions of the Ethics Committee on the Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry. Arlington, VA: Author. American Psychiatric Association (2015). The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. Washington, DC: American Psychiatric Publishing. American Psychoanalytic Association (2018). Code of Ethics. New York, NY: Author. American Psychological Association (2009). Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Washington, DC: Author. American Psychological Association (2016). “Revision of Ethical Standard 3.04 of the ‘Ethical Principles of Psychologists and Code of Conduct’ (2002 as amended 2010).” American Psychologist 71: 900. American Psychological Association Presidential Task Force on Evidence- Based Practice. (2006). “Evidence-Based Practice in Psychology.” American Psychologist 61: 271–285. Avis, J. M. (1992). “Where Are All the Family Therapists? Abuse and Violence within Families and Family Therapy’s Response.” The Journal of Marital and Family Therapy 3: 225–232. Barnett, J. E. and Shale, E. J. (2013). “The Integration of Complementary and Alternative Medicine (CAM) into the Practice of Psychology: A Vision for the Future.” Professional Psychology: Research and Practice 43: 576–585. Bialas, W. and Fritze, L. (2014). Nazi Ideology and Ethics. Newcastle upon Tyne: Cambridge Scholars Publishing. Blease, C. R., Lilienfeld, S. O., and Kelly, J. M. (2016). “Evidence- Based Practice and Psychological Treatments: The Imperatives of Informed Consent.” Frontiers in Psychology 7: 1170. doi:10.3389/ fpsyg.2016.01170 Blom, R.  M., van Wingen, G.  A., van der Wal, S.  J., Luigjes, J., van Dijk, M.  T., Scholte, H.  S., and Denys, D. (2016). “The Desire for Amputation or Paralyzation: Evidence for Structural Brain Anomalies in Body Integrity Identity Disorder (BIID).” PLoS One 11: 1–13. Bottini, G., Brugger, P., and Sedda, A. (2015). “Is the Desire for Amputation Related to Disturbed Emotion Processing? A Multiple Case Study Analysis in BIID.” Neurocase 21: 394–402. Brock, G. W. and Coufal, J. D. (1994). “A National Survey of the Ethical Practices and Attitudes of Marriage and Family Therapists.” In American Association for Marriage and Family Therapy Ethics Casebook (ed. G. W. Brock, pp. 27–48). Washington, DC: American Association of Marriage and Family Therapy. Brown, L. S. (1991). “Ethical Issues in Feminist Therapy.” Psychology of Women Quarterly 15: 323–336. Camp, N. M. (1993). “The Vietnam War and the Ethics of Combat Psychiatry.” The American Journal of Psychiatry 150: 1000–1010. Craimer, A. (2009). “The Relevance of Identity in Responding to BIID and the Misuse of Causal Explanation.” American Journal of Bioethics 9: 53–55. Davidson, P. R. and Parker, K. C. (2001). “Eye Movement Desensitization and Reprocessing (EMDR): A Meta-Analysis.” Journal of Consulting and Clinical Psychology 69: 305–316. de Jong, M.  H., Kamperman, A.  M., Oorschot, M., Priebe, S., Bramer, W., van de Sande, R., and Mulder, C. L. (2016). “Interventions to Reduce Compulsory Psychiatric Admissions: A Systematic Review and Meta-Analysis.” JAMA Psychiatry 73: 657–664. de Jong, M. H., Wierdsma, A. I., van Baars, A. W., Van Gool, A. R., and Mulder, C. L. (2019). “How Dangerousness Evolves after Court-Ordered Compulsory Psychiatric Admission: Explorative Prospective Observational Cohort Study.” BJPsych Open 5: 1–5. Evans, K. M., Kincade, E. A., Marbley, A. F., and Seem, S. R. (2005). “Feminism and Feminist Therapy: Lessons from the Past and Hopes for the Future.” Journal of Counseling & Development 83: 269–277. Feminist Therapy Institute (2008). “Feminist Therapy Institute Code of Ethics.” Women & Therapy 19: 79–91.

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Summary/Conclusions   175 Freckelton, I. (2013). “Sexual Surrogate Partner Therapy: Legal and Ethical Issues.” Psychiatry, ­Psychology & Law 20: 643–659. Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., and Wampold, B. E. (2016). “Do Psychotherapists Improve with Time and Experience? A Longitudinal Analysis of Outcomes in a Clinical Setting.” Journal of Counseling Psychology 63: 1–11. Haldeman, D. H. (1994). “The Practice and Ethics of Sexual Orientation Conversion Therapy.” Journal of Consulting and Clinical Psychology 2: 221–227. Hänggi, J., Vitacco, D. A., Hilti, L. M., Luechinger, R., Kraemer, B., and Brugger, P. (2017). “Structural and Functional Hyperconnectivity within the Sensorimotor System in Xenomelia.” Brain and ­Behavior 7: 3. doi:10.1002/brb3.657 Howe, E. G. (1986). “Ethical Issues Regarding Mixed Agency of Military Physicians.” Social Science and Medicine 23: 803–815. Jotkowitz, A. and Zivotofsky, A. (2009). “Body Integrity Identity Disorder (BIID) and the Limits of Autonomy.” American Journal of Bioethics 9: 55–56. Kallert, T. W. (2008). “Coercion in Psychiatry.” Current Opinion in Psychiatry 21: 485–489. Kisely, S.  R., Campbell, L.  A., and O’Reilly, R. (2017). “Compulsory Community and Involuntary Outpatient Treatment for People with Severe Mental Disorders.” Cochrane Database of Systematic Reviews 3. Kocet, M.  M. and Herlihy, B.  J. (2014). “Addressing Value-Based Conflicts within the Counseling ­Relationship: A Decision-Making Model.” Journal of Counseling & Development 92: 180–186. Lay, B., Nordt, C., and Rössler, W. (2011). “Variation in Use of Coercive Measures in Psychiatric ­Hospitals.” European Psychiatry 26: 244–251. London, P. (1986). The Modes and Morals of Psychotherapy (2nd ed.). New York: Routledge. Margolin, G., Shapiro, L. S., and Miller, K. (2015). “Ethics in Couple and Family Psychotherapy.” In The Oxford Handbook of Psychiatric Ethics (Vol. 2) (ed. J. Sadler, K. W. M. Fulford, and W. V. Van Staden, pp. 1306–1314). Oxford: Oxford University Press. Masters, W. H. and Johnson, V. E. (1970). Human Sexual Inadequacy. Boston: Little, Brown. Miller, W.  R. and Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). New York: Guilford Press. Miller- Perrin, C. and Rush, R. (2018). “Attitudes, Knowledge, Practices, and Ethical Beliefs of ­Psychologists Related to Spanking: A Survey of American Psychological Association Division Members.” Psychology, Public Policy, and Law 24: 405–417. Murphy, G. E. and Guze, S. B. (1960). “Setting Limits: The Management of the Manipulative Patient.” American Journal of Psychotherapy 14: 30–47. Orme, D. R. and Doerman, A. L. (2001). “Ethical Dilemmas and U.S. Air Force Clinical Psychologists: A Survey.” Professional Psychology: Research and Practice 3: 305–311. Pope, K. S. (2015). “Record-Keeping Controversies: Ethical, Legal, and Clinical Challenges.” Canadian Psychology/Psychologie canadienne 3: 348–356. Rosenbaum, T., Aloni, R., and Heruti, R. (2014). “Surrogate Partner Therapy: Ethical Considerations in Sexual Medicine.” Journal of Sexual Medicine 11: 321–329. Sadler, J.  Z. (1997). “Recognizing Values: A Descriptive-Causal Method for Medical/Scientific ­Discourses.” The Journal of Medicine and Philosophy 22: 541–565. Sadler, J. Z. (ed.) (2002). Descriptions and Prescriptions: Values, Mental Disorders, and the DSMs. Baltimore, MD: Johns Hopkins University Press. Sadler, J. Z. (2005). Values and Psychiatric Diagnosis. Oxford: Oxford University Press. Sadler, J. Z. van Staden, C. W., and Fulford, K. W. M. (eds.) (2015). The Oxford Handbook of Psychiatric Ethics. Oxford: Oxford University Press. Sandberg, D. A., McNiel, D. E., and Binder, R. L. (2002). “Stalking, Threatening, and Harassing Behavior by Psychiatric Patients toward Clinicians.” Journal of the American Academy of Psychiatry and the Law Online, 30: 221–229. Tjeltveit, A. C. (1986). “The Ethics of Value Conversion in Psychotherapy: Appropriate and Inappropriate Therapist Influence on Client Values.” Clinical Psychology Review 6: 515–537.

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176   Legitimate and Illegitimate Imposition of VALUES Wall, J., Needham, T., Browning, D. S., and James, S. (1999). “The Ethics of Relationality: The Moral Views of Therapists Engaged in Marital and Family Therapy.” Family Relations 48: 139–149. Willbach, D. (1989). “Ethics and Family Therapy: The Case Management of Family Violence.” Journal of Marital and Family Therapy 15: 43–52. Zerubavel, N. and Wright, M. O. D. (2012). “The Dilemma of the Wounded Healer.” Psychotherapy 49: 482–491.

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Chapter 11

V irtu e Ethics i n Psychother a py Michael Laney and Adam Brenner

Introduction In 1958, Elizabeth Anscombe argued that it was simply misguided to do the kind of moral philosophy that had been done for the last several hundred years and that the prevailing concepts of moral obligation and moral duty—the moral sense of ought—should be jettisoned from our ethical language and thought, “because they are survivals . . . from an earlier conception of ethics which no longer generally survives” (Anscombe 1958: 1). That earlier conception of ethics was drawn from centuries of ecclesiastical cultural dominance embedding divine law into our ethical discourse. This discourse planted the ideas of moral obligation, proscription, and permission that continue to be invested with a specifically moral force even as we no longer generally accept their metaphysical foundation. Anscombe likened it to retaining the notion of criminal when “criminal law and criminal courts had been abolished and forgotten”—that is, when the system that gave that term meaning ceases to exist (Anscombe 1958: 6). More dramatically, Alasdair MacIntyre (1981) allegorizes this lexical change as a sort of silent ethical apocalypse. To make his point, he wants us to imagine another, hypothetical scenario in which the natural sciences were blamed for a series of environmental disasters, widespread riots destroying our books and laboratories, an ascendant political movement later executing the remaining scientists and abolishing the teaching of science in schools. Some number of election cycles or overthrows later, enlightened people attempt to revive this earlier science in fragmentary form, “knowledge of experiments detached from any knowledge of the theoretical context which gave them significance” (MacIntyre 1981: 1). We would still use terms like neutrino, mass, and atomic weight and would have memorized, as children, the periodic table and recited Euclid’s theorems. However, we would not be doing natural science in any proper sense and furthermore would not realize that we were not, though we may suspect that the terms themselves and their application were at times arbitrary. This, according to MacIntyre, was the status of a great deal of ambitiously rational ethical thought; and ironically it was the Enlightenment project with its attempt to ground morality

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178   Virtue Ethics in Psychotherapy in rationality rather than divine law that was the political movement that destroyed the context in which moral terms like duty and right derived their meaning. Kant’s categorical imperative spoke of a rational duty to adhere in the end to those same moral principles that were already embedded in our ethical language, but in doing so dislodged them from what had historically grounded them. Mill and Bentham (1987) wrote of maximizing the good, where the good was either some untenable concept of quantifiable pleasure or was somewhat arbitrarily ranked into different goods, and what counted as good was inevitably influenced by the non-­rational ethical heritage they were hoping to escape. This foundational collapse provoked Anscombe, MacIntyre, and others to do away with our unmoored notions of good and right and return to a yet earlier ethical framework—one predating ecclesiastical morality in the West—that would ground our ethical language anew. As mentioned above, Anscombe wanted to rid ought of these metaphysical trappings and begin speaking of what man ought to do or ought to be in the way that we speak of what features a particular plant ought to have or what in its environment it should seek. This would not be so much an ethical analysis in the usual sense but a conceptual one that would allow us at some point to speak of why an unjust man is a bad man and an unjust action a bad one—just as we speak of a machine running without oil as bad in a factual way—only after we have determined under what circumstances a man or action is to be considered “just” in a factual way. Her suggestion was that instead of using the rather thin and dislodged concepts of duty and right, we should talk in terms of just (or benevolent or courageous) actions and the just (or benevolent or courageous) people that perform them. Compared to duty and right, the terms justice, benevolence, and courage are thick concepts with both evaluative and descriptive components. Her philosophy was thoroughly and consciously Aristotelian, focusing on what it means to live well and the characteristics—or virtues—needed to do so. When she says, or when Aristotle says, that we ought to be virtuous, they mean that we ought to perform only those actions that could be characterized as virtuous, because not to do them would spoil life in its essentials. A principal characteristic of this virtue approach is its fundamentally teleological character; the virtues are a means to but also partly constitutive of a well-­lived life. To  distinguish this from another teleological ethic—consequentialism—it may help to reference MacIntyre (1981), who gives the example of a young boy first learning to play chess who is rewarded with candy for each match won. The boy at this point has no real interest in the game of chess itself, only the candied reward at the end. He could not be said to be playing chess well, his increasing technical skills being no more than a byproduct of his pursued aim—he can be said to win well but not play well. In time though, he may begin to value the game of chess itself and devote himself to understanding its structure, its theories, and its possibilities. He even risks losing to promote this understanding, challenging more skilled opponents or investigating new strategies and tactics for attack and defense. At this point the boy can be said to be playing chess well. In other words, virtues must be grounded in the ability to promote a well-­lived life, but virtuous activity is also itself partly an expression of living well. Clearly, a great deal of thought is needed—and has been already been devoted—to determine just what a well-­lived life is and what virtues constitute it. The well-­lived life is unlikely to be the same for everybody and would depend on one’s circumstances, opportunities, talents, and proclivities. However, this subjectivism does not need to collapse into abject relativism. Instead, what seems most important is that one’s life brings about a personal

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virtues and the psychotherapist   179 satisfaction, that “it is meaningful because it is devoted to projects that are worthwhile” (van Zyl 2018: 56). This view appears to exclude a wide variety of possible lives, even pleasurable ones, as few are likely to count as meaningful or worthwhile an existence spent in hedonic fantasy even if supported by the most faithful and advanced virtual reality. Virtue ethics seeks to clarify with some objectivity those features common to the range of well-­lived lives, particularly those features of human character that make them possible. Of course, aspects of virtue ethics have been criticized by ethical theorists of many ­persuasions, who make the argument—among others—that the oughts of virtue ethics are fundamentally the same as those of standard deontological and teleological approaches and furthermore that virtue theory can be successfully incorporated into those approaches (Louden 1984). However, we take the standard position that the oughts of virtue theory are distinct in that they are not metaphysically dependent on the notions of duty, right, and good in the way that standard deontological and teleological ethics are (Anscombe 1958). What has been generally recognized as clearly unique to virtue theory is that “the primary object of moral evaluation is not the act or its consequences, but rather the agent” himself (Louden 1984: 228). The arguments of virtue ethics have been persuasive enough that virtue ethics is now represented alongside deontology and consequentialism in introductory textbooks as a credible third perspective in approaching ethical choices. Virtue ethics approaches have been applied to law, politics, medicine, and even epistemology. Our focus will be on what this approach can tell us about the ethical practice of psychotherapy in particular. We will do so by providing an overview of the salient features of select virtues that are critical to psychotherapeutic practice.

Virtues and the Psychotherapist The ethical demands on therapists are great. At our therapeutic best, we are deeply affectively involved in a patient’s dilemmas. Such dilemmas resonate with us, and this helps us to understand them in a way that detached concern never can, no matter how technically adept we are at identifying patterns of relating and interpretive distortions. This resonance is essential if we are seeking excellence in therapy. But this also means that effective therapy can be hazardous for both therapist and patient, as this kind of deep engagement makes demands on the character of the therapist, who can behave admirably, deplorably, or somewhere in between, depending on the circumstances. Such therapist behavior may have either beneficial or deleterious effects on the patient’s health as a result. Patients may attempt to seduce us or push us away. The seduction is not necessarily erotic—they may wish to befriend us rather than discuss what is unpleasant. Alternatively, they may seek admonishment or frustration rather than change. These aims and interactions will necessarily invoke in us characteristic responses. We may be tempted to indulge them in their seduction, either because we fear their response to our pointing it out—our lack of courage—or because we too have a weakness for a particular seduction—what the ancients referred to as intemperance—or for any number of other reasons and motivations derived from our character. That any action can be interpreted as an expression of a variety of reasons and motivations— and that these putative reasons and motivations govern to some degree our moral assessment

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180   Virtue Ethics in Psychotherapy of that action—is a feature particular to virtue ethics. Consider the example of an interpretation made early in psychoanalytic treatment, that a particular man derives some primitive ­gratification from withholding what his partner desires, even to his own detriment. The interpretation could simply be true and fitting to the patient’s narrative so far. However, the timing of the interpretation could also be a reflection of the therapist’s wish to be seen as wise rather than to be helpful, or an expression of his hubris rather than humility, or evidence of recklessness rather than courage and firmness. Whichever of these is the case would likely affect not only our assessment of the therapist’s character but of the appropriateness of his actions. In the above discussion, reference has already been made to a number of virtues—courage, temperance, benevolence, truthfulness, humility—and also to corresponding vices—like cowardice and recklessness at polar extremes of courage. What is important to note is that whether something is to be counted as courageous or reckless, appropriately cautious or cowardly, depends to a great degree on the specifics of the situation. Plowing boldly ahead with an ill-­conceived interpretation or other intervention should be counted reckless, not courageous, no matter the fear that has been overcome. Moreover, holding back on making an interpretation deliberately and meticulously arrived at is not prudent but cowardly if fear drives the hesitation. As may be clear by now, the virtues tend to supplement and even depend on each other. This doctrine is known as the unity of the virtues (Aristotle  2002)—that we cannot be counted fully courageous if we do not also have the virtues of benevolence, temperance, and humility. In other words, the characterization of an act as courageous can be undermined by intemperate motivations and hubris among other vices.

Moral and Intellectual Virtues One distinction to make is between virtues that are primarily moral in nature—those that generally govern our interactions with other people—and virtues that have to do with our pursuit of knowledge or the practical application of our beliefs and intentions—the intellectual virtues (Roberts and Wood  2007). Moral virtues include courage, benevolence, and temperance as well as the ability to put another’s needs before one’s own when the occasion calls for it. Intellectual virtues include love of knowledge, practical wisdom, autonomy, and firmness but also humility and self-­knowledge. Aristotle draws another important distinction between the virtuous person and one who merely shows discipline and restraint with respect to his actions as well as between a person who lacks this restraint and one who is truly vicious. In this nosology, there are three features of any action that contribute to its moral evaluation: the agent’s desire, his considered choice, and the act itself. Virtuous people—say, with respect to temperance—not only indulge in pleasures modestly after deciding that they ought to do so: they do not even desire immodesty. The merely self-­restrained person by contrast similarly indulges himself only to the degree that reason dictates but is pained to do so because his desire for food or drink or any other number of pleasures outstrips the bounds of temperance. The person lacking in restraint would share with the self-­restrained an excessive desire for certain pleasures and the simultaneous recognition that he ought not to fully indulge them but is unable

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courage   181 to stand firm on his reason, giving way to his desire in intemperate acts. However, there are some who act intemperately not from a weakness of will but from choice—these are the  truly vicious, the potentially incorrigible. The import of these distinctions is to set apart the truly virtuous from the ambitiously so and to introduce the role of restraint and desire that will be essential in our later discussion on the education of those who are ambitiously virtuous.

Courage Courage is a virtue included on nearly anyone’s list of admirable character traits, and that it has been mentioned already several times above speaks to its paradigmatic status. Its classical scope given by Aristotle comprised those situations in which bodily harm was at risk, and courage was defined in this context as a disposition to fear only those things worth fearing in the proper amount and feeling confident only when one had warrant to do so. At one extreme of courage lies the vice of cowardice. Cowardice involves, on the one hand, fearing those things unworthy of fear as well as fearing too much what one may rightly fear, while, on the other hand, not being appropriately confident when the occasion calls for it. This is not to say that the courageous do not experience fear or are confident in every situation, only that when the goal is worthy the threat of pain is considered subordinate to that goal. A person who charged into every situation without consideration of the goal and likelihood of success would be considered rash or reckless, not courageous. Thus, the vice of rashness lies at the opposite extreme of courage, fearing too little and feeling more confident than the situation calls for. We just noted that courage deals with how we evaluate and respond to situations that risk bodily harm, but we would like to extend the scope of courage to those encounters that risk our well-­being more generally. Courage forms the vanguard of social protest—well before the ranks are filled in, conditions become less hostile, and the threat of imprisonment or public harassment wanes. It takes courage to point out error and injustice in the workplace when one’s livelihood is at stake. However, courage is also required for the kind of relationship that psychotherapy demands, which can disturb us in ways particular to the empathetic engagement with another person (Brenner and Khan 2013). As mentioned above, at our therapeutic best, we are deeply affectively involved in a patient’s life as told to us. We resonate with their dilemmas, their victories, and their losses, and it is this resonance that helps us to understand them in a way that detached concern cannot. When we resonate with what patients tells us, we don’t just understand it as a historical record of their experience but are moved by insights into possible fears and motivations that underlie the variety of troubles spanning their lives. Furthermore, we are involved not only in the life as told to us, but also as a character in a story that begins to include us. We become part of their dilemmas, part of their frustrations and losses. We will provoke anger and sadness and feel them ourselves through unintended failures as well as necessary confrontations, and at times we may find ourselves painfully lost. But not allowing oneself to be a character in another’s painful story—not saying what one should, not understanding as one should—for fear of what may happen would miss the aim of and potentially spoil the therapy itself.

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Benevolence Of course, the goal of psychotherapy is to alleviate the suffering of the patient, and the therapist possessing the virtue of benevolence would more easily achieve that aim than one who does not. It may seem natural that therapists would have this virtue in excess, but that is unfortunately not necessarily the case. People find themselves in the position of therapist for any number of reasons. Freud himself described his interest in the minds of his patients as a scientific concern more often than as a benevolent one; and one may be able to cite this interest as the source of one of his most well-­known failures in the case of Dora, whose repeated traumas went unacknowledged or even unseen (Freud 1905). That is actually one of the more charitable assessments of Freud’s motives in the development of his theory. Benevolence is a virtue that finds itself at the center of both secular and religious moralities. Aristotle devoted a portion of his Nicomachean and Eudemian Ethics (Aristotle 2002, 2013) to it, though restricted his discussion to monetary benevolence—what we might call liberality. Aquinas, who was explicitly Aristotelian, devoted questions 23 to 26 of his Summa Theologica (Aquinas 1999) to what he called charity and argued for extending one’s love of God to the altruistic love of one’s neighbor. For our purposes, the virtue of benevolence can be seen essentially as a desire and a disposition to benefit others (Curzer 2012). As a virtue, benevolence governs our attitudes toward and relationships with other people, particularly with respect to taking and giving. The giving part is relatively straightforward, but there are some useful clarifications to be made. Notably, giving benevolently is distinct from justice. Justice involves giving people what they are due with respect to fairness and moral desert. In benevolence, giving is simply meant to benefit the other person without further justification from fairness or moral desert. To continue the polarities of excess and deficit with respect to the virtues, benevolence too has vice at its polar extremes. Its deficiency, or disregard, is generally easier to recognize, and can have the therapist begin to act in ways that service intentions—conscious or otherwise—other than the benefit of the patient as in the above example of Freud and Dora. But the other extreme— let us call this vice indulgence—can have us taking on and being consumed by the role of surrogate parent or protector, similarly derailing the requisite therapeutic work. Benevolent impulses can be the source of many an errant intervention in psychotherapy, particularly those that spare the patient the pain of recognizing his own role in the conflicts in which he finds himself, to the overall detriment of his progress in the treatment. At its best, benevolence depends not only on the desire to benefit others but also on the wisdom to know when and what not to give. Benevolence also governs what we take from others; that is the benevolent person takes for himself only from appropriate sources and only to the benefit, or at least not to the harm, of others. He does not take from the needy but only from those who can afford to give. This has clear implications in psychotherapy, where the patient, in terms of emotional resources, has much less to give, particularly in a therapy that already asks so much of him. In other words, the therapeutic relationship is not mutual, and a certain amount of restraint and “unselfing” (Radden and Sadler 2010) is necessary to make it more likely that our interactions are not driven by our own interests. Boundaries can be crossed without malicious

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temperance   183 intent, but are nonetheless unconsciously motivated by using the therapeutic relationship to satisfy our own needs and desires. In the extreme, such a non-­benevolent interaction can constitute violation and exploitation.

Temperance The therapeutic relationship, for patient and therapist, has the potential to provide many gratifications, but only a few are to be endorsed; and temperance is the classical virtue that governs those temptations and weaknesses that are inherent in and potentially subversive to the therapeutic process itself. Recommendations from early in psychoanalytic history held that monetary reimbursement ought to be our only gratification, but certainly the joys of learning and a job well-­done can also be considered legitimate satisfactions for the therapist. However, there are more insidious pleasures available in the therapeutic relationship that threaten the enterprise itself. For Aristotle, the scope of temperance included touch, taste, and the whole range of sensual pleasures (Aristotle 2002). In psychoanalytic thought, the boundaries between sensual and other pleasures are fundamentally blurred. Admiration and admonishment, friendliness and frustration all have the potential to be seductions with important meanings in a patient’s story. We mentioned temperance in detailing the distinction between virtue and self-­control above—that while the merely self-­controlled person is exceedingly pained to curb his indulgence because of his immodest desire, the virtuous do not even desire immodestly. Or as Aristotle states it, “the temperate man craves for the things he ought, as he ought, and when he ought” (Aristotle  2002). These parameters of object, occasion, and degree are fundamental in understanding the virtue of temperance, and we can go wrong with respect to any of them. Fundamentally, temperance governs pleasure and desire, and psychoanalytic therapy is in many ways the understanding of, without acting on, desire, whether it be the patient’s or  the therapist’s. There will be seductions and there will be temptations to respond, so temperance in psychoanalytic treatment is not the lack of pleasure and desire but rather concerns the pain of unsatisfied desire. How pained are we to forgo certain pleasures when they constitute resistance to working more meaningfully and deeply? At one vicious pole is the intemperate, self-­indulgent person, whose longing for friendship, admiration, recognition of expertise, or any number of other pleasures, up to and including the frank exploitation of the patient for monetary or licentious gain, can distract from the proper work of psychotherapy and distort, derail, or even destroy therapeutic intention. The opposite of self-­indulgence can sometimes be difficult to appreciate and has often been overlooked or even supposed not to exist. In the latter case, for someone not to experience pleasure was considered inhuman (Young 1988). Called insensibility by translators of Aristotle—though numbness and indifference may jointly capture its meaning as well—it is the inability to be moved by or experience pleasure and would describe those people who are unable to experience the joys of a patient’s story unfolding and the recognition of thematic unities that in some ways are dependent precisely on being enthralled by the narrative and therapeutic process itself.

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Phronesis Phronesis, generally translated as practical wisdom, is unique among the virtues not only in that its scope includes the entirety of human life and action but is considered a meta-­virtue to be found in the proper application of all other virtues (Radden and Sadler 2010). Practical wisdom elevates what are merely naturally courageous or benevolent dispositions to the status of proper virtues. For while we may “have the natural dispositions to these qualities, without thought . . . one may be led astray by them, as a strong body which moves without sight may stumble badly” (Aristotle 2002). Practical wisdom is different from mere cleverness, for practical wisdom not only comprises deliberation and skill with respect to chosen ends but the perception of what matters in the first place, what virtuous ends are to be sought for any given situation in its complex particularity. Above, we noted that determining whether actions are virtuous or vicious depends to a great degree on the specifics of the situation, including the motivations of the agent himself—we cannot be considered courageous if we offer an ill-­conceived interpretation despite our fear, nor prudent if we hold back on making a considered one because of that fear. Furthermore, the characterization of an act as courageous can be undermined by intemperate ends and a variety of other vices. For example, we are pained to call an executive courageous who embezzles funds despite the risks. In the same way, ends that may be appropriate and the height of benevolence in one case may be wholly inappropriate and deleterious in another. A therapist seeing a mostly healthy patient for many years with the goal of fundamentally changing basic patterns of relating would likely approach a patient’s report of family conflict very differently than he would a man in crisis who was having thoughts of suicide after recognizing the effect that his chronic mental illness has had on his family. In the former case, it may be the height of benevolence to help the patient see his own contribution to the conflict despite the risk of provoking guilt and remorse. However, for the person in acute crisis, interventions focused on making the patient aware of his role in family hardships could hardly be expected to be helpful. So recognizing what constitutes benevolence in any one context is necessary to fully instantiating that virtue. That is to say that ends matter in the instantiation of virtue, and phronesis is that virtue that allows us to see what ends matter in what cases and how best to achieve them. We have spoken repeatedly of the interdependency of the virtues, but clearly virtues can be in conflict as well, and practical wisdom forms the basis for moral perception of apposite values and deliberation about achieving them. In any psychotherapeutic treatment, the reality of plural and conflicting values frequently impresses itself on us. When a patient tearfully loses himself in speaking of his father’s callous, almost thoughtless, dismissal, the therapist is faced with complex values to consider. Whether to speak at all, or what to say— silence, support, exploration, or interpretation—will fundamentally depend on the ultimate goals of the therapy, but more particularly on what the patient needs at that moment in the treatment to permit progress toward those goals. The therapist may see that in this case, the therapist’s stated recognition of the pain of those childhood moments would be the only way the patient could bear to continue. Alternatively, he may explore with the patient how

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sophia   185 his conflict with superiors at work represent preemptive strikes against perceived new editions of this callous father, contingent on his own history rather than necessary ways of interacting. Making these determinations moment by moment depends upon more than a natural disposition to be kind or intelligent, but rather the wisdom that comes from years of virtuous deliberation.

Sophia Though psychotherapy can be simply defined as a treatment aimed at alleviating mental suffering, to define it this way would be an injurious and unnecessary reduction, for one of the characteristics essential to psychotherapy is the vehicle through which it achieves its aim—knowledge and understanding. When a woman comes to us professionally stalled, we want more than amelioration of her present condition. We want to come to some understanding with her about how things came to be this way in all their complexity. We want to understand that her insecurity was encouraged by a childhood of economic and political subjugation, that she felt guilt in distancing herself from the mother who symbolized this subjugation, and that both conspired to make professional achievement deeply conflicted. Coming to this understanding is certainly not without difficulty. A number of vices threaten to undermine this inquiry at every stop along the way. For this reason, love of knowledge in itself—what classical authors called sophia—and the virtues attendant to it are central to the psychotherapy process. Love of knowledge drives not only the difficult proc­ ess of understanding another person but also motivates the sometimes laborious theoretical and technical research necessary to the continual growth of our therapeutic abilities. Of note, both phronesis and sophia could be translated as wisdom, but sophia, in contrast to the practical wisdom of phronesis, is the wisdom that deals with knowledge of the world and the things within it. Mathematics and biology would fall under the purview of sophia but so would the nature of human life and understanding of a single patient’s expression of it. As with the above virtues, sophia lends itself to its own vicious polarities. Of course, identifying stubborn ignorance as a vice is straightforward enough. Making no effort to understand the theoretical underpinnings of our therapeutic work or to understand the particular truth of a person’s experience threatens our ability to be effective in that work. When a man tells us of his intense childhood, full of longing for his father’s admiration, we have to be curious not only about the details of their relationship but come to understand what his longing has to do with seeking therapy. On the other hand, the interpretive wizardry that accompanies sophistry—which we may call a vice—can sometimes be difficult to differentiate from the thoughtful, informed comments of the epistemically virtuous therapist. However, sophistry is that cleverness and theoretical ingenuity not tempered by a focus on discovering what is fundamental and true. In sophistry, the use of knowledge is not for the benefit of the patient but rather the benefit of the therapist as a means to impress for narcissistic gratification. Importantly, love of knowledge is more than simple curiosity, though a curious mind is a prerequisite for it. It is the valuing of knowledge and understanding in itself but also toward a meaningful end. We are interested in understanding how a boy’s tantalizing rejection by

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186   Virtue Ethics in Psychotherapy his father informs the sadomasochistic pull of all subsequent men in his life because this is valuable in itself and because it is in service of treatment. However, while curiosity is to be found in the most inquisitive of minds, curiosity is also found in gawkers and can thus ­serv­ice less than virtuous ends. We may pry into aspects of our patients’ lives not to understand them better or to help them understand themselves but rather to satisfy our voyeuristic desire for intimate detail or triviality. Therapists should regularly reflect on the array of possible motives for their curiosity. Thus, intemperate desires are not the only distractions to the kind of virtue-­guided inquiry required by psychotherapy. A variety of epistemic vices—ignorance and sophistry, but also dogmatism and intellectual flaccidity among others—fatally undermine our attempts to understand something true about the patient’s experience (Cassam  2016; Roberts and Wood 2007). Any patient’s experience is bound to be overwhelmingly complex. The number of moments in the vast expanse of one’s life that inform its fundamental and derivative conflicts are incompletely knowable, and on our way to even incomplete understanding lies bewilderment interspersed by moments of clarity that have to be continually revised. The epistemically virtuous therapist in these situations is forced to embrace this complexity and be intellectually firm without resorting to subjugating the patient’s narrative to some theoretical dogmatism or letting the initial formulation rigidly structure all of the patient’s subsequent communications. Dogmatism, but vanity as well, may emerge from this subjugation and rigidity. However, we must not let the complexity of an unfolding therapeutic process, through intellectual flaccidity or insecurity, or the motivated resistance of the patient, lead us to hastily abandon crucial insights into the patient’s central conflicts. So, we must be firm in our conviction that the patient holds something to be known and humble enough to recognize that any understanding we reach is temporary and necessarily incomplete.

Conclusion Aristotle wrote that character virtues come about not through natural disposition or unaided development but through the habitual exercise of virtuous actions dependent upon moral education, an education that involves the cultivation of moral perception and reasoning rather than mere shaping through repetition, punishment, and reward (Jimenez 2016). The mechanism by which a virtuous character develops is likely as varied and multiform as are the debates around it. Linda Zagzebski (2017), in formulating her exemplarist moral theory, draws upon the admiration we have for virtuous characters both to establish the foundation of her moral theory and for the practical purpose of moral education. The direct and indirect encounters that we have with admirable people—the stories we tell ourselves and hear about them— crucially shape understanding of virtuous actions and their embedded motivations. Furthermore, the emotions elicited by the stories we either tell ourselves or are told about these virtuous exemplars have the potential to capture our imaginations and motivate action (Zagzebski 2013). In our development as psychotherapists, we would do well to seek out those people we admire and understand what it is about them—the way they approach

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conclusion   187 ethical situations and the virtues they exercise in doing so—that makes them admirable in order to model ourselves and our work with patients. Julia Annas (2011) likens the development of virtue to the development through habituation of practical skills that pianists, dancers, programmers, and mechanics possess. Becoming a good chess player is an ongoing process of learning that begins early and never stops. In the same way becoming a good person and a good therapist begins with those things we learn from our parents, teachers, and culture at large—either through their roles as models or explicit instruction—but invariably has to be learned again and again as we apply it to our lives and the work we do in therapy. Didactics and dispositions are not sufficient for the development of virtue without the active and continual process of learning through doing. There will be endless opportunities in our work with patients for the practice of our skills— technical and virtuous—and like the skilled chess player, we ought to see every move as an opportunity to become more so. Particularly early on, but never irrelevant to the learner, is the supervision of this process, ideally by someone whom we admire for the virtues we hope to perfect (Brenner and Khan 2013). Modeling ourselves on those we admire and seeing every ethical decision as an opportunity to perfect our moral character are two ways in which the ambitiously virtuous can become so more fully. Psychotherapy, as already noted, is a treatment that makes a number of demands on the character, moral and intellectual, of the therapist. And it is only through the purposeful exercise of the virtues detailed above that we are able to develop the kind of character needed to achieve in therapy the kind of excellence we all ought to strive for— ought to in the sense that it is fundamental to psychotherapy itself.

References Annas, J. (2011). Intelligent Virtue. Oxford: Oxford University Press. Anscombe, E. (1958). “Modern Moral Philosophy.” Philosophy 33: 1–19. Aquinas, T. (1999). Selected Writings. New York: Penguin Classics. Aristotle (2002). Nicomachean Ethics (trans. and ed. C.  Rowe and S.  Broadie). Oxford: Oxford University Press. Aristotle (2013). Eudemian Ethics (ed. B. Inwood and R. Woolf). Cambridge: Cambridge University Press. Brenner, A. and Khan, F. (2013). “The Training of Psychodynamic Psychiatrists: The Concept of ‘Psychodynamic Virtue.’ ” Psychodynamic Psychiatry 41: 57–74. Cassam, Q. (2016). “Vice Epistemology.” The Monist 99: 159–180. Curzer, H. (2012). Aristotle and the Virtues. Oxford: Oxford University Press. Freud, S. (1905). “Fragment of the Analysis of a Case of Hysteria.” In The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 7 (ed. J. Strachey et al., pp. 7–122). London: Hogarth. Jimenez, M. (2016). “Aristotle on Becoming Virtuous by Doing Virtuous Actions.” Phronesis 61: 3–32. Louden, R. (1984). “On Some Vices of Virtue Ethics.” American Philosophical Quarterly 21: 227–236. MacIntyre, A. (1981). After Virtue. Notre Dame, IN: University of Notre Dame Press. Mill, J. S. and Bentham, J. (1987). Utilitarianism and Other Essays. New York: Penguin Classics. Radden, J. and Sadler, J. (2010). The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice. New York: Oxford University Press. Roberts, R. C. and Wood, W. J. (2007). Intellectual Virtues: An Essay in Regulative Epistemology. Oxford: Oxford University Press.

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188   Virtue Ethics in Psychotherapy van Zyl, L. (2018). Virtue Ethics: A Contemporary Introduction. New York: Routledge. Young, C. (1988). “Aristotle on Temperance.” The Philosophical Review 97: 521–542. Zagzebski, L. (2013). “Moral Exemplars in Theory and Practice.” Theory and Research in Education 11: 193–206. Zagzebski, L. (2017). Exemplarist Moral Theory. New York: Oxford University Press.

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Chapter 12

How Do Peopl e M a k e Mor a l M edica l Decisions? Eleanor Gilmore-­S zott AND Thomas V. Cunningham

Introduction This chapter covers the topic of how people make moral decisions in the context of clinical relationships. For reasons elaborated below, we focus on the contributions bioethics has made to understanding decision making in healthcare, within which we include psychotherapy. We define psychotherapy broadly to include a range of methodologies in which a patient works with a therapist to address mental health issues, whether in conjunction with or independent of pharmacological interventions. We assume that psychotherapy is a type of medical care, which makes it appropriate to draw from ethical discourse in somatic medicine, however this may vary in healthcare contexts internationally. It is important to note that we focus on the American context, though our approach is applicable in others.1 We begin with the historical, legal, policy making, and scholarly background to contemporary work on ethical medical decision making. There are many forms of patient decision making in medicine, however the pre-­eminent example of this is the practice of informed consent, which applies to the practice of psychotherapy (Saks and Golshan 2013). Crucially, there are unique challenges for decision making in psychotherapy due to potential issues with decisional capacity and competency. With the historical foundation in place we focus on the contemporary landscape of ethical decision making in the third section; importantly this includes normative and practical discourse, much of which deals with a range of theoretical issues pertaining to the concept of capacity. We discuss varying kinds of surrogate or substituted decision making to highlight important elements to the concept of capacity for decision making, and the theoretical challenge raised to this capacity by the concept of 1  For a short, yet comprehensive introduction to bioethics that includes discussion of international developments in the field, see McMillan (2018).

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190   How Do People Make Moral Medical Decisions? transformative experience. The third section explores practical interventions to facilitate decision making, including health literacy, values clarification, and shared decision making. We highlight the relationship each empirical domain has with the concept of capacity for decision making as well as bioethical principlism. In the fourth and final section we turn to a rich case analysis to demonstrate the many challenges that come with applying moral frameworks for decision making to actual patient care and possible ways to resolve them.

Informed Consent and Bioethical Principlism We make a crucial assumption that psychotherapy is a type of healthcare within the broader setting of healthcare practices, however we recognize there is room for debate on this point. From this assumption, it is appropriate to apply work on decision making in medicine to inform considerations for decision making in mental health care, including psychotherapy. Contemporary models of moral decision making in medical settings arise from the field of bioethics, following on developments in legal precedent, policy making, and humanist scholarship over the twentieth century (Faden and Beauchamp 1986; Rothman 1992). A key concept for decision making in the medical context is the practice of informed consent, the foundations of which took shape in the 1950s through developments in case law and medical ethics. The timing of this origin is the result of the social and historical context, including civil rights movements (Starr 2008), and in response to the loss of trust in the medical profession following revelations of serious abuses (Berg et al. 2001). Crucial court cases set legal precedents for the practice of informed consent, including Canterbury v. Spence and Salgo v. Leland Stanford University Hospital. Jeffery Canterbury sued his physician, Dr. William T. Spence, after surgery to repair a ruptured disk left him paralyzed; Canterbury had not been informed that this outcome was a possibility. Similarly, Martin Salgo sued Leland Stanford University Hospital following a procedure that left him paralyzed; again he had not been informed of that risk. The Salgo case establishes the importance of adequate information, while Canterbury requires patients be provided with information to enable intelligent choices. While settled out of court, Osheroff v. Chestnut Lodge is regarded to support the psychotherapy patient’s right to be informed of alternative treatment options. These cases are important elements of the comprehensive legal basis for informing patients of risks both serious and likely, as well as alternative treatment options.2 From this legal foundation, the practice of informed consent is connected to the ethical principle of respect for autonomy, whereby individuals are entitled to direct the course of their medical care through authentic, non-­coerced decision making.

2  For more information about complex, historical, legal foundations of informed consent, see Faden and Beauchamp (1986) or Berg et al (2001). For an analysis of informed consent law from a psychoanalytic perspective, see Saks and Golshan (2013).

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informed consent and bioethical principlism   191 Paralleling the legal developments that eventuated in contemporary standards of informed consent, international and American policy makers began to establish the importance of consent and respect for autonomous choice in the decades prior to the 1970s. Following World War II, the importance of free consent to participate in biomedical research was established in the Nuremberg Code (1946) (BMJ 1996), and then reiterated in the Declaration of Helsinki (World Medical Association 2013 [1964]). Following the publication of Henry Beecher’s expose documenting commonplace unethical practices by physician-­researchers in 1965, the National Institute of Health and the Federal Drug Association revised their policies governing human subjects research to include a requirement that research be overseen by institutional review boards. An unintended consequence of this policy is that it normalized committee oversight in biomedical research, which eventually made committee oversight of decision making in hospitals and other clinical environments routine, in the form of hospital ethics committees (Rothman 1992). Growing attention to ethical issues in research in the late 1960s led to the formation of  the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, which, in 1979, resulted in publication of the Belmont Report. The report is a critical moment in the American history of ethical medical decision making because it marks a key moment where policy making and humanist scholarship align in the allied development of new foundations for decision making in medicine (Rothman 1992). With his colleague, James Childress, the report’s lead author, Tom Beauchamp, expanded the positions articulated in the Belmont Report in their seminal text in bioethics, which also appeared in 1979. In Principles of Biomedical Ethics, Beauchamp and Childress first delineate their framework, which has since come to be known as bioethical principlism. On this view, there is no single moral framework that should be given priority in conceptualizing moral issues in bioethics; however, there are four principles that are shared across ­different moral theories that provide a foundation for ethical decision making in the ­biomedical context (Beauchamp and Childress 2019). The four principles are respect for autonomy, beneficence, non-­maleficence, and justice (Beauchamp and Childress 2019). Respect for autonomy captures the intuition that adult persons should be supported in making un-­coerced, authentic, and voluntary medical choices after having been provided all material information regarding the decision at issue. This principle serves as the ethical foundation for the concept of informed consent for medical treatment (Berg et al. 2001). Beneficence is the notion that medical interventions should aim to benefit the patient, and, accordingly, healthcare professionals should act with the intent of benefiting patients. Non-­maleficence conveys the concept that medical interventions should minimize treatment burdens, or harms, and, accordingly, healthcare ­professionals should act with the intent of reducing harms to patients. Together these two principles strive to maximize benefit and minimize harm to the patient. The principle of justice expresses the view that medical interventions ought to be equally accessible to those who need them, or that the distribution of medical treatment is equitable. Each of the principles is afforded equal priority and none is more important than the others. When a particular medical choice arises, the principles should be specified to show how they fit the case and then balanced against one another to delimit what options are morally permissible, insofar as they are consistent with the specified principles (Richardson 1990, 2000). This process of specification and balancing justifies choices that follow from it.

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192   How Do People Make Moral Medical Decisions? Following the initial conceptualization of bioethical principlism in the 1980s and 1990s, many scholars argued for revisions or alternatives. The most popular critique of bioethical principlism is that it overly prioritizes autonomy-­based decision making at the expense of the other principles, and further, that it unjustifiably shifts the full burden of moral, medical decision making onto patients.3 Two examples of this response, internal morality of medicine and relational autonomy, discussed below, demonstrate the point. Developing a view called the internal morality of medicine, Pellegrino argues that revisions to principlism are needed because the principles are too abstract to be readily applicable to common clinical scenarios, which Pellegrino holds ought to provide the foundation for a theory of moral decision making in clinical situations. Rather, Pellegrino describes his view of the correct foundation in terms of an idealized depiction of the physician–patient relationship, which should be oriented toward improving the well-­being of a particular patient who seeks healing (Pellegrino 2001, 2008). Consequently, Pellegrino holds that the concept of beneficence-­in-­trust provides a foundation for moral decision making, as it calls on the physician (and patient) to attend to her respect for the patient, coupled with an obligation to do good for the patient when engaging in a healing relationship. In this way, Pellegrino’s view differs from principlism in explicitly prioritizing a commitment to beneficence over autonomy when conceptualizing and making decisions in healthcare. The Gambler case illustrates Pellegrino’s view and its importance for psychotherapy: At his first appointment, a new patient presents as excited, with quickened speech and rapid movement from one idea to the next. This patient quickly tells the therapist that he has a big trip planned to Las Vegas, Nevada, where he will win millions of dollars gambling. Engaging him in discussion, the therapist learns that the patient recently started taking Zoloft (sertraline), which was prescribed by his family physician to treat depression associated with bipolar disorder. While this is their first session together, and a time typically appropriate for setting expectations and conducting informed consent, the patient’s presentation suggests he is experiencing mania as a side effect of taking Zoloft, which should be immediately addressed (adapted from Fisher and Oransky 2008). This case highlights tensions between the principles of beneficence, non-­maleficence, and autonomy, as it shows that in real time a therapist may need to consider whether explicitly pursuing informed consent for treatment is a higher priority than immediately pursuing a treatment pathway that will prevent patient harm.4 The therapist in the Gambler case 3 Importantly, autonomy, as rooted in rationality, may have special challenges in psychotherapy. Rationality is often thought to require a particular type of reasoning, in which the patient weighs the pros and cons of a choice, before reaching a conclusion. Additionally, this entails the ability to explain the reasons behind one’s choices when solicited. For example, depression or anxiety have been shown to affect decision-­making processes (Paulus and Yu 2012), which is particularly concerning for rationality accounts, as patients with these conditions may not be able to perform the tasks needed to demonstrate autonomy and complete informed consent processes. In cases where people cannot do this, it is still necessary to treat people with respect. However, there is then a further challenge to determine whether or not it is appropriate to respect their decisions. 4  Saks and Golshan (2013) present the results of a small survey (n = 62) of predominantly older, male, physician, members of the American Psychoanalytic Association working in a private practice setting, which suggest that this perceived conflict between procuring consent from patients and performing a warranted therapeutic intervention may be common in psychotherapy. However, the limitations of their sample size and make up prevent their results from confirming this intuition.

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informed consent and bioethical principlism   193 may perceive that the highest clinical priority in this situation is to determine whether the patient should cease taking his antidepressant and begin taking a mood stabilizer, in which case an urgent referral to a psychiatrist or nearby emergency medicine physician for evaluation would be prudent. The therapist may also wonder whether the Gambler is capable of giving consent to treatment at this moment, in light of his mania. She may also wonder about her professional obligation to discuss the family physician’s off-­label prescription with him or with her colleagues. Using Pellegrino’s framework, the therapist would be guided to prioritize the patient’s benefit and to make whatever recommendations or referrals are necessary to change his drug regimen. On the principlist approach, the therapist would be guided to attend to the Gambler’s capacity to consent, and to pursue consent prior to making treatment recommendations. This approach highlights an interesting issue of the timing of informed consent discussion in psychotherapy. Paradigmatically, consent should be pursued at the beginning of a therapeutic relationship (Saks and Golshan 2013). However, as the Gambler case indicates, there are situations where a patient’s presentation implies consent, and where prioritizing beneficence and non-­maleficence suggests that consent may be explicitly procured later in time, once the patient’s immediate issues have resolved and the patient returns to the therapeutic environment.5 A more significant departure from principlism is found in the concept of relational autonomy, the idea that respect for autonomy ought to be understood as being sensitive to social circumstances that promote the development and expression of autonomy and those that constrain them.6 Proponents of relational autonomy point out that “autonomy” has historically been articulated in ways that emphasize traditionally masculine traits and virtues while de-­prioritizing or remaining silent about traditionally feminine traits and virtues that nevertheless are important for the formation and expression of autonomy. In this response to principlism, autonomous agents are, as Mackenzie and Stoljar argue, “emotional, embodied, desiring, creative, feeling, as well as rational . . . [which] highlights the importance to autonomy of features of agents that have received little discussion in the literature, such as memory, imagination, and emotional dispositions and attitudes” (2000: 21). These accounts include social context and social affirmation as relevant to the expression of autonomy. The recognition of the social nature of autonomy and influence of social contexts may be of special importance in a group therapy where, in the course of treatment, a patient shares the intersubjective and social elements of one’s self as part of one’s own treatment and the treatment of other group members. The relational autonomy paradigm challenges scholars and clinicians to consider whether and how the social environment (either ­historically or presently) influences how people make moral decisions. It urges us to consider how we participate in furthering social arrangements that make it more or less difficult for agents to express their autonomy in making decisions, especially in clinical care. Additionally, relational autonomy is expressly aligned with moral psychology, and ways of thinking about moral choice that are likely to resonate with those working in psychotherapy and related fields. 5  It is worth noting that there is debate in the literature about whether or not implied consent is possible or if actions taken on the assumption of implied consent are ethical. 6  For more on relational autonomy in medicine see also McLeod and Sherwin (2000) and Sherwin (1992).

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194   How Do People Make Moral Medical Decisions?

Contemporary Approaches to Moral Medical Decision Making The current state of moral decision making in medicine is split between theoretical debates and empirical inquiry. Theoretical discourse related to decision making is multi-­faceted, with much attention paid to the topic of capacity, or the patient’s ability to form an understanding sufficient to make a decision about their care. In this section we emphasize literature on decision making in the absence of patient capacity by surrogate or substituted decision makers. By exploring different ways in which patients can lack capacity, we aim to clarify the criteria for having capacity, especially in the setting of psychotherapy and mental illness. From here we turn to an exploration of practical interventions to improve decision making, including to alter the decision-­making environment in ways that are sensitive to the relationality between patients, therapists, and the patient’s ability to authentically agree to undergo therapy. While we focus on the empirical contributions in shared decision making, health literacy, and values clarification, we do so to emphasize the current state of empirical work in decision making and its implications for psychotherapy. Before turning to our discussion of theoretical and practical issues related to decision making it is worth explicitly summarizing the general consensus on what a good decision looks like. Crucially, a good decision is free from coercion, such that the patient has not been inappropriately compelled towards or against a particular option. The patient has been provided comprehensive information about his or her care and understands varying features of the decision landscape, including risks and benefits of the proposed intervention as well as alternatives. Importantly, for a patient to possess an appropriate understanding, he or she should be able to weigh these different pieces of information in order to form a particular, personal preference that reflects his or her values and preferences. Once the patient has formed this preference the decision has been made. However, as we will see in the following two subsections, there are a number of things that can go wrong in this formulation.

Theoretical Concerns Over Beauchamp and Childress’s eight editions describing their view, bioethical principlism has evolved to accommodate the early criticisms lodged against it. However, critics continue to argue that their view overly emphasizes autonomous choice, leading to an illicit de-­prioritization of beneficence, non-­maleficence, and justice. Arguments against this approach have likewise evolved over the years, to the point where there are multiple im­por­ tant accounts of moral decision making in medicine that must be considered to comprehensively cover the prevailing views of the moment. While patients who seek psychotherapy often have the capacity to consent to treatment, therapists should be attentive to situations where this is not the case, as such cases are common in other areas of medical practice and have shaped theories of ethical medical choice. For example, consider a case where a 36-­week pregnant woman presents at a hospital emergency department complaining of abdominal pain and spotting. Her medical history shows she is being treated for schizoaffective disorder by a licensed clinical social worker affiliated

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contemporary approaches to moral medical decision making   195 with the hospital system. The obstetrician on call that day recommends fetal monitoring because an ultrasound shows no imminent complications, but her complaints are con­sist­ ent with premature labor and fetal distress. The patient refuses monitoring, leading the obstetrician and emergency medicine physician to request a psychiatry consult to evaluate her decisional capacity. In this setting, an interplay occurs as the clinicians reflect on the patient’s known mental health symptoms, current somatic issues, refusal of recommended diagnostic interventions, and uncertain capacity. In such a case, a psychiatrist or other mental health professional may be asked to issue a clinical judgment about the patient’s capacity. To do so, a clinician should be aware of ethical frameworks for assessing capacity in the setting of mental health symptoms (Baruth and Lapid 2017). Theories of ethical medical choice are best understood as distinguishing between situations where patients have decisional capacity and where they do not. For those who lack capacity, a further distinction arises between making choices for persons who previously were able to make decisions but now are incapacitated and decision making for persons who have not yet developed the capacity for medical decision making. Bioethical theory holds that decisions for patients who previously had decision-­making capacity, but are incapacitated, should be made by a surrogate decision maker in accordance with one of three different standards or processes, depending upon how much information was known about the patient’s preferences prior to losing capacity (Buchanan and Brock  1989). These standards are the stated preferences standard, substituted judgment standard, and best interest standard. Yet, while they are well understood theoretically, how well they are used in clinical practice is unclear (Cunningham et al. 2018). For example, consider the case of the pregnant mother above: If the psychiatrist on call deems her to lack capacity because she is experiencing severe depression from schizoaffective disorder, then the patient therefore loses the right to make treatment decisions for herself. A trusted loved one, such as her husband, parent, or adult sibling, should be authorized to make decisions for her so long as she lacks capacity, in a way that is consistent with local laws concerning proxy decision making in healthcare. As we will discuss more below, the licensed clinical social worker who has been caring for this woman for years may rightly feel moral distress about this situation and the move to de-­prioritize the pregnant woman’s autonomy to refuse fetal monitoring, depending upon her ethical analysis of the situation. Moral medical decision making for patients who never had the capacity to make decisions for themselves falls under a model of parental authority rather than surrogate decision making. That is, parents who must make choices for sick children differ from adults who must make choices for themselves or for other adults who previously had capacity, because parents have special relationships with their children.7 Parents are expected to raise children in accordance with the parents’ conception of the good, which entails making choices for the child’s future benefit, but not necessarily their present satisfaction (Hester  2012). Respect for parental decision making in ethics includes the parents’ ability to make decisions for their children based on their cultural or religious beliefs. For example, a parent may compel a child to attend religious services despite the child’s refusal. And a parent may 7  This analysis also applies to persons who are parents (or guardians) of adults who have never developed decisional capacity due to significant cognitive or intellectual disability. Though we speak of parents and children here, the same approach applies to decision making for adults who have legal guardians, whether the guardian is a parent or otherwise.

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196   How Do People Make Moral Medical Decisions? also compel a child to receive a vaccination, take medication for allergies, or attend therapy sessions, despite the child’s refusal. In this way, a parent may make choices for a child that the child herself deems to be coercive and against her will. This is the crux of parental authority, and why the parent–child relationship is logically different than the relationship between a proxy decision maker and an incapacitated adult who previously had capacity. However, parental authority for decision making is not absolute. Ethical and legal analysis shows that there are situations where parents should not be permitted to make decisions for their children, and, consequently, the state is justified in limiting parental authority (Diekema 2004). Many children experience symptoms of mental illness leading to a diagnosis, with the most recent estimates indicating that in the United States, “among children aged 3–17 years, 7.1% had current anxiety problems, 7.4% had a current behavioral/conduct problem, and 3.2% had current depression,” and children who are diagnosed with a mental illness are more likely to be diagnosed with other co-­morbidities indicative of poor health (Ghandour et al. 2019: 256). Thus, when engaging parents and children in making choices about psychotherapy, we recommend therapists keep in mind the differences between decision making for adults and for children discussed above. Thus far we have talked about how to make decisions for persons who were previously capable, but currently incapacitated, and instances where an individual has not yet demonstrated capacity. We will now introduce a third and distinct example of when patients may lack capacity. In this case of incapacity, the patient is unable to form preferences about a treatment situation, and so, is incapable of making a meaningful choice. Here, we have in mind the concept of transformative experience, as discussed by L. A. Paul (2014). In the case of transformative experience, a decision maker lacks the capacity to form preferences about the available options, because he or she lacks the experience that is necessary to form an authentic preference between said options. In other words, there are some experiences that are so significantly transformative that individuals lack the experience necessary to know which option they prefer, and thus lack the requisite capacity to make meaningful choices. Importantly, this incapacity is specific, rather than general, and limited to the particular decision at hand. The possibility of incapacity due to inexperience is relevant to medical decision making, and particularly to psychotherapy. Moral decision making in psychotherapy and healthcare should aim at helping patients understand the risks, benefits, and alternatives of their chosen treatment as well as what that choice will mean for their lives. When a choice is made without clear preferences, it entails the absence of meaning and this undermines the crucial moral aims of informed consent. A commonplace example of transformative experience is parenthood: Non-­parents can reflect on their possible futures as parents. Yet, they are unable to genuinely forecast about personal preferences in a future with children and accordingly cannot form meaningful preferences about becoming parents, making their claims about such preferences suspect. In this case, we can imagine a couple who thoughtfully reflects on whether to become parents. They both work long hours, make good money, and travel to faraway places many times a year. The concept of transformative experience urges us to consider whether this couple sufficiently understands whether (and to what extent) their lifestyle is consistent with the demands of parenting, and thus, what type of reasoning would be required for them to form authentic preferences about becoming parents. Similarly, it is possible to imagine that someone who has never participated in psychotherapy may not be able to form a preference about forms of psychotherapy or even to pursue psychotherapy itself.

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contemporary approaches to moral medical decision making   197 Alternatively, someone who does have experience with psychotherapy, but has never ­participated in group therapy may not be able to make an informed choice between the two. Accordingly, it is a significant worry that some patients will not be able to form the preferences necessary to appropriately make authentically, morally considerate, healthcare decisions, although the prevailing practices in medicine assume patients can readily make such choices without controversy. Another point to consider when considering capacity and incapacity is the concept and application of Ulysses contracts, wherein a person enters into a contract that restricts his or her freedom in the future. In the medical context this entails the self-­restriction of autonomy of a competent individual. This theoretical issue becomes a practical one when deciding to enforce a mental health advance directive or simply a patient’s prior commitment to a treatment plan that they now wish to alter. In this situation there is a conflict between the patient’s current wishes and previously stated goals: why ought the former wishes be respected over the present? For example, a patient taking medication for schizophrenia establishes a contract with his psychiatrist, which, should the patient go off his meds, allows the psychiatrist to enforce a medication protocol even if the patient does not meet the standards for incapacity. There are multiple justifications in the literature, including Spellecy’s account of planning based intentions (2003) and Davis’s (2008) diachronic respect for autonomy. Under each of these accounts the previous preference can be respected, not merely because that choice was first, but because the first choice facilitates the patient’s long-­term and deeply held personal goals (Spellecy 2003), and respecting the first choice allows the patient to shape his circumstances through time (Davis 2008). While there are theoretical justifications and legal strategies for overriding a competent patient’s present wishes, there are other practical concerns that would need to be considered, particularly the potential for harm to the patient and loss of trust in the therapeutic relationship. These are considerations should be discussed during the creation of the Ulysses contract or mental health advance directive, and again be considered prior to enforcement.

Empirical Investigations There are a number of empirically oriented fields working on medical decision making. While these often occur at a distance from theoretical debates, they may inform some particular goals or aims of studies. Here we discuss empirical interventions in health literacy, values clarification, and shared decision making. Each of these three perspectives can be seen as related to assessing and supporting patient capacity. To determine whether a patient has the capacity to make a decision, we need to know if other factors are hindering their reasoning process. For example, it would be wrong to conclude that a patient who reads at an eighth grade level lacks decision-­making capacity, when the written materials provided were at a college level or higher reading level. In this instance the inability to understand is due to inappropriate materials, and not the ability of the patient. Health literacy works to ensure that patients can understand the material provided to them, so that we can eliminate other possibilities when assessing incapacity. Similarly, values clarification verifies that patients understand how their values are relevant in a treatment context. Each way of understanding is part of medical decision making. However, if the patient’s understanding of the materials and application of his or her values has been verified, then an alternative

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198   How Do People Make Moral Medical Decisions? like shared decision making may be appropriate. It is also possible for approaches in these fields to come together in a particular research project or a specific moment of medical decision making. Health literacy works to facilitate medical decision making by ensuring patients understand the information that is provided to them, typically presenting information in an appropriate format that aligns with the patient’s reading level. Importantly, this area of research recognizes that the way information is provided to patients can impede their understanding, which can be a barrier to decision making. For instance, a patient may have capacity, but be unable to make a decision because the information provided includes too much jargon. Accordingly, the interventions developed and evaluated by this field aim to facilitate patient understanding of the material presented and ensure it meets the patient’s informational needs, such that with this understanding in place the patient is able to complete the reasoning tasks associated with medical decision making. Importantly, this field can work independently or in tandem with ethical theories, such as principlism. For example, understanding is considered necessary for autonomy, but we could also aim to facilitate patient understanding in order to produce better healthcare outcomes or, in other words, to increase patient benefits. In either case, the root assumption is that patient understanding is desirable and improving the amount of information or how it is presented facilitates this goal (Hammil et al. 2011; Lorenzen et al. 2008; Wee et al. 2009). Lessons from health literacy for psychotherapy would suggest minimizing jargon and terms of art when communicating with patients, and providing careful explanation when they cannot be avoided. For example, explaining the particular interventions the patient is likely to experience, as appropriate to the form of psychotherapy practiced by the provider. Other scholars have suggested that as part of the informed consent process, psychoanalysts should inform patients about concepts like transference when they arise during therapy, as well as inform patients about therapeutic methods, such as the common approach of remaining silent throughout much of a session, even to the point of not answering questions posed by the patient (Saks and Golshan  2013). This explanation may help facilitate trust and strengthen the therapeutic relationship. Another empirical domain aimed at facilitating patient decision making is the field of values clarification. In a departure from health literacy, values clarification seeks to improve the decision-­making process by bringing to light how an individual’s values apply to the decision at hand. This is relevant to respecting an individual’s autonomy, as it does not require a stretch of the imagination to believe that two individuals with the same diagnosis, but different values, would make very different treatment choices. These values can cover a range of personal preferences. For example, it may be unclear to a patient how valuing living independently or participating in quality family time relates to making decisions about entering in-­patient treatment for an eating disorder. Accordingly, poor recognition of how one’s values apply to medical decision making risks leading to decisional regret when the medical treatment is not what the patient would have preferred had they successfully applied their values to the decision. In order to overcome this barrier to decision making, an individual’s values ought to be solicited in order to discuss reasons for or against various options. This field of research seeks to improve patient decision making by clarifying the individual patient’s values and in turn their application and relevance to the particular medical decision (Fagerlin et al.  2013; Peate et al.  2013; Scheunemann et al.  2012; Witteman et al. 2016). Bringing the patient’s values to bear on the decision can be crucial for facilitating

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contemporary approaches to moral medical decision making   199 authentic, autonomous choice. However, as with health literacy, this field need not depend on a principlist justification, as there may be other reasons for determining the relevance of patient values to the decision. Values clarification and health literacy can both be complementary to principlism if they are taken to be facilitating patients’ capacity for carrying out autonomous decision making. Alternatively, a popular response to principlism moves away from this, which is the stridently empirical, practically oriented approach called shared decision making. What differentiates shared decision making from principlism is its commitment to the possibility that moral medical choice may sometimes entail clinicians or other stakeholders taking more responsibility in medical decision making than would appear to be permitted by the principle of respect for autonomy. Proponents of shared decision making reject the assumption that patients should necessarily be fully informed about their choices, and that respecting patient autonomy is a necessary component of moral medical decision making.8 Instead, in shared decision making, “clinicians and patients share the best available evidence when faced with the task of making decisions” and “patients are supported to consider options, to achieve informed preferences” (Elwyn et al.  2010). Research in shared decision making indicates patients exhibit a diverse range of preferences regarding seeking information about their illness and participating in treatment decision making (Arora and McHorney 2000; Deber et al. 1996; Ende et al. 1989; Levinson et al. 2005; Stiggelbout and Kiebert 1997). From this, it follows that clinical circumstances will arise where supporting decision making that is adequately informed requires allocating some responsibility for making choices to the clinician who counsels the patient, as opposed to solely to the patient. This way of understanding decision making permits the clinician to be more directive and more beneficently paternalistic than would be consistent with respect for autonomy, provided the clinician is in a situation where the patient’s preferences are for less information or less involvement in decision making. Under these conditions, the clinician is justified in directing the patient toward an appropriate treatment plan, despite the patient’s reluctance or refusal to engage in information processing and individual decision making, in the senses entailed by the principle of respect for autonomy. Consider the Gambler case again. A recent practice model of shared decision making describes it in terms of three steps: discussing choices, discussing options, and discussing decisions. Discussing choices requires “making sure that patients know that reasonable options are available”; discussing options “refers to providing more detailed information about options”; and, discussing decisions “refers to supporting the work of considering preferences and deciding what is best” (Elwyn et al. 2012: 1363). The key for the practicing clinician is to recognize that shared decision making invites her to explicitly discuss decision making with her patients. A clinician who adopts this approach should be clear with her patient that the patient faces a genuine decision, and that the clinician aims to share in the process, which may include being directive in the form of soliciting the patient’s values and preferences, both for information and related to different treatment options. In the case of the Gambler (see “Informed Consent and Bioethical Principlism” in this chapter), the 8  Those who advocate for the practice of nudging make a similar assumption, specifically that patients need not be fully informed. For more detail on nudging see Sunstein and Thaler (2003), Thaler and Sunstein (2009), Blumenthal-­Barby et al. (2013), Caplan (2014), Blumenthal-­Barby and Naik (2015), Nagel (2015), Ploug and Holm (2015a), Ploug and Holm (2015b), and Fridman et al. (2018).

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200   How Do People Make Moral Medical Decisions? patient’s presentation causes the therapist to deviate from the consent process out of concern. Her assessment is that she should protect him by immediately suggesting a change in his medication regimen or a referral to a physician for medical management, without fully procuring his informed consent to this treatment plan. Ideally, the therapist would collaborate with the Gambler, and they would come to an agreement on the goals and desired objectives for their work together. This ideal is consistent with both the informed consent model and the shared decision-­making model. However, the shared decisionmaking model also permits a therapist to be more directive, to assume responsibility for information processing and to act to prioritize beneficence, even to the point of de-prioritizing respect for autonomy. In this case, the therapist may use open-­ended questions, direct explanation, or other communicative methods to convey to the patient that she perceives him to be in a state of mania and that her worry about his well-­being leads her to recommend an abrupt change to his treatment regimen. There is an opportunity here for the therapist to solicit the Gambler’s desire to share in the decision-­making process. However, if, in the therapist’s clinical judgment, the Gambler is unable to share in the explicit process of identifying and agreeing on near- or long-­term treatment objectives, then she may nevertheless view his presence in her office as tacit agreement to some type of treatment, which justifies her prioritization of beneficence and consequent directive recommendation that he change his current treatment plan. This approach is consistent with shared decision making, given the facts of the case, though it falls below the ideal articulated by Elwyn and others. In this way, the Gambler case also demonstrates an affinity between the shared decision-­making model and the relational autonomy account. Just as a shared decision-­ making approach guides clinicians to reconceptualize the prioritization of autonomy common to principlism, relational autonomy also guides the clinician to question an unreflective reading of autonomy that privileges individual choice, when that is understood as choice that is idealistically isolated from the social environment. Yet, the Gambler case is one where ethical dilemmas are more patent than others. More generally, in psychotherapy, competently performing shared decision making frequently will require being more explicit about the process of decision making than when procuring informed consent, which only requires that a patient be provided all material information about his or her choice. In shared decision making, the clinician typically should think through how the decision is framed (Entman  1993) as well as discuss framing with the patient, so that the patient is involved in the decision-­making process in a way that is con­ sist­ent with his or her desire to be informed and involved. Perhaps because of this, scholars working on shared decision making in mental health care suggest that it is employed less frequently than in somatic medicine. A recent, British meta-­analysis suggests that shared decision making may benefit patients receiving care for psychosis by improving patients’ subjective senses of involvement in treatment, self-­efficacy, and autonomy, as well as reducing the frequency of medical holds for psychiatric patients experiencing future crises by advanced planning (Stovell et al. 2016). Yet, this analysis also concludes that research on shared decision making in medicine is generally based on low-­quality evidence, is understudied, and is sometimes hampered by poor implementation of research protocols designed to study the impact of shared decision making, a conclusion that is consistent with other recent reviews of the literature in mental health (Beitinger et al. 2014; Friedrichs et al. 2016) as well as more generally (Durand et al. 2014; Shay and Lafata 2015).

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moral decision making in psychotherapy practice   201 This section has discussed a range of issues, both conceptual and practical, that impact patient capacity and in turn the decision-­making process. It has established that ­meaningfully informed decision making is an appropriate goal for patients with capacity, and discussed how to facilitate decision making in the absence of capacity. While the conceptual element is crucial, we also need to provide an account of the challenges to facilitating this idealized vision of decision making. We’ve done this by highlighting interventions (health literacy, values clarification, shared decision making), which are intended to overcome or bypass hindrances to the decision-­making process. However, as we will show in the next section, even with the important contributions from these fields, moral decision m ­ aking remains a challenge.

Moral Decision Making in Psychotherapy Practice As the previous discussion indicates, there are many ways to understand moral decision making in medicine and psychotherapy. The thoughtful clinician or scholar may be excused for wishing for a tidier field of research, or a clearer account of how to make moral choices in clinical contexts, rather than a canvassing of views, which one must fit to the circumstances to make sense of her obligations for action in practice. We understand and sympathize with this wish. We too hope for a tidier conceptual landscape in the future; yet, experience shows that making moral medical decisions is often complex, complicated, and fraught. Such conditions make it reasonable that our theories of such choices lack systematization. Nevertheless, it is possible to show how our current theories of moral decision making in medicine provide guidance for a specific psychotherapy situation. Consider the hypothetical case of the Cahlan family (Box 12.1). This case is both unusual and, sadly, all too normal: While it is unusual for the trajectory of a routine case to go in this direction, seasoned therapists know that it is normal for at least some, infrequent cases to end up in unusual and sometimes ethically unsettling places. As written, this case has no resolution. It is purposefully designed to spur a reader to identify with one or both therapists (or a parent), and to promote the question, “What should I do?” To answer this question, we may draw on our discussion of moral medical choice. Established psychotherapists often know healthcare professionals working at other institutions in their community. It is possible that a therapist in the case knows a colleague at the children’s hospital and may wonder whether she should “get involved” to some degree in supporting Alyssa or her parents. One insight that follows from our discussion of moral decision making is that conceptual tools exist for thinking through this question. Using the principlist approach (see “Informed Consent and Bioethical Principlism” in this chapter), one should think both that specification and balancing are required to apply the principles to specific cases, and that one or more of the principles may apply well, helping crystallize intuitions about right action under the circumstances. Consider the principles of beneficence and non-­maleficence: Absent additional information, keeping Alyssa’s parents away from

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202   How Do People Make Moral Medical Decisions?

Box 12.1  The Cahlan case Eight weeks ago, Abbylyn Cahlan and her husband, Dexter, brought their 6-­year-­old daughter, Alyssa, to a child therapist for evaluation. Alyssa’s kindergarten teachers expressed concerns about her behavior, saying she sometimes isolates herself from other students and other times acts out without the ability to control herself. Alyssa was not enrolled in daycare prior to starting kindergarten. She spent most of her time in Abbylyn’s care, with her 4-­year-­and 18-­month-­old siblings. Initially, Alyssa’s therapist was concerned that her behaviors resulted from dysfunctional family dynamics. Abbylyn and Dexter gave the therapist consent to speak with a couples’ therapist they had been seeing for a year to work on issues of trust and responsibility. The two therapists became concerned that while Abbylyn and Dexter were working through critical issues in their relationship, they thought it unlikely that Alyssa’s behavior was explained by family dysfunction. Rather, Alyssa’s therapist suspected that Alyssa may be suffering from an undiagnosed somatic process, since her behaviors were worsening despite weekly therapy. Alyssa’s therapist referred her to a nearby children’s hospital, where she was diagnosed with spinal cancer. Alyssa responded well to treatment, although the side effects of the cancer and its treatment left her paralyzed and unable to speak, both of which were likely to improve over time. Abbylyn and Dexter responded poorly to the fear, stress, and anxiety associated with her treatment. During Alyssa’s third week of treatment, Dexter shifted to focusing on the care of their other two children at home while Abbylyn focused on Alyssa. While Dexter was absent from the hospital, Abbylyn got into a verbal altercation with the social worker assigned to Alyssa’s case, and was temporarily restricted from visiting Alyssa’s room. Furious, the next day Dexter argued with the social worker about the situation and found himself barred from visitation too. Three days came and went, without the hospital permitting the Cahlans to visit their daughter. Distraught and confused, they called Alyssa’s therapist and their couples therapist, asking both to help them. Abbylyn implored: “This isn’t right! They won’t let me see my baby. She needs us. This can’t be good for her mental health.”

her is unlikely to be beneficial to her and is likely to harm her. For a 6-­year-­old who is recovering from aggressive cancer treatment that has left her paralyzed and unable to speak, being without her parents must presumably be additionally traumatic. The question thus arises: Does a therapist have an obligation to help? On the principlist approach, healthcare providers are encouraged to cultivate moral character as they fulfill their professional roles. Moral character is defined in terms of five virtues: compassion, discernment, trustworthiness, integrity, and conscientiousness (Beauchamp and Childress  2019: 32ff.). Following Beauchamp and Childress’s analysis, a therapist’s commitment to his or her professional integrity, for example, may lead to an obligation to help the Cahlans. However, Beauchamp and Childress also distinguish obligatory responses from supererogatory ones, where the latter represent moral ideals that are to be strived for, but for which one is not blameworthy for not reaching (Beauchamp and Childress 2019: 46–48). It might be reasonable for a therapist to assess the possibility of assisting the Cahlans as being supererogatory, and in this way, morally outside the scope of his or her practice.

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conclusion   203 Another insight that comes out of our discussion emphasizes that Alyssa is a minor. A prudential therapist may wonder: Who is making medical decisions for her while she is hospitalized? If neither of her parents are permitted access to her, then, what happens if her treatment trajectory changes and she is a candidate for medical interventions? Who should decide for her? Who would give consent for a procedure? Above, we summarized literature on parental authority in medical decision making (see “Theoretical Concerns” in this chapter) and referred to Diekema’s concept of the “harm principle” as providing a method for assessing when the state is justified in limiting parental authority for making decisions (Diekema 2004). Something that a prudent psychotherapist should do in the Cahlan case is to look to Diekema’s account for guidance. What she would find is that Diekema summarizes eight steps that should be taken to evaluate whether a sufficient harm to the child has occurred or will occur such that restricting parental authority is justified. There is nothing in the way the case is written that indicates the Cahlans’ actions are likely to be harmful to Alyssa; thus, to the extent hospital personnel restrict the Cahlans’ role in decision making, they would not be justified in doing so unless additional facts emerged from those presented. For the psychotherapist who, after thinking about principlism and the harm principle, concludes that he or she should help the Cahlans in their dispute with the hospital, an important question that will follow is: How? Earlier in our discussion (see “Informed Consent and Bioethical Principlism” in this chapter), we mentioned the development of hospital ethics committees that followed out of mid-­twentieth-­century developments in research ethics. Herein lies a suggestion: A therapist might request that the ethics committee at the hospital review Alyssa’s case and evaluate whether the actions of hospital personnel are ethical. All hospitals are required to have some mechanism for ethics oversight, so Alyssa’s hospital should have one that the therapist can appeal to. The ethics committee may employee a clinical ethicist who is responsible for performing consults, the committee may perform consults, or they may use another method for evaluating the case (MacRae et al. 2005). Whichever model the committee uses, an ethics consult may lead to a resolution that is beneficial to Alyssa and reduces the harms that are likely to follow from her parents’ absence. This approach may lie within the psychotherapist’s scope of practice while permitting her to facilitate moral decision making for a child under difficult medical circumstances.

Conclusion We have surveyed the history of ethical discourse on medical decision making and summarized important responses to these developments. By highlighting the theoretical and practical arms of the contemporary work on medical decision making, a number of things become clear: There are both conceptual challenges to the theoretical possibility of meaningfully informed medical decision making, and the empirical efforts discussed embrace varying levels of optimism about facilitating this normative aim. Ultimately, this tension is further encapsulated by the difficulties of appropriately applying these concepts to cases, such that real patients can be benefited. So, to the question, “How do people make moral

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204   How Do People Make Moral Medical Decisions? medical decisions?” we answer that they do, but only to lesser or more degrees. Multidisciplinary research indicates that we better understand today how people make moral choices in medicine than we did decades ago. Yet, the state of the field also demonstrates that significant work remains to be done to improve our theories of moral choice in medicine, and evermore so, how those theories reliably and robustly apply to clinical practice.

References Arora, N. K. and McHorney, C. A. (2000). “Patient Preferences for Medical Decision Making: Who Really Wants to Participate?” Medical Care 38: 335–341. Baruth, J. M. and Lapid, M. I. (2017). “Influence of Psychiatric Symptoms on Decisional Capacity in Treatment Refusal.” AMA Journal of Ethics 19: 416–425. Beauchamp, T. L. and Childress, J. F. (2019). Principles of Biomedical Ethics (8th ed.). New York: Oxford University Press. Beitinger, R., Kissling, W., and Hamann, J. (2014). “Trends and Perspectives of Shared DecisionMaking in Schizophrenia and Related Disorders.” Current Opinion in Psychiatry 27: 222–229. Berg, J., Applebaum, P. S., Lidz, C. W., and Parker, L. S. (2001). Informed Consent: Legal Theory and Clinical Practice. New York: Oxford University Press. Blumenthal- Barby, J. S., Cantor, S. B., Voelker Russell, H., Naik, A. D., and Volk, R. J. (2013). “Decision Aids: When ‘Nudging’ Patients to Make a Particular Choice Is More Ethical than Balanced, Nondirective Content.” Health Affairs (Project Hope) 32: 303–310. Blumenthal- Barby, J. S. and Naik, A. D. (2015). “In Defense of Nudge–Autonomy Compatibility.” The American Journal of Bioethics 15: 45–47. BMJ (1996). “Nuremberg Code (1947): Doctors’ Trial, N.” British Medical Journal 313: 1448. Buchanan, A. and Brock, D. (1989). Deciding for Others: The Ethics of Surrogate Decision Making. New York: Cambridge University Press. Caplan, A. L. (2014). “Why Autonomy Needs Help.” Journal of Medical Ethics 40: 301–302. Cunningham, T.  V., Schenemann, L.  P., Arnold, R. M., and White, D. (2018). “How Do Clinicians Prepare Family Members for the Role of Surrogate Decision-Maker?” Journal of Medical Ethics 44: 21–26. Davis, J.  K. (2008). “How to Justify Enforcing a Ulysses Contract When Ulysses Is Competent to ­Refuse.” Kennedy Institute of Ethics Journal 18: 87–106. Deber, R. B., Kraetschmer, N., and Irvine, J. (1996). “What Role Do Patients Wish to Play in Treatment Decision Making?” Archives of Internal Medicine 156: 1414–1420. Diekema, D. (2004). “Parental Refusals of Medical Treatment: The Harm Principle as Threshold for State Intervention.” Theoretical Medicine and Bioethics 25: 243–264. Durand, M.  A., Carpenter, L., Dolan, H., Bravo, P., Mann, M., Bunn, F., and Elwyn, G. (2014). “Do  Interventions Designed to Support Shared Decision-Making Reduce Health Inequalities? A Systematic Review and Meta-Analysis.” PloS One 9: e94670. Elwyn, G., Coulter, A., Laitner, S., Walker, E., Watson, P., and Thomson, R. (2010). “Implementing Shared Decision Making in the NHS.” British Medical Journal 341: c5146. doi:10.1136/bmj.c5146 Elwyn, G., Frosch, D., Thomson, R., Joseph- Williams, N., Lloyd, A., Kinnersley, P., . . . Edwards, A. (2012). “Shared Decision Making: A Model for Clinical Practice.” Journal of General Internal Medicine 27: 1361–1367. Ende, J., Kazis, L., Ash, A., and Moskowitz, M. A. (1989). “Measuring Patient’s Desire for Autonomy: Decision Making and Information-Seeking Preferences among Medical Patients.” Journal of General Internal Medicine 4: 23–30. Entman, R. M. (1993). “Framing: Toward Clarification of a Fractured Paradigm.” Journal of Communication 43: 51–58.

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conclusion   205 Faden, R.  R. and Beauchamp, T.  L. (1986). A History and Theory of Informed Consent. New York: ­Oxford University Press. Fagerlin, A., Pignone, M., Abhyankar, P., Col, N., Feldman- Stewart, D., Gavaruzzi, T., Kryworuchko, J., . . . Witteman, H. O. (2013). “Clarifying Values: An Updated Review.” BMC Medical Informatics and Decision Making 13 (Suppl. 2): S8. Retrieved from doi:10.1186/1472-6947-13-S2-S8 Fisher, C. B. and Oransky, M. (2008). “Informed Consent to Psychotherapy: Protecting the Dignity and Respecting the Autonomy of Patients.” Journal of Clinical Psychology 64: 576–588. Fridman, I., Hart, J.  L., Yadav, K.  N., and Higgins, E.  T. (2018). “Perspectives on Using DecisionMaking Nudges in Physician–Patient Communications.” PloS One 13: e0202874. Friedrichs, A., Spies, M., Härter, M., and Buchholz, A. (2016). “Patient Preferences and Shared Decision Making in the Treatment of Substance Use Disorders: A Systematic Review of the Literature.” PloS One 11: e0145817. Ghandour, R. M., Sherman, L. J., Vladutiu, C. J., Ali, M. M., Lynch, S. E., Bitsko, R. H., and Blumberg, S.  J. (2019). “Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children.” The Journal of Pediatrics 206: 256–267. Hammil, S., Helitzer, D. L., and Rogers, R. G. (2011). “Health Literacy and Surgical Informed Consent.” Female Patient 36: 51–55. Hester, D. M. (2012). “Ethical Issues in Pediatrics.” In Guidance for Healthcare Ethics Committees (ed. D. M. Hester and T. Schonfeld, pp. 114–121). New York: Cambridge University Press. Levinson, W., Kao, A., Kuby, A., and Thisted, R. A. (2005). “Not All Patients Want to Participate in Decision Making: A National Study of Public Preferences.” Journal of General Internal Medicine 20: 531–535. Lorenzen, B., Melby, C. E., and Earles, B. (2008). “Using Principles of Health Literacy to Enhance the Informed Consent Process.” AORN Journal 88: 23–29. Mackenzie, C. and Stoljar, N. (2000). “Introduction: Refiguring Autonomy.” In Relational Autonomy: Feminist Perspectives on Autonomy, Agency and the Social Self (ed. C.  Mackenzie and N.  Stoljar, pp. 3–34). New York: Oxford University Press. McLeod, C. and Sherwin, S. (2000). “Relational Autonomy, Self-Trust, and Health Care for Patients Who Are Oppressed.” In Relational Autonomy: Feminist Perspectives on Autonomy, Agency and the Social Self (ed. C. Mackenzie and N. Stoljar, pp. 259–279). New York: Oxford University Press. McMillan, J. (2018). The Methods of Bioethics: An Essay in Meta-Bioethics. New York: Oxford University Press. Mac Rae, S., Chidwick, P., Berry, S., Secker, B., Hébert, P., Shaul, R. Z., . . . Singer, P. A. (2005). “Clinical Bioethics Integration, Sustainability, and Accountability: The Hub and Spokes Strategy.” Journal of Medical Ethics 31: 256–261. Nagel, S.  K. (2015). “When Aid Is a Good Thing: Trusting Relationships as Autonomy Support in Health Care Settings.” The American Journal of Bioethics 15: 49–51. Paul, L. A. (2014). Transformative Experience. Oxford: Oxford University Press. Paulus, M. P. and Yu, A. J. (2012). “Emotion and Decision-Making: Affect-Driven Belief Systems in Anxiety and Depression.” Trends in Cognitive Sciences 16: 476–483. Peate, M., Watts, K., and Wakefield, C. E. (2013). “The ‘Value’ of Values Clarification in Cancer-Related Decision Aids.” Patient Education and Counseling 90: 281–283. Pellegrino, E. D. (2001). “The Internal Morality of Clinical Medicine: A Paradigm for the Ethics of the Helping and Healing Professions.” Journal of Medicine and Philosophy 26: 559–579. Pellegrino, E. D. (2008). “The Four Principles and the Doctor–Patient Relationship: The Need for a Better Linkage.” In The Philosophy of Medicine Reborn: A Pellegrino Reader (ed. H. T. Englehardt and F. Jotterand, pp. 187–203). Notre Dame, IN: University of Notre Dame Press. Ploug, T. and Holm, S. (2015a). “Doctors, Patients, and Nudging in the Clinical Context: Four Views on Nudging and Informed Consent.” The American Journal of Bioethics 15: 28–38. Ploug, T. and Holm, S. (2015b). “Informed Consent, Libertarian Paternalism, and Nudging: A Response.” The American Journal of Bioethics 15: 10–13.

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206   How Do People Make Moral Medical Decisions? Richardson, H.  S. (1990). “Specifying Norms as a Way to Resolve Concrete Ethical Problems.” Philosophy and Public Affairs 19: 279–310. Richardson, H. S. (2000). “Specifying, Balancing, and Interpreting Bioethical Principles.” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25: 285–307. Rothman, D. J. (1992). Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making. New York: Routledge. Saks, E. R. and Golshan, S. (2013). Informed Consent to Psychoanalysis: The Law, the Theory, and the Data. New York: Oxford University Press. Scheunemann, L. P., Arnold, R. M., and White, D. B. (2012). “The Facilitated Values History: Helping Surrogates Make Authentic Decisions for Incapacitated Patients with Advanced Illness.” American Journal of Respiratory and Critical Care Medicine 186: 480–486. Shay, L. A. and Lafata, J. E. (2015). “Where is the Evidence? A Systematic Review of Shared Decision Making and Patient Outcomes.” Medical Decision Making 35: 114–131. Sherwin, S. (1992). No Longer Patient: Feminist Ethics and Health Care. Philadelphia: Temple University Press. Spellecy, R. (2003). “Reviving Ulysses Contracts.” Kennedy Institute of Ethics Journal 13: 373–392. Starr, P. (2008). The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books. Stiggelbout, A. M. and Kiebert, G. M. (1997). “A Role for the Sick Role: Patient Preferences Regarding Information and Participation in Clinical Decision-Making.” Canadian Medical Association Journal 157: 383–389. Stovell, D., Morrison, A.  P., Panayiotou, M., and Hutton, P. (2016). “Shared Treatment DecisionMaking and Empowerment Related Outcomes in Psychosis: Systematic Review and Meta-Analysis.” The British Journal of Psychiatry 209: 23–28. Sunstein, C. R. and Thaler, R. H. (2003). “Libertarian Paternalism Is Not an Oxymoron.” The University of Chicago Law Review 70: 1159–1202. Thaler, R. H. and Sunstein, C. R. (2009). Nudge: Improving Decisions about Health, Wealth, and Happiness (Revised & expanded edition). New York: Penguin Books. Wee, C. C., Pratt, J. S., Fanelli, R., Samour, P. Q., Trainor, L. S., and Paasche- Orlow, M. K. (2009). “Best Practice Updates for Informed Consent and Patient Education in Weight Loss Surgery.” Obesity 17: 885–888. Witteman, H. O., Scherer, L. D., Gavaruzzi, T., Pieterse, A. H., Fuhrel- Forbis, A., Dansokho, S. C., Exe, N., . . . Fagerlin, A. (2016). “Design Features of Explicit Values Clarification Methods: A Systematic Review.” Medical Decision Making: An International Journal of the Society for Medical Decision Making 36: 453–471. World Medical Association (2013 [1964]). “World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects.” JAMA 310: 2191.

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Chapter 13

Ex isten ti a l Phil osoph y a n d Psychother a py Ethics Alexander Noyon and Thomas Heidenreich

Introduction Existential philosophy has been crucial in the development of several psychotherapeutic “schools”—for example, Ludwig Binswanger, Medard Boss, and Viktor Frankl are considered early founders of existential approaches to psychotherapy, and more recently especially Irvin Yalom has contributed extensively to making existential thinking in psychotherapy known to therapists, counselors, researchers, and also non-­professionals all over the world (for an overview see Schneider and Krug 2017; Schulenberg 2016). As this brief list of names—it could be much longer—already implies, there is not one school of “existential psychotherapy,” and of course there is also not one “existential philosophy.” In both areas there is a vast body of highly differentiated concepts and ideas that—to make matters more complicated—regularly contradict each other. Trying to derive ethical implications for psychotherapy from existential philosophy is thus both challenging and highly interesting. Existential psychotherapists, just like therapists from other psychotherapeutic schools, come from different professional backgrounds (e.g., psychiatry/medicine, psychology, [clinical] social work, [psychiatric] nursing). Professional bodies of these professions provide detailed codes of conduct that must be adhered to by the respective psychotherapists. These rules cover areas such as therapeutic abstinence (e.g., not developing personal and/or sexual relationships with patients), professional discretion (not disclosing private information gained in the therapeutic relation with others), documentation (keeping track of therapeutic developments) and the like. Thus, professional ethics provide boundaries that are also binding for existential psychotherapists. Training in existential psychotherapy (e.g., logotherapy and existential analysis) is in some contexts also provided for non-­clinical

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208   Existential Philosophy and Psychotherapy Ethics groups such as clergy or laypersons. As these groups are not subject to the ethical standards of professions with clinical backgrounds, training of non-­clinicians has to include ethical content, e.g., therapeutic abstinence, documentation, etc. An interesting question in this context is whether there are ethical practice dilemmas specific to existential therapy? Or put in other words: Do existential therapists find themselves in ethical conflicts that are relatively unique to existential therapies? In ­general, we think that the ethical dilemmas that existential psychotherapists are ­confronted with show more commonality with than differences to other schools of psychotherapy. Yet, one theme specific to existential psychotherapy might be that dealing with existential issues very often is challenging for patients rather than providing easy  remedies for psychological conditions. Being “true” in the sense of confronting patients with an existential issue is in direct conflict with the need to support the patient, help her or him deal with the troubles of life. Existential psychotherapists have to decide when they can confront a patient and when they have to take a more caring and soothing stance. Therefore, in our chapter we will focus on the ethical aspects that go beyond or emphasize aspects of the code of conduct of different professions. In this, our task is to choose those concepts of existential philosophy that most existential therapists would agree on as being relevant to the core of their work. We point these out in the following paragraphs and deduce ethical principles for psychotherapy. A short discussion will conclude the chapter.

Key Concepts of Existential Philosophy Relevant to Psychotherapy Ethics In this section, we describe some of those key ideas of existential philosophy that are valuable in order to deduce ethical principles as guidelines for psychotherapy. The need to deduce these ethical principles from the key ideas of existential philosophy rather than just summarize them from written material arises from the fact that many existential philosophers (such as Sartre or Camus), while being strongly involved with ethical issues, never felt the need to provide a code of conduct that characterizes clinical professions such as medicine and psychological psychotherapy. Therefore, numerous philosophers have been skeptical as to whether building an existential ethical theory might even be possible (Crowe 2004). We don’t want to enter the philosophical debate here, but this might explain why we chose the path to describe key concepts of existential philosophy and deduce from them instead of citing existential ethics ideas directly. In this context, the concepts we consider to be very important are the phenomenological perspective, authenticity, the paradox of human existence, isolation, and freedom and responsibility. Of course, there are other aspects that would be fruitful to examine in detail, but the concepts listed above are, from our point of view, key concepts that are especially useful for finding ethical principles.

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Existential Philosophy and Phenomenology   209

Existential Philosophy and Phenomenology The term “phenomenology” was introduced by Edmund Husserl in the early 1900s. A thorough description of the concept cannot be provided within the scope of this chapter (for those interested in more details on Husserl and phenomenology: see Zahavi 2018, and chapter 14 in this volume). In the context of existential thinking, phenomenology means that every person has to be characterized in terms of individuality and uniqueness. Therefore, the phenomenologist is much more interested in the specific world view of a person and his or her way of perceiving the things that are surrounding us all than in general psychological principles valid for groups of people. “Understanding instead of explaining” is one of the contrasts that is helpful to grasp the idea of how phenomenologists attempt to encounter human beings. This is one of the reasons why existential therapy was developed in the first place: Founders of this approach such as Ludwig Binswanger or Medard Boss did not consider the somewhat mechanistic, deterministic, and explanation-­oriented psychoanalysis of Sigmund Freud to be appropriate to describe human beings in their wholeness. One of the goals of phenomenology in existential philosophy is to avoid any attempt to reduce human experience to elements such as drives and/or conditioning phenomena as much as possible and rather explore the way of perceiving of the individual. Applied to psychotherapy ethics, these notions mean that it is of utmost importance for the therapist to encounter the person of the patient without any preconceived assumptions and interpretations. The therapist should focus on understanding the patient as much as possible in the patient’s own world, system, way of thinking and observing, values, and so on, without judgment, simplification, or categorization. Most existential therapists would agree that only the kind of therapeutic stance described here can be accepted as being respectful, non-­reductionistic, holistic, on an eye-­to-­eye level, thus all in all authentic in the therapist–patient relationship. As van Deurzen and Adams (2016: 46) pointed out: “In  being phenomenological, the existential therapist endeavours to put aside all assumptions about what the client is saying and aims just to listen and be curious about what it all means.” Of course, this perspective is not fully consistent with at least a few positions from scientifically oriented clinical psychology. As it is portrayed here, existential psychology highlights the importance of the therapeutic relationship as the focus of what psychotherapy is all about: first of all, therapy is an encounter (which is more than just a “meeting”; the German term Begegnung is hard to translate into a single English word with the same philosophical underpinnings) between two persons who, on the one hand, share all the same existential issues (like the tension between human freedom and destiny, life and death, and so on) and, on the other hand, are living in two distinctly separate worlds, defined by how they experience the surrounding reality. Such a relationship almost automatically comes with utmost respect toward the perspective of the other human being: A phenomenological view on the world is to adopt a position from which it is easier to avoid “I am right and you are wrong” statements. The existential therapist is much more interested in the question of what is working and what is not.

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210   Existential Philosophy and Psychotherapy Ethics To state it very bluntly: It does not help you to be “right” when you are standing on the zebra crossing and a truck is barreling towards you at full speed, with the driver obviously clueless about your presence. But it very much does “work” to jump to safety. This is a very trivial example, but it highlights one of the aspects important to the existential psychotherapist: When planning your behavior, you should always take into account the facts and phenomena around you. These can be very rich and include all aspects of the world. Ludwig Binswanger (1963) differentiated the world into the personal (Eigenwelt; own world, 70), social (Mitwelt; with world, 70), and physical (Umwelt; surround world, 296) dimensions. Van Deurzen (2002) added a fourth aspect, the spiritual (Überwelt; over world) dimension. In helping clients, it is always useful to have a good idea of the dimension that is relevant at a certain time. For example, the Umwelt consists of our whole environment, including objects, the ground we stand on, the weather, and so on. If a woman loses her wedding band, then this is a loss of a part of the Umwelt. But the Umwelt aspect—at least to most people—is probably the least important aspect of a wedding band. The Mitwelt aspect might actually be much more important, as the wedding band is a symbol of one’s perhaps most important relationship, and our social life is the most important part of the Mitwelt. Also, the Eigenwelt might be affected here. This is the world of one’s inner dimension, one’s personality and characteristics, self-­esteem and self-­confidence, that is, just who we are. On that level it might be upsetting to one person to lose the wedding band, while somebody else might not be distressed at all. On the Überwelt level we can describe a person’s spiritual ideas. This is the world of the unknown, of beliefs, values, and ideas of what this whole experience of living might be about. On this level, a wedding band might be a (or in extreme cases the) symbol of meaning to a person. The wedding band example may be somewhat superficial, but it demonstrates that deeper meaning for some people may lie in objects or situations that are not so easily grasped by other persons. From an existential perspective, it is of utmost importance to have the best understanding of the world view of a client as possible—and especially in cases where the world view of the client differs significantly from that of the therapist. To have an idea of these four dimensions of our existence can be helpful to understand the world(s) our clients experience themselves in, and it helps to gain a fair, empathetic, and thereby helpful perspective of the situation as perceived by the client him- or herself. This emphasis on accurately understanding the patient’s world view is, of course, not unique to existential philosophy and psychotherapy. Cognitive therapy, for example, also emphasizes an in-­ depth understanding of the patient’s interpretation of the world.

Existential Philosophy and Authenticity As the last paragraphs have clarified, the existential therapist should place a strong focus on the relationship he or she has with his or her patient. That is not really surprising—many therapists and therapeutic systems highlight the importance of the relationship for the therapeutic outcome (see, e.g., Wiseman and Tishby 2015). But following existential philosophy and ethical thinking, it becomes clear that the therapist should immerse him- or herself as

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Existential Philosophy and Authenticity   211 much as possible in this relationship without losing the necessary distance to the patient that is needed to remain helpful. What is meant here has been pointed out by Karl Jaspers, for example, in his idea of “existential communication” (see Jaspers 1970; Salamun 1988). Jaspers highlights that human development is (at the least, substantively) about elucidating one’s own existence—that means to understand as much as possible about the conditions of one’s own life as it happens from situation to situation. One of the key moments of understanding one’s own existence is found in the situations that Jaspers called Grenzsituationen (in English sometimes translated as “boundary situations” or “ultimate situations”). Usually, these situations are associated with a personal crisis of one type or another (e.g., the death of a loved one or the experience of severe illness), but also more mundane situations such as becoming aware of personal responsibility of an act committed or omitted. These situations may cause the person to seek the help of a therapist, and then—in therapy—an encounter may happen that consists of two people engaging in what Jaspers designates “existential communication.” Jaspers (1970) assumes that encountering another human existence and engaging in honest and authentic communication is one of the most im­por­ tant means to find the truth to one’s own life (or to at least get closer to a livable truth—of course, the “whole and real truth,” serving as an always working key to life’s mysteries, is beyond reach). And only facing the truth of one’s own conditions, situations, talents, and limitations, and so on, is considered as a valid basis for an authentic life. This notion in realizing, for example, one’s own mortality can be found in many existential concepts, among them most prominently in the work of Irvin Yalom (1980). In total agreement with Jaspers and Yalom, we are convinced that a powerful stance toward death and dying, as probably the most important and radical Grenzsituation of them all, is only possible if one is in authentic contact with the underpinnings of one’s own existence and not in any kind of illusion or avoidance or neglect: “We become ourselves by entering with open eyes into the boundary situations” (Jaspers 1970: 179). This authenticity as a consequence of existential thinking can be fostered by mindfulness-­ based ideas. Bays (2011) describes fifty-­ t hree specific ideas on how mindfulness-­meditation ideas can be integrated into everyday life. One of these ideas is captioned “This person could die tonight” (reminiscent of the old Cat Stevens song “but I might die tonight”). Without the preparing ideas above that headline, this may sound weird, even offensive to a lot of people. But if the existential idea of authenticity in life in general and the notion of the meaning of death in particular are taken into account, the idea portrayed here gets a whole new distinction. The idea is to “feel” into a relationship one has toward a person, to get a feeling for the quality of the communication taking place, and then to visualize that the person that one is in contact with might die today, and to realize how one’s own feelings toward and thoughts about the person change. Everyone can do this exercise quite easily, and it is probably not surprising, after reading the ideas outlined in Bays’s book, that the feelings toward the person at hand become more positive, welcoming, forgiving, patient, maybe even “loving” (love was the most important existential issue for Karl Jaspers). An ethical principle deriving from these existential thoughts on death, dying, and authenticity is that, under normal circumstances, a therapist should focus on “disillusioning” her or his patients with regard to mortality and the option to “postpone” important aspects of life. Especially inexperienced, but also experienced therapists know how tempting it can be to just co-­avoid with a patient—sometimes in these cases therapy

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212   Existential Philosophy and Psychotherapy Ethics might resemble a tacit agreement to just navigate around the “hard topics.” Of course, therapy might feel much more comfortable to the therapist and the patient as well—but it may also be totally missing the point. And that may result in a client leading a pale, unauthentic, postponing life. We believe that one of a therapist’s primary duties is to guide a patient as far and as thoroughly as possible on his or her search for “truth,” even if this means encountering “unpopular facts.” The background to this is that reality is  always stronger than human beings are—thus living a life guided by an illusion or “wishful thinking” mostly leads to nothing but despair. That despair might come later in life, but as a rule of thumb you can state that the later it comes, the harder it hits. We prefer short-­term suffering that often is the price of an honest view into one’s own circumstances over the short-­term well-­being that might be achieved by circumnavigating all the “hot spots” in a person’s life. We do so because the former normally results in options of authentic behavior in the present, while the latter might cause deeper regrets in the future. The main purpose of any ethical debate is the question of how one should live. Existential therapy, as demonstrated here, tends to highlight authenticity as an orientation for a life lived along certain standards that are characteristic of an individual’s world view. Insofar, there are strong relations between the concepts of “authenticity” and “integrity” because the latter word describes the quality of having principal moral guidelines and the power to live by them. Authenticity from an existential perspective agrees with that but focuses on the ambivalence and paradoxes that might be present in one’s own moral map. While integrity mostly is associated with terms like “honesty,” “responsibility,” “friendliness,” and so on, we believe (and observe) that in human life also a lot less pleasant and dignified aspects play an important role, like “envy,” “laziness,” “gloating,” and so on. Of course, a moral compass helps to guide one’s life as good as possible along the concepts mentioned above. But to pretend that the other aspects do not play a role or are not existent may lead to an unauthentic life—maybe that differentiation helps to better clarify what authenticity means (e.g., in distinction from integrity). From that, ethical therapeutic conclusions can be drawn that should help a patient to lead an authentic life without neglecting inner parts that might not be too awe-­inspiring at first glance, but that are important aspects of the individual personality nevertheless. Validation of that part of the human condition we described here is most important, and also therapeutic self-­disclosure might be helpful. Of course, authenticity is a concept that can be interpreted in many ways. However, research shows that the ideas illustrated here can not only serve as a guide for therapists but can also be used in empirical studies. Boyraz, Waits, and Felix (2014), for example, were able to demonstrate a significant predictive power of authenticity (as measured with the Authenticity Scale; Wood et al. 2008) toward later measured life satisfaction (higher) and experienced distress (lower). Burks and Robbins (2012) interviewed seventeen clinical psychologists of different schools and gathered 262 statements indicating authentic aspects in the therapeutic area. “It is of note that both humanistic and nonhumanistically inclined psychologists equally valued authenticity in the professional and therapeutic setting” (Burks and Robbins 2012: 75). This finding demonstrates that authenticity serves as an important guideline for how to live your life not only to patients, but also of course to therapists—and for them both as a ground rule for living and for doing therapy.

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The Paradox of Human Existence   213

The Paradox of Human Existence As we described, the experience of Grenzsituationen can be essential in leading an authentic life. Being confronted with death, to most humans, is the most challenging boundary ­situation of all. In contemplating the meaning of death, the idea of how paradoxical our ex­ist­ence is also becomes visible: we want to live, but we all will die. And the further you look, the more you realize how paradoxical our life is in so many matters: we want to have guarantees and safety, but such assurances of any value cannot be found on this planet. We really want to “know,” but no matter how hard we try to get close to the truth, in the end we will always be left with more questions than we had in the beginning (if we are honest toward ourselves). We want to be powerful and healthy, and maybe we are, but as we age, all our potency will be taken away, part by part. We want to be “good human beings,” but the longer we live and the more we realize about life, the more we are also aware of our failings, how we hurt other people, how we cause consequences we did not want or anticipate, and what the dark sides of our own personalities are. This list could be lengthened almost infinitely—­our whole life, our very existence is characterized by paradoxes that cannot be “solved.” That is the important aspect of paradoxes: they are not mere problems that can be overcome if one tries hard enough. No matter how hard you try: in the end death will still be looming on the horizon. This paradox between life and death is probably the one outraging mankind the most. It is not by chance that humankind has been struggling against mortality since the very beginning of consciousness. And right now, there are indeed—more than ever before— scientifically based ideas of how to overcome our mortality. In 2013, Google Inc. founded Calico, a biotech company dedicated to combatting aging and, in the very end, death itself (see de Grey 2013). With Singularity University in Moffett Field, California, a whole university has been founded with the goal of developing technology that is powerful enough to address “humanity’s grand challenges” (Singularity University, n.d.). At least some of these grand challenges can be interpreted in accordance with what is described above as “paradox.” This chapter is not the appropriate place to discuss whether technological science will someday be able to overcome mortality, for example, by finding ways to transfer a human’s consciousness into a computer system (see Richard Morgan’s Altered Carbon [2001] for a science fiction approach to this topic). If one takes history as a prediction of the future— what actually seems to be the most sensible way—we can assume that mankind will develop technology beyond our wildest dreams, maybe even technology to overcome mortality. But will this solve the issue, thereby rendering mortality to a mere “problem” that can be overcome? We do not think so—as in Richard Morgan’s science fiction novel (which to some extent can be read as a philosophical treatise), the so-­called “meths” (rich people who can afford to live 200 and more years) harbor their own kind of troubles. Entirely new questions will arise, also circling around the idea of mortality, like the question of whether an endless life really is as promising as it might be at first glimpse—and in naming this aspect we have not even begun to discuss all the “technical” problems like overpopulation and so on. This brief digression focusing on mortality and death intended to demonstrate that the element of paradox seems to be inseparable from existence, no matter how far advanced we may be in our development. According to Mick Cooper, “Paradoxes . . . are

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214   Existential Philosophy and Psychotherapy Ethics contradictions in the very fabric of being that makes a final state of ‘perfection’ unattainable” (Cooper 2015: 123). As humans, we will always be facing one dilemma or another, until the end of time. This notion has a substantial impact on how to do psychotherapy from an ethical point of view. In our view, it is very important that the therapist serves as a good model in facing the dilemmas and paradoxes of the world and existence, at the very beginning by naming the fact instead of avoiding it, by, for example, living an “anything goes” ideology. Humans are free to act, but also limited; we are able to attach to other people, but some isolation will always remain; we are creative and in contact with the world, but our talents and powers only reach so far; and—of course—we live, but one day we will die. The existential therapist embodies a stance from which he or she faces all the potentials and the boundaries at the same time, and especially acknowledging the latter aspects while doing so, without resignation and despair. At this point we can see a clear connection to Acceptance and Commitment Therapy (ACT; Hayes et al. 2016), where one of the main ideas of therapy focuses on the fact that it is life-­fostering to face unchangeable dilemmas from a stance of acceptance instead of continuing to fight a losing battle. An in-­depth examination of the similarities and differences between ACT and existential approaches was carried out by Ramsey-­Wade (2015). One of the most important words in the paragraph above is “resignation.” One may think that taking into account all the boundaries, obstacles, paradoxes, dilemmas, imperfections . . . of existence can lead to resignation and frustration. Our experience as therapists shows that, in fact, it is the opposite: getting in touch with the paradoxes of the world enables us to make good choices of where to invest our energy and where not. Accepting an unchangeable, unwanted aspect of our life as being true and a fact provides us with the opportunity to start grieving about that aspect and thereby really moving one step further— after the mourning is done. Sustaining the stance that something is just a “problem” that has to be overcome no matter what it costs frequently leads to ever-­increasing regret. One is spared from mourning, but that advantage may be short-­lived. And since psychotherapy always should have long-­term development on its agenda, we consider the dilemma-­side of our existence to be a very fruitful topic for therapeutic discussion.

Isolation Interpersonal relationships are in the absolute center of almost every human being’s striving. Of course, also existential authors and therapists were and are fascinated by questions around our need to not be alone. Besides Yalom (1980), we especially value Rollo May’s (2007) thoughts about the matter, and we want to describe those aspects that from our point of view are most important in deriving ethical ideas for therapists. One of the most prominent terms to describe the human condition from an existential perspective is Heidegger’s (1996) “thrownness” (German: Geworfensein) into the world. Many concepts and thoughts are woven into this one word, and one among them is related to the fact that we come into this world “naked and alone,” and that we stay like this until we die. To many people this is one of the hardest existential aspects to grasp, because: How could we be alone if there are so many other human beings surrounding us? “Naked” is obviously true, but since parents or other caretakers are immediately there for the newborn,

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Isolation   215 and from then on almost every human being tends to be not only near to, but also de­pend­ent on other people—are we really “alone”? The concept of existential isolation focuses on the fact that human beings are “individuals.” That word is part of most English-­speaking people’s vocabulary, but probably the majority of them is not aware of the fact that it stems from the Latin “in dividere,” which means “cannot be split into parts.” And something that cannot be split into parts also cannot be really fused with other parts. Or in a more appropriate way: every human being stays him- or herself, and for him- or herself, and is not and will never be able to really “fuse” with another human being. My thoughts and feelings are just that—mine. I can speak about them, I can show them (e.g., by facial expression), but in fact I cannot really “share” them, because I cannot take them out of me and plug them into another person so that he or she really feels exactly my feelings or thinks my thoughts. To rephrase it one more time: No matter how close I am to somebody, there will always remain a gap between me and the other person. The gap might be tiny, but it is there, and there is no way to really close it. We may empathize with one another, we may laugh and cry and be emotionally “in sync,” but we experience just our own thoughts and feelings, never directly those of another person. Oddly enough, we propose that it is exactly that impossibility of really fusing with another human being that makes human relationships so utterly important to us all. If we really easily could share our feelings with one another, by some kind of emotional osmosis, or if we really could stop being individual and become one with another human being, thereby removing isolation from our existence—probably relationships wouldn’t be our number one goal at all. The space in this chapter is not sufficient to pursue that debate in all its detail here, but one glance at the question of which things are most valuable to humans should solve the case—mostly it is the things that are seldom, hard to get, or easy to lose that we value highly, not those that are to be taken for granted. What does that mean for the therapeutic relationship or for psychotherapy in general? Again, the limited space of this chapter doesn’t allow us to go into many details. According to the agenda of this book we want to highlight a couple of ethical principles that derive, that is, what a therapist aware of existential thoughts about isolation can do to help patients to find answers on the question of how to live. Yalom (1980) states that relationships are our best stronghold against isolation. If we stay in this metaphor of a stronghold, then it is important to note that a stronghold might keep the enemy in check, but that it is not capable of rendering the enemy to non-­existence. Furthermore, the metaphor casts isolation as the enemy, but in the paragraph above we pointed out that isolation is not an enemy—it is just a condition of our existence, and without that condition relationships wouldn’t be what they are to us. It can be very valuable for patients to work with them on these thoughts, because thereby they can develop a more healthy and fruitful idea about their own relationships. If I enter relationships with the need to find somebody who fills my own holes, with whom I can blend totally, who understands everything I feel or say before I even say it, and so on and so on, then I will necessarily fail. In our practice we regularly see patients who have a career of entering relationships with unrealistic ideas like those portrayed above, a couple of happy months afterwards, and then the unavoidable disappointment, consequently separation, and the same all over again. These may be patients who deep down feel the truth about human isolation, but who just don’t want to accept the reality and therefore keep searching for “the one.” That stance overloads a relationship with expectations that no relationship will ever be possible to satisfy.

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216   Existential Philosophy and Psychotherapy Ethics Also, the therapeutic relationship will not be an exception. We consider it to be one of the unspecific tasks of every therapist to be a model of a person with ideas about healthy human relationships, because being able to approach personal relationships with appropriate expectations (not overloading, but also not disappointed and disillusioned in a bad way) is one of the key assets to a good life. In our therapeutic experience it often has been helpful to differentiate with a patient the diverse relevant emotions and situations that are meant by “isolation,” “loneliness,” “alone,” “solitude,” “seclusion,” and so forth. Clarity about one’s own motives, emotions, and needs in relation to what is really possible in human relationships and what is not is a good basis to approach other people in a life-­supporting and enriching way.

Freedom and Responsibility As probably already obvious to the reader, none of the concepts described so far can stand for themselves separately, without connections or dependencies to each other. This is also the case for the last central aspect of existential therapy we want to discuss. Freedom and destiny are the endpoints of every one of the dimensions on which human life is developing itself. This could also be considered under the headline of “paradoxes”: as humans we want to be free, but we are fated. Or to be more precise: we have a specific range of freedom, but our freedom is not unlimited. So, both aspects are core descriptions of our lives: existential psychotherapy postulates that humans are not determined in all aspects of their being (we can make choices), but that at the same time we are bound by several conditions constraining our radius of operation (we cannot choose completely freely). This distinction is critical in discussing responsibility. One position on responsibility (put forth by Galen Strawson) is that if we were totally determined in every aspect of our thinking and behavior (by whatever: genes, our surroundings, or the forces of nature), there would be no responsibility. More compatibilist positions (e.g., by Harry Frankfurt or Peter Bieri) would argue that we can be free and responsible although determinism is true (for references and a more detailed discussion of these points see Zürcher, this volume). Existential philosophy, as the basis of existential psychotherapy, states that it probably is not only valid, but also most useful to adopt a middle position from which both sides of the same coin are acknowledged in order to give the best available orientation to living a good life. Among those who examined the subtleties of that dimension most thoroughly in the therapeutic world, we particularly admire Rollo May, whose book Freedom and Destiny was first published in 1981. Almost forty years later, his ideas are still enlightening, and fortunately the text is still available (May 2012). Viktor Frankl was another leading figure in the array of existential approaches, and he voted strongly against either extreme position. He suggested the idea that every human action might be determined by specific circumstances, thereby completely stripping human beings of their free will, pan-­determinism. The other extreme, namely negating fate and destiny as forces that are able to impose conditions on humans that they cannot free themselves from, he called psychologism. “A human being is a finite thing, and his freedom is restricted. It is not the freedom from conditions, but it is freedom to take a stand toward the conditions” (Frankl 1984: 153). We consider this distinction to be critical because it sheds important light on where personal responsibility ends and where unchangeable suffering of

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Conclusion   217 conditions begins. From this perspective, models that, for example, explain every single illness as a consequence of own behavior, thereby giving the responsibility for everything that happens to the person itself, are strongly rejected. Frankl would call such a model psychologistic, in ignoring the fact that for humans—despite having a specific range of free will—certain aspects of the conditions they live in are completely beyond control. The understanding of illness as portrayed by Dahlke and Dethlefsen (2016) is an example of such a model that would have to be rejected from an existential point of view. The dimension of freedom on the one hand and destiny on the other can help the therapist to navigate together with his or her client to find a course of life that is both responsible and considerate in relation to the world the client lives in. From this perspective, life can be seen as a series of choices, and of course all of our choices do have consequences. But it is very often the case that not all the consequences of our actions are transparent to us in the beginning. The distinction between “responsibility” and “guilt” can be very interesting. It is probably useful to reserve the term “guilt” for negative consequences that not only could have been anticipated in the very beginning of an action, but that rather were brought about intentionally. In that area of psychotherapy, the motives of a person should be thoroughly examined—that is also an example of where a “social mission” of the therapist might come into view. Ethical principles to a therapists’ behavior do not only come from the client, but also from the whole society. “Responsibility” goes further, because even if destiny or whatever power larger than a single human being forces something onto us, it is still “us” who are in the middle of the situation. Every second we are alive, we make decisions about what we do or do not do. And of course, we are not only responsible for what we do, but also for the “not happening” of all the alternatives that we would have had as a plan of action. The separation between “guilt” and “responsibility” is necessary, otherwise—if every consequence of our behavior attributed as “negative” would be experienced as “guilt”—we would be crushed under the weight of guilt of our lives. Of course, our behavior and its consequences cannot be divided easily into these two drawers of responsibility and guilt, and even best intentions will never lead to a guiltless life (see, e.g., Lucas 2004). Therapists should help clients to make these distinctions, to commit themselves to lead responsible lives, and to bear existential (or other) guilt as courageously as possible.

Conclusion Philosophy and psychotherapy share a very long historical tradition. In this chapter, we tried to shed light onto some of the key aspects of existential philosophy and the ethical principles that existential thinking can provide. As we hopefully were able to point out, the most important thing about psychotherapy based on existential philosophy is the stance from which the therapist encounters his or her client. The focus of existential therapy is not at first on specific techniques, but all on the relationship between therapist and client. Following existential principles means that the therapist should focus strongly on the world view of a client, and from that starting point he or she should invest all their powers to help the client to lead a fruitful life. Authenticity is both the best way of being a credible therapist and a successful client. And being in authentic contact with the world leaves little space for

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218   Existential Philosophy and Psychotherapy Ethics illusions about what can be done and what cannot: fully committing to life itself and the options we have while accepting the paradoxes and dilemmas of our existence seems to be the best orientation we can give to our clients.

References Bays, J.  C. (2011). How to Train a Wild Elephant & Other Adventures in Mindfulness. Boston, MA: Shambala. Binswanger, L. (1963). Being-in-the-World: Selected Papers of Ludwig Binswanger. New York: Basic Books. Boyraz, G., Waits, J.  B., and Felix, V.  A. (2014). “Authenticity, Life Satisfaction, and Distress: A Longitudinal Analysis.” Journal of Counseling Psychology 61: 498–505. Burks, D. J. and Robbins, R. (2012). “Psychologists’ Authenticity: Implications for Work in Professional and Therapeutic Settings.” Journal of Humanistic Psychology 52: 75–104. Cooper, M. (2015). Existential Psychotherapy and Counselling: Contributions to a Pluralistic Practice. London: Sage. Crowe, J. (2004). “Is an Existentialist Ethics Possible?” Philosophy Now 47: 29–30. Dahlke, R. and Dethlefsen, T. (2016). The Healing Power of Illness: Understanding What Your Symptoms Are Telling You. Boulder, CO: Sentient Publications. de Grey, A.  D.  N.  J. (2013). “Google’s Calico: The War on Aging Has Truly Begun.” Rejuvenation ­Research 16: 343. Deurzen, E. van (2002). Existential Counselling and Psychotherapy in Practice (2nd ed.). London: Sage. Deurzen, E. van and Adams, M. (2016). Skills in Existential Counselling & Psychotherapy (2nd ed.). Thousand Oaks, CA: Sage. Frankl, V. E. (1984). Man’s Search for Meaning. New York: Simon & Schuster. Hayes, S.  C., Strosahl, K.  D., and Wilson, K.  G. (2016). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (2nd ed.). New York: Guilford Press. Heidegger, M. (1996). Being and Time. Albany, NY: SUNY Press. Jaspers, K. (1970). Philosophy, Vol. 2: Existential Elucidation. Chicago: University of Chicago Press. Lucas, M. (2004). “Existential Regret: A Crossroad of Existential Anxiety and Existential Guilt.” Journal of Humanistic Psychology 44: 58–70. May, R. (2007). Love & Will. New York: W. W. Norton. May, R. (2012). Freedom and Destiny. New York: W. W. Norton. Morgan, R. (2001). Altered Carbon. London: Orion. Ramsey-Wade, C.  E. (2015). “Acceptance and Commitment Therapy: An Existential Approach to Therapy?” Existential Analysis 26. Salamun, K. (1988). “Moral Implications of Karl Jaspers’ Existentialism.” Philosophy and Phenomenological Research 49: 317–323. Schneider, K. J. and Krug, O. T. (2017). Existential-Humanistic Therapy (2nd ed.). Washington, DC: American Psychological Association. Schulenberg, S. E. (ed.) (2016). Clarifying and Furthering Existential Psychotherapy: Theories, Methods, and Practices. Cham: Springer International Publishing. Singularity University (n.d.). Global Grand Challenges. Retrieved from https://su.org/about/­ global-grand-challenges/ Wiseman, H. and Tishby, O. (2015). The Therapeutic Relationship: Innovative Investigations. London and New York: Routledge. Wood, A. M., Linley, P. A., Maltby, J., Baliousis, M., and Joseph, S. (2008). “The Authentic Personality: A Theoretical and Empirical Conceptualization and the Development of the Authenticity Scale.” Journal of Counseling Psychology 55: 385–399. Yalom, I. D. (1980). Existential Psychotherapy. New York: Basic Books. Zahavi, D. (2018). Husserl’s Legacy: Phenomenology, Metaphysics, and Transcendental Philosophy. Oxford: Oxford University Press.

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chapter 14

Phenom enol ogica lHer m en eu tic R esou rces for a n Ethics of Psychother a peu tic Ca r e Giovanni Stanghellini

Introduction In this chapter, I will introduce, define and discuss four concepts that seem to be relevant to develop a phenomenologically- and hermeneutically-­based ethics for psychotherapeutic care. These concepts are “dialogue,” “attunement,” “recognition,” and “intimacy” (Stanghellini 2019a).

The Dialogical Principle In a phenomenological-­hermeneutical perspective, the first resource for psychotherapeutic care and the overall framework in which it is set is the dialogical principle, according to which we are human insofar as we can engage in dialogue since the “I” is originally and ontologically relational (Buber  1958). What we call “I” is not a substance, but a relation. There is no “I” taken in itself, but only “I” in the “I-­you” or “I-­it” combinations. These two standpoints constitute respectively, the world of “you,” and the world of “it.” Unlike an “it,” which can be owned, “you” cannot be grasped and possessed. Until the “I” is linked with “you,” the latter cannot be reduced either to a possession or a mere object of experience. The therapeutic relationship is always suspended between the “I-­it” and the “I-­you” relation

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220   Phenomenological-Hermeneutic Resources for an Ethics

Box 14.1  Dialogue We are humans since we can dialogue Dialogue is the essential happening of language It is not a mere exchange of information Dialogue is the possibility to listen to each other A genuine dialogue is a genuinely social act In it, at a given moment, the interlocutors themselves become the subject matter In dialogue subjectivity is displaced One enters into dialogue, but one does not control its progression and outcome In dialogue something new about the interlocutors is revealed

(Cargnello 1977). The “I-­it” relation in clinical practice produces the world of objectifying diagnosis, whereas the “I-­you” world produces the world of dialogue. Some observations are necessary to unfold the concept of dialogue (Stanghellini 2019b) (see Box 14.1). (1) Dialogue is not mere conversation, i.e., what happens in the informal exchanges of everyday life or in idle chat. Whereas these conform to and reinforce the axioms of common sense, dialogue provides conditions that give rise to a new comprehension starting from a multitude of voices. Dialogue is not merely an exchange of pre-­ established information, rather something unexpected emerges from it. Dialogue is directed by a theme, but for the interlocutors it unveils something new about that theme. The participants’ initial assumptions are questioned, become evident and thus they can be examined, contested, and modified. Therefore, through dialogue one becomes conscious of one’s prejudices, while simultaneously enabling new developments to arise. Through dialogue, the notion of identity as constant across time is cast asunder: it comes to a point in which participants are taken by surprise and obliged to look at things and themselves anew. (2) Dialogue is not a simple discussion regarding a subject matter that is outside the interlocutors. At a certain moment, the interlocutors themselves become the theme. In dialogue, not only is something new revealed about a certain theme, but a quid novi—a new insight—is also unveiled about the interlocutors. (3) Dialogue is the fundamental occurrence of language—and language is the means through which we exist because through language we encounter alterity face-­to-­face and we let the unexpected happen. There are two ways in which we can use language. We can use language to label, that is to designate something and to distance ourselves from it. The language employed in dialogue is not merely labeling, it is the exact opposite of monadic language: the language of dialogue implies being-­in-­situation, and the situation modifies each participant’s pre-­existing knowledge, thereby generating new insight. Through the language of dialogue we let alterity touch us (see Box 14.2). (4) Dialogue is a kind of experience. It allows something to happen. The psychotherapy based on the dialogical principle is something more than a narrative or interpretative practice aimed at self-­knowledge (Stern et al. 1998). Something unexpected happens during the dialogue. What emerges is neither mine nor yours, and thus transcends the

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the dialogical principle   221

Box 14.2  Alterity My personal identity stems from the dialectics between what I am and the alterity that I encounter in my life I encounter alterity in two main domains of my life: –  in myself, that is, in the involuntary dimension of myself, –  in the external world Internal alterity consists in the pre-­individual elements not yet appropriated by myself which are the closest and the remotest at the same time For instance: my un-­chosen “character,” my emotions, my desires and values (and the conflicts between them), my habits in relating with other persons External alterity consists in the challenging otherness of the events (limit-­situations) the encounters with other persons that constellate my life the conflicts with social rules, roles, etc. Who I am stems from the fragile dynamics of my voluntary efforts to make sense of the involuntary what inherent in myself Only as I recognize my alterity as an incoercible datum can I begin to use it in my service

interlocutors’ subjective perspectives. Dialogue moves in unpredictable directions to generate new experience for both participants. Being in dialogue is having lost the sense of immutability of the self. Dialogue is what places us in a situation inhabited by alterity. (5) Something more than self-­narrative emerges in dialogue. In dialogue, insight is not constituted via the construction (or co-­construction) of clinical narratives, rather narratives are at the threshold of a categorial novum or “new thing.” Insight is an unforeseeable phenomenon, not the predictable outcome of a step-­ by-­ step system of question-­and-­answers or theory-­driven interpretations. Dialogue is an open-­ended, dynamic exchange that facilitates the emergence of novel, supervenient insight. In this perspective, insight can be thought of as an emergent phenomenon that takes place when we get lost in dialogue (Stanghellini  2016)—not the mechanistic product of a series of episodes and experiences, nor of the co-­construction of a shared narrative as the synthesis of the clinician’s and patient’s perspectives. The dialogical principle paves the way to a radical dialogical practice in psychotherapy. There are ontological implications inherent in the construction of an “I-­you” relationship. Treating the other as a “you” is not merely instrumental in establishing better quality relations in ethical or epistemological terms. Rather, being in the “I-­you” world (rather than the “I-­it”) may generate a profound transformation in the basic structures of both partners’ life-­worlds. A life-­world is the everyday reality with its own meaning structure inhabited by a given person characterized by a personal style of experience and action (Husserl 1970; Schütz and Luckmann 1973). Both the “I” (the therapist) and the “you” (the patient) are located in a given life-­world, and establishing an “I-­you” relation in the therapeutic context

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222   Phenomenological-Hermeneutic Resources for an Ethics can generate a deep transformation of the fundamental structures of each partner’s way of experiencing reality and acting upon it—transformations in selfhood, corporeality, spatiality, temporality, and language (Stanghellini and Mancini 2017). The “I-­you” relationship is a way of being that can re-­shape the “I” and the “you” and their life-­worlds. The dialogical relation has a specific temporal structure centered on now-­ moments of “filled presence” (Buber 1958: 12)—moments of profound “I-­you” attunement. Some of these moments of actual “presentness, meeting, and relation” are so powerful that they may emerge as experiences of “we-­ness” in which patient and therapist share a feeling of intimacy (attunement and intimacy will be described later in this chapter).

Attunement Attunement is the prerequisite for dialogue. Being in dialogue is a consequence of taking part in the other’s discourse. Taking part in another’s discourse calls for attunement (see Box 14.3). Attunement is an entanglement between persons based on a silent mode of relating, a non-­propositional flow of communication between persons embedded in a given at­mos­ phere. Attunement is thus based on a pre-­reflexive receptivity, enabling one to feel an at­mos­phere and to adjust to it. Attunement is the capacity to orchestrate one’s own feeling state according to the feeling state of the other. It is like playing music together where one musician coordinates and synchronizes his personal tempo (which in music indicates a mood, e.g., allegro, vivace, etc.) with the tempo of the other without the external help of a metronome. Dialogue involves giving space to the manifestation of the other’s tempo, while acknowledging it and validating it through one’s attunement. In an essay significantly entitled “Making Music Together,” Alfred Schütz (Schütz 1976) explains that the experience of the “We” that is at the foundation of all possible communication is a mutual tuning-­in relationship, a sharing of the Other’s flux of experiences similar

Box 14.3  Attunement I am always attuned to the world and other persons through my emotional feelings Attunement is based on a pre-­reflexive spontaneous receptivity enabling me to feel situated in a given place or relationship Attunement is also the reflexive capacity to orchestrate my emotions according to the other’s emotions and adjust to it—a modulation of the emotional field in-­between myself and the other Attunement is thus inter-­emotionality Attunement is also the capacity to pre-­reflexively or reflexively coordinate my tempo with that of the other Attunement is thus inter-­temporality Attunement—inter-­emotionality—inter-­temporality are grounded in corporeality as a form of intercorporeality

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recognition   223 to that of two co-­performers who execute a piece of music. Each co-­performer’s action is oriented not only by the music sheet, but also by the experiences in inner and outer time of his fellow performer. Each of them has not only to interpret his own part, which as such remains necessarily fragmentary, but he has also to anticipate the other player’s interpretation of his—the Other’s—part and, even more, the Other’s anticipations of his own execution. Either has to foresee by listening to the Other, by protentions and anticipations, any turn the Other’s interpretation may take. This is possible because making music together occurs in a true face-­to-­face relationship. The Other’s facial expressions, his gestures in handling his instrument, in short his embodiment and all the activities of performing, gear into the outer world and have to be grasped by the partner in immediacy. Even if performed without communicative intent, these activities are interpreted as indications of what the Other is going to do and therefore as suggestions for his own behavior. The face-­to-­face relationship is this dimension that unifies the fluxes of inner time and warrants their synchronization into a vivid present. This togetherness is experienced as a “We” and only within this We-­experience do the Other’s body and his movements become meaningful to the partner tuned in to him. A similar “ecological” approach is developed by Fuchs (Fuchs 2019a, 2019b) who grounds psychotherapeutic care on body memory and intercorporeality, corresponding to an embodied and embedded view of the self and its becoming.

Recognition The kind of teleology at play in human relationships is the desire for reciprocal recognition (Ricoeur 2005) (see Box 14.4). We desire to be recognized by the Other to such a degree that our being-­so is acknowledged by the Other as a value in itself. Our deepest need and desire is to be loved as we are, notwithstanding our limitations, weaknesses, faults, and culpabilities. We need the recognition of a “You” to become and remain an “I.” Honneth (Honneth 2008) indicates three paradigmatic forms of experience whereby a person feels recognized by the Others. The first is Love, whereby the person experiences the

Box 14.4  Recognition Recognition is the capacity to acknowledge the alterity in myself and of the other person The former is called self-­recognition: the acknowledgment of the pre-­individual elements not yet appropriated by myself The latter, other-­recognition, is the acknowledgment of the other person as a fellow man to whom I attribute value, life and consciousness Other-­recognition has a spontaneous emotional side grounded in attunement and an intellectual non-­spontaneous side fueled by my attempt to understand the other’s experience as meaningfully situated in a world that is similar to my own, but also indelibly marked by the other person’s particular existence Recognition has an epistemic as well as an ethical value

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224   Phenomenological-Hermeneutic Resources for an Ethics recognition of his particular needful nature in order to attain that affective security that allows him to articulate his needs. The prototype of this is the experience of parental care. This form of recognition is necessary to achieve “basic trust,” that is, to trust oneself. The second is Law: the person experiences that juridical institutions guarantee the recognition of his autonomy. This form of recognition is necessary to achieve “respect,” that is, to respect oneself. The third is Solidarity: the person experiences the recognition of the value of his own capacities. This form of recognition is necessary to achieve “integrity,” that is, to feel a meaningful part of society and to contribute with his capacities to sustain other subjects and, reciprocally, to be sustained by them. These three forms of recognition are basic requirements for the good life. They cannot be achieved by the person as an individual separated from the others. They can be only achieved through interaction, that is, through the experience of recognition. Recognition can be split into self-­recognition and other-­recognition. Freud, in his own terms, spoke of the need for self-­recognition—the understanding of the alterity that becomes manifest in my emotions, drives, acts, and symptoms as my own alterity, that is, as an integral part of the person that I am although it may come as an uncanny experience— something strangely familiar rather than simply familiar or simply unfamiliar—when I find myself face to face with it. Acknowledging the alterity that becomes manifest in my deeds as an inseparable part of the person that I am paves the way to the reconciliation between myself and the alterity that inhabits me (Freud 1914: 152). Self-­recognition, in the case of the recoil of the unintended consequences of my actions (as it is the case in so called parapraxes, for instance slips of the tongue, forgetfulness, mislaying objects, etc., as well as in dreams and neurotic symptoms) implies both self-­knowledge—knowing myself as reflected in my actions—and responsibility—acknowledging that I avow all the consequences of my actions, although they are unintended, and I am ready to respond to them. Other-­recognition is the acknowledgment of the other person as a fellow man to whom I attribute value, life, and consciousness. It is neither mere understanding (the identification of the Other’s mental state that causes his actions), nor simple approval (a kind of judgment or ethical stance) of the Other’s actions. Other-­recognition is a much more complex kind of emotional and intellectual phenomenon. It consists in the readiness to acknowledge the reasons and intimate motivation of the other person’s behavior. Other-­recognition is set within an experience of relatedness or “We-­experience” in which I am aware of the Other’s emotional distress and I try to attune with it. Obviously, this is a difficult task, rather than a mere automatism (Stanghellini 2016). The complex phenomenon of other-­recognition can, in its own turn, be split into two complementary phenomena, the first chiefly emotional in nature, and the second of a more intellectual kind. Emotional recognition presupposes in the first place a You-­orientation, that is, the mode in which I am aware of another human being as a person. The You-­ orientation, that is, the default mode in human existence (as we are all born and raised within a social world), makes it possible to coordinate temporally the series of my own experiences with a series of yours. Thus the emotional side of other-­recognition presupposes attunement with the Other. It is a mode of being with the Other, a modulation of the emotional field in-­between myself and the Other. While I am living in the We-­relationship, I am living in our stream of consciousness. The We-­relationship is like an undivided stream, and every experience is colored by this involvement. It is an experience of intimacy, an “interlocking of glances,” a “thousand-­faceted mirroring of each other” (Schütz 1967: 170).

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intimacy   225 This intimacy is not extrinsically observed, but lived through. The greater my awareness of the We-­relationship, the less my involvement in it, and the less I am genuinely related to my partner. This experience of simultaneity and of temporal coordination that I share with a “you” is, in its own turn, the necessary precondition for apprehending your subjective experiential contents and meanings. Understanding another person presupposes this experience of intimacy and simultaneity that Schütz, poetically, names “growing older together.” Given this emotional semi-­spontaneous experience, the following step, the intellectual side of recognition, is a fairly complex and non-­spontaneous mode of relatedness that requires a training entailing five basic steps (Stanghellini 2013a). First, I must acknowledge that the life-­world of the other person is not like my own. Second, I need to grant the meaningfulness of the other person’s actions as embedded in the other person’s life-­world. Third, I must learn to neutralize my natural attitude that would make me evaluate and judge the other’s experience as if it took place in a world like my own. Fourth, I must try to reconstruct the existential structures of the world the other lives in. Fifth, I can finally attempt to understand the other’s experience as meaningfully situated in a world that is indeed similar to my own, but also constantly and indelibly marked by the other person’s particular ex­ist­ence.

Intimacy The climax of the psychotherapeutic encounter is an aesthetic happening enveloped in an atmosphere and leading to an experience of intimacy. It brings about a pre-­reflexive experience of shared meaningfulness, a pre-­conceptual assemblage of the assortment of all sensorial inputs available to both partners. One must avoid the scientific objectification in order to preserve the phenomenological understanding and achieve an understanding of the meaning of a clinical situation as felt, rather than simply assessing objective signs and symptoms in a “I-­it” clinical relationship. In order to understand intimacy and its relevance in psychotherapeutic care one needs to understand what an atmosphere is, as intimacy with a person is a kind of atmosphere. Both happen in the in-­between. They do not involve language, or at least ordinary forms of language. Rather, they involve the sense of tact (see Box  14.5) as a means for sharing. Intimacy has a “haptic architecture” being based on a feeling that is neither private or internal, but spatially spread out and tinges the situation in which two or more persons happen to be involved and get in touch with each other (Costa et al. 2014; Francesetti and Griffero 2019). Intimacy is an atmosphere that brings about a fragile but profound understanding. Atmospheres inhabit what Straus named the “pathic” moment of perception (Straus 1963), where the subject–object distinction is fuzzy and so the sensorial domains are inchoate. Deleuze and Guattari’s (Deleuze and Guattari  2001) concept of haecceity provides an insight on the nature of this in-­between that constitutes the atmosphere of intimacy described by Buber. Haecceities consist of relations of movement and rest between particles, capacities to affect and be affected, but are nonetheless concrete individuations that have a status of their own and direct the metamorphosis of things and subjects. The at­mos­phere of intimacy resembles a haecceity in the fact that it exists fleetingly as a nomadic crisscross or

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Box 14.5  Tact Tact as the capacity to feel and attune with an atmosphere the elusive and often almost indefinable “air,” “mood,” or “ambience” that envelops a given situation in which is sited our global awareness of that situation It is the dexterity not to intrude into the other’s sphere to avoid instrumental relationships to let the other manifest her uniqueness Tact touches upon the very origin of the moral law It is a form of connection released from instrumental relationship It expresses a kind of contact that is not that of possession physical (e.g., to take hold of the other in order to force him to do something) or intellectual (e.g., to grasp the significance of the other’s behavior) It is a kind of grace, an implicit promise, and the capacity to wait until the moment is ripe for making explicit what I sensed

network of experiences between two (or more) persons. It fills the space, changing the intervenients, whilst having no concrete origin or destination. It is inter-­emotionality and inter-­temporality grounded on intercorporeality. Atmospheres arise through an actively endorsed aesthetic attitude adopted in a­ esthetic experiences, which shares with Husserl’s epoché the detachment from common sense and any preconceptions (including scientific preconceptions). The aesthetic attitude is a kind of disinterested attention and detachment from one’s intention. For instance, the clinician has to learn how to avoid his intention of finding symptoms in order to allow for the appearance of atmospheres. The aesthetic attitude paves the way to the pathic moment of perception, the moment when self and world/other are merged. Yet, their presence is felt to interpose a tacitly agreed distance between Self and Other. This apparent paradox is peacefully embodied by the sense of tact (Stanghellini 2013b). Like the sense of touch, atmospheres exist in a dialectic space of resonance between self and other, allowing for the tacit/inexplicit understanding of a situation. If on the one hand the whole that is experienced through at­mos­pheres is perpetually irreducible to the concepts we use to understand a situation, the ineffability of the experience shelters a latent relevance, which invites the creation of metaphors that may bring about the disclosure of a new understanding. The leading role of metaphors in the process of understanding atmospheres reflects the pre-­reflexive nature of the experience (Costa et al. 2014, 2019). Metaphors don’t pin down atmospheres, on the contrary they enhance atmospheres, amplifying them and enchaining other metaphors in the attempt to get closer to the truth of the experience itself in a perpetually unfinished process. The acceptance of atmospheres as clinically relevant phenomena is ultimately related to the acknowledgment of the ambiguous nature of the clinical encounter. The clinical encounter is an event suspended between the pathic and the linguistic domains of experience, an open event that invites participation, and must remain so in order to preserve the phenomenological precision and hermeneutic understanding.

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conclusions   227

Box 14.6  Intimacy Intimacy is an atmospheric experience of aloneness-­togetherness, self- and other-­recognition My sense of being a Self emerges in the experience of resonance with another person This experience is embedded in an atmosphere An atmosphere is based on a feeling that is neither private or internal, but spatially spread out and tinges the situation in which two or more persons happen to be involved Enveloped in an atmosphere of intimacy I get in touch with myself via getting in touch with each other

From a psychodynamic angle, Meares developed a similar argument in his conversational model of psychotherapy. Intimacy (see Box 14.6) is to Meares a kind of at-­oneness in which both partners feel a sense of connectedness and a shared understanding. Intimacy is not equivalent to fusion, since fusion is the desperate attempt to fill, with the figure of the Other, the emptiness left by the absence of the self (Meares 2004: 55). Meares encapsulates this in the formula “aloneness–togetherness”—sharing one’s own aloneness with another person. Intimacy is the meeting of two solitudes. The two partners’ orientation is not directed at themselves but at something else, a third thing that arises between them. This relatedness is transformational. Transformation is mediated by dialogue consisting of more than its content, the simple transmission of information. Language is not just the instrument for conveying semantics or meanings. Dialogue is not merely a vehicle for pieces of information. Of central importance is the form of language, that is, the way words are used, or the tone of voice. The language of intimacy is non-­linear, associative, apparently purposeless, and apparently its function is not communicative. It is enveloped into the implicit atmosphere of intimate relatedness. It is like a kind of inner speech, or a poetic language. Privilege is given to feeling-­tones and how they arise in particular forms of relatedness (Stern 2010). And to emotions, out of which “meanings” frequently come. The sense of self in the patient emerges as a resonance between her inner experience and the responses of the therapist. Intimacy involves the sharing of inner experience, a kind of at-­oneness in which both partners feel a sense of connectedness and a shared understanding. If psychotherapy is directed towards the restoration of a disrupted sense of personal being or “self,” then the success or failure of therapeutic conversations is not judged by its theoretical correctness, but by the evolution of intimacy and the experience of aloneness-­ togetherness reflected in changes in the totality of the patient’s experience of self, bodily feelings, and sense of spatiality.

Conclusions What is the role of attunement, dialogue, intimacy, and recognition in psychotherapeutic care? Are they just a nice-­to-­have and an add-­on? Or a must? Are they simply ethical commitments to all kinds of clinical encounters? Do they belong to the list of so-­called non-­specific treatment factors in psychotherapy? Or are they the cardinal points of a stand-­alone psychotherapeutic method?

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228   Phenomenological-Hermeneutic Resources for an Ethics Attunement, dialogue, intimacy, and recognition, as succinctly described in this chapter, are the columns of the phenomenological-­hermeneutical-­dynamic method of psychotherapy (Stanghellini 2016, 2019a, 2019b; Stanghellini and Mancini 2017); yet, I suggest to consider them indispensable ethical resources for any good-­enough clinical practice. The non-­denotative language of dialogue, the willingness to get lost in dialogue, the reciprocal quest for recognition and tactful attunement, all commingle to let alterity be in the experience of intimacy. Thus the relationship with alterity established through psychotherapeutic care is a kind of acquaintance or familiarity, neither merely a kind of knowledge aimed at the cognitive modification of a dysfunctional part of oneself, nor the adoption of some kind of social praxis; also, dialogue is not a novel interpretation of a given symptom or way of being in the world. Rather, it is a kind of we-­ness set within an atmosphere that feels like a synesthetic intercorporeal experiential dance that develops between clinician and patient and is transformational since it may generate a deep change of the fundamental structures of each partner’s life-­world, that is their habitual way of experiencing reality and acting upon it. This experience may correct maladaptive forms of relatedness and generate a kind of dialogical attitude, contributing to the restoration dialogue within oneself and with others.

References Buber, M. (1958). I and Thou. New York: Scribner. Cargnello, D. (1977). Alterità e alienità (2nd ed.). Milan: Feltrinelli. Costa, C., Carmenates, S., Madeira, L., and Stanghellini, G. (2014). “Phenomenology of Atmospheres: The Felt Meanings of Clinical Encounters.” Journal of Psychopathology 20: 351–357. Costa, C., Carmenates, S., Madeira, L., and Stanghellini, G. (2019). “Atmospheres and the Clinical Encounter.” In The Oxford Handbook of Phenomenological Psychopathology (ed. G.  Stanghellini, M. Broome, A. Raballo, A. V. Fernandez, P. Fusar-Poli, and R. Rosfort, pp. 872–881). Oxford and New York: Oxford University Press. Deleuze, G. and Guattari F. (2001). A Thousand Plateaus: Capitalism and Schizophrenia. London: A&C Black. Francesetti, G. and Griffero, T. (2019). “Introduction.” In Psychopathology and Atmospheres: Neither Inside nor Outside (ed. G. Francesetti and T. Griffero, pp. 1–5). Newcastle upon Tyne: Cambridge Scholars Publishing. Freud, S. (1914). Remembering, Repeating and Working Through (Further Recommendations on the Technique of Psychoanalysis II (Standard Edition, vol. 12). London: Hogarth Press. Fuchs, T. (2019a). Ecology of the Brain: The Phenomenology and Biology of the Embodied Mind. Oxford: Oxford University Press. Fuchs, T. (2019b). “The Interactive Phenomenal Field and the Life Space: Sketch of an Ecological Concept of Psychotherapy.” Psychopathology 52: 67–74. Honneth, A. (2008). “Reconnaissance et reproduction sociale.” In La reconnaissance à l’épreuve. Explorations socio-anthropologiques (ed. J.-P.  Payet and A.  Battegay, pp. 45–58). Villeneuve d’Ascq: Presses Universitaires du Septentrion. Husserl, E. (1970). The Crisis of European Sciences and Transcendental Phenomenology: An Introduction to Phenomenological Philosophy. Evanston, IL: Northwestern University Press. Meares, R. (2004). “The Conversational Model: An Outline.” American Journal of Psychotherapy 58: 51–66. Ricoeur, P. (2005). The Course of Recognition (trans. D.  Pellauer). Cambridge, MA: Harvard ­University Press.

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conclusions   229 Schütz, A. (1967). The Phenomenology of the Social World. Evanston, IL: Northwestern University Press. Schütz, A. (1976). “Making Music Together.” In Collected Papers II: Studies in Social Theory (ed. A. Brodersen, pp. 159–178). The Hague: Nijhoff. Schütz, A. and Luckmann, T. (1973). The Structures of the Life-World, Volume I. Evanston, IL: Northwestern University Press. Stanghellini, G. (2013a). “The Ethics of Incomprehensibility.” In One Century of Karl Jaspers’ General Psychopathology (ed. G. Stanghellini and T. Fuchs, pp. 166–183). Oxford: Oxford University Press. Stanghellini, G. (2013b). “The Portrait of the Psychiatrist as a Globally Minded Citizen.” Current Opinion in Psychiatry 26: 498–501. Stanghellini, G. (2016). Lost in Dialogue: Anthropology, Psychopathology and Care. Oxford: Oxford University Press. Stanghellini, G. (2019a). “Phenomenological Psychopathology and Psychotherapy.” In The Oxford Handbook of Phenomenological Psychopathology (ed. G.  Stanghellini, M.  Broome, A.  Raballo, A.  V.  Fernandez, P.  Fusar-Poli, and R.  Rosfort, pp. 952–971). Oxford and New York: Oxford University Press. Stanghellini, G. (2019b). “The PHD Method for Psychotherapy: Integrating Phenomenology, Hermeneutics, and Psychodynamics.” Psychopathology 52: 75–84. Stanghellini, G. and Mancini, M. (2017). The Therapeutic Interview in Mental Health. A Values-Based and Person-Centered Approach. Cambridge: Cambridge University Press. Stern, D. N. (2010). Forms of Vitality: Exploring Dynamic Experience in Psychology, the Arts, Psychotherapy and Development. New York: Oxford University Press. Stern, D.  N., Sander, L.  W., Nahum, J.  P., Harrison, A.  M., Lyons-Ruth, K., Morgan, A.  C., ­Bruschweiler-Stern, N., and Tronick, E. Z. (1998). “Non-Interpretive Mechanisms in Psychoanalytic Therapy: The ‘Something More’ than Interpretation. The Process of Change Study Group.” The International Journal of Psychoanalysis 75: 903–921. Straus, E. (1963). The Primary World of Senses: A Vindication of Sensory Experience. New York: Free Press of Glencoe.

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chapter 15

Fr ee W il l , R esponsibilit y, a n d Bl a m e i n Psychother a py Tobias Zürcher

Why Should We Consider Free Will in Psychotherapy? Let us look at two cases: (1) Alma suffers from major depressive disorder. She shows typical physical symptoms, such as headaches, irritability, and difficulty concentrating. Sudden attacks of deep sadness and outbursts of rage occur quite regularly. Accomplishing small tasks, or leaving home to go to work, has become very tedious, and she blames herself for failing. She thinks that her performance at work is very low, and she generally has strong doubts about her abilities and considers herself worthless. Alma doubts her condition will ever improve and has no hope that the therapy she has been undergoing for several weeks will help her. She doesn’t hide this pessimism from her therapist and wants to stop therapy. (2) Ben is a man who must stand trial for assault and blackmail. The forensic psychiatrist appointed by the court diagnoses him with antisocial personality disorder. Ben is manipulative and deceitful. He shows neither remorse nor empathy for his victims. He believes that people who had to suffer from his behavior were weak and deserved no better. His loneliness, which he brought upon himself through his egocentric behavior, does not bother him either. Along with the common medical aspects, these two cases confront us with the fundamental human question of whether Alma and Ben are free. Does Alma decide freely and responsibly that she no longer wants to engage in therapy? Do we think Ben is responsible for his crimes and the court (or society) entitled to blame and punish him? These questions are somewhat peculiar. On the one hand, they are very simple—we immediately understand what is at stake. On the other hand, they are very technical, and we will

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why should we consider free will in psychotherapy?    231 see the diverse ways in which the connection between free will and responsibility is conceptualized. The concept of free will is controversial itself, just as much as its significance for psychotherapy. If freedom of will is relevant at all (for anything), then it is also relevant for psychotherapy. When claiming that free will is important, it follows that it is crucial for important decisions (about our well-­being, our life plans, etc.) and the question arises of whether these decisions are made by ourselves. In psychotherapy, patients and therapists are confronted with such decisions and the resulting consequences. Let us consider some examples. First is the decision of whether to undergo therapy at all, and then to continue it (or not), and then the patient’s and the therapist’s approach to the course of treatment. When we make decisions, we want to be respected as persons. This claim is fundamental to the medical practice, where it is most prominently expressed as one of the “principles” of Beauchamp and Childress (2013). This idea can be traced back to the ultimate principle of Kant’s ethics, which demands that human beings must always be respected “as an end in ­themselves,” as free and dignified (Kant 1996). Along this line of thought, autonomy is accepted as a value in itself (we can call this the “intrinsic” view). Besides the intrinsic view, there is a second, instrumental argument for the importance of free will for psychotherapy: (P1) Good psychotherapy is necessarily efficient in the achievement of goals set, such as for living a healthier, happier, and more productive life. (P2) Respecting people’s autonomy as understood by the “intrinsic” view promotes good psychotherapy. (P3) Respecting people’s autonomy implies considering (not ignoring) free will. From this we can conclude that free will must be considered (not ignored), assuming we are aiming for good psychotherapy.

Premise 1 is uncontroversial. Premise 2 is empirically more demanding but can be supported with some evidence. It has been shown that respect for autonomy strengthens the therapeutic relationship (Beahrs and Gutheil 2001). In many cases, the increase in autonomy by improving a patient’s agency is vital for the overall therapy success (see, for example, Biegler 2010 for depression and Ziser et al. 2018 for anorexia nervosa). However, we have not yet decided whether it is really necessary to consider free will by taking into account both the intrinsic and the instrumental view (as it is assumed in both arguments that we should), or whether it is sufficient to deal with less demanding concepts such as autonomy or rationality. One might argue that, after all, we can evaluate decision-­making capacity by means of structured interviews, for example (Grisso and Appelbaum  1998). Practical instruments like this are of undeniable significance and use; however, they cannot solve the ethical question as to whether it is possible to decide freely and responsibly—questions they do not actually address at all. We must therefore examine different conceptions of free will in the philosophical debate and discuss their importance for psychotherapy. The ideas discussed in this chapter range from pessimism, which basically denies freedom of will, to an optimistic position which affirms ultimate freedom and responsibility. I will then argue that we can reasonably claim freedom of will in the context of psychotherapy and that this concept can be coherently integrated into our understanding of ourselves, the understanding of mental disorder, the practices of taking and attributing responsibility, and praise and blame.

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Concepts of Free Will The Threat and the Commonsense Response The threat to freedom of will can be perfectly demonstrated with the following thought experiment by Pierre-­Simon Laplace: We may regard the present state of the universe as the effect of its past and the cause of its future. An intellect which at a certain moment would know all forces that set nature in motion, and all positions of all items of which nature is composed, if this intellect were also vast enough to submit these data to analysis, it would embrace in a single formula the movements of the greatest bodies of the universe and those of the tiniest atom; for such an intellect nothing would be uncertain and the future just like the past would be present before its eyes. (Laplace 1951: 4)

What would the possibility of such an intellect (a “Laplacian demon”) mean for our will, our actions, and the living of our lives in general? To most people, the mere possibility of a Laplacian demon is highly suggestive and scary. We can imagine the universe as a complex machine, or we may think of it as a set of dominoes. Our part to play in this picture would be nothing more than that of a single cogwheel, which inevitably has to turn along, or that of a single domino tile—both of which are completely subject to the preceding events under the rule of natural laws. No single tile is free to fall if the tile next to it falls. Now, do we think this analogy is adequate? The answer to this question is—in a nutshell—the problem of free will. Let us assume Ben is preparing his defense. He is familiar with Laplace’s thought experiment and he honestly believes it is true. He therefore pleads as follows: he confesses to the crimes but denies that he (or anybody else) may be held responsible for the simple reason that free will doesn’t exist and therefore neither does personal responsibility. He lays out for the court how the events preceding his crime, along with his character traits (which are just the way they are), have caused him to commit the crime, and that it was not up to him to choose another path of action. What do we think of Ben’s defense? His claim is strengthened by the fact that he can refer to the US Supreme Court, which held that freedom of will, consisting of the ability to choose between good and evil, is a premise of a modern legal system.1 However, if the Laplacian demon existed, he would not be able to choose between good and evil. Therefore, the condition of free will, which the Supreme Court postulates, is not fulfilled, and there is no responsibility and justification for punishment. How could we oppose this argument? We might simply deny that freedom of will has any relevance in defense in court, as well as in forensic psychiatry, or indeed in the attribution of responsibility in general. Morse (2007), for example, argued that rationality is sufficient to be a responsible person from the point of view of the law and “the justifiability of 1  “It is as universal and persistent in mature systems of law as belief in freedom of the human will and a consequent ability and duty of the normal individual to choose between good and evil.” Morissette v. United States, 342 U.S. 246 (72 S.Ct. 240, 96 L.Ed. 288) (1952).

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concepts of free will   233 responsibility is assumed” (Morse 2007: 204). This is, however, just begging the question, and neither is it the strategy the court would pursue (and in fact has pursued, albeit in a slightly less dramatic context). In my opinion, this strategy demonstrates a kind of commonsense defense of free will. In a verdict that may seem tailored to Laplace’s thought experiment, the US Supreme Court ruled that “the notion that a person’s conduct is a simple function of extrinsic forces and circumstances over which he has no control is an unacceptable contradiction of the concept of free will, which is the sine qua non of our criminal justice system” (Bethea v. United States, 365 A.2d 64, 83 n.39 (D.C.  1976)). The German Supreme Court, in a landmark case in 1952, expressed this idea in a similar way when it held that the verdict accuses the perpetrator of having chosen injustice, even though he could have decided to obey the law.2 Therefore, according to these rulings, complete causation of behavior is incompatible with free will, for it rules out the possibility to do otherwise. According to the courts’ view, responsibility is possible (as the law presupposes), and therefore free will exists. Denying free will would entail denying responsibility, which would contradict the assumption of responsibility in law and everyday life. In this line of thought, the defendant’s argument is rejected because of its unwelcome result. Such an appeal to consequences is not a convincing refutation, because the consequences may be highly undesirable, but they are neither illogical nor empirically impossible. When we think of the truth of determinism and its destructive potential to all sorts of rules, a peculiar tension or even contradiction emerges: we normally claim that people may not be responsible for their actions if it is obvious to us that they were not able to choose between good and evil. This conviction is pervasive in law, for instance in the “insanity defense” or the characteristics of juvenile justice, which is more open to the consideration of deterministic factors in the assessment of crime than adult criminal law (Cotton 2005). In everyday interaction as well, we regularly excuse behavior when it becomes apparent that an action was unavoidable. This observation shows how powerful deterministic thinking is in our lives. But this does not fit in with accepting determinism in these cases, not only as an exception but also in everyday life. Should we not resolve this contradiction and face the consequences of determinism?

The Importance of Determinism This question leads us to the crucial point in the debate on freedom of will: what is the ­significance of determinism for freedom of will? Determinism is the thesis that certain conditions entail the occurrence of every present and future event (as in fatum, God’s foreseeing, or most importantly, the laws of physics plus events in the past). If determinism is true, then every event is inevitable, occurring in every possible world where the same initial conditions and laws exist (Kane 2011). Incompatibilism and compatibilism represent two answers to the threat of determinism. They differ insofar as they draw different conclusions in view of the possibility of the Laplacian demon (McKenna and Coates  2015a). Incompatibilists consider free will and 2 The German original says, “Strafe setzt Schuld voraus. Schuld ist Vorwerfbarkeit. Mit dem Unwerturteil der Schuld wird dem Täter vorgeworfen, daß er sich nicht rechtmäßig verhalten, daß er sich für das Unrecht entschieden hat, obwohl er sich rechtmäßig verhalten, sich für das Recht hätte entscheiden können.” BGHSt 2, 194, 200.

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234   Free Will, Responsibility, and Blame in Psychotherapy determinism to be incompatible. They can be further categorized into pessimists and optimists. The pessimists (or hard determinists or hard incompatibilists) start from the truth of determinism and conclude that there is no freedom of will. Contrary to this, the (optimistic) libertarians assume that determinism is not true, so freedom of will is possible (Van Inwagen 2008). Libertarians therefore deny that Laplace’s thought experiment is possible, given the actual laws of nature. Compatibilists, finally, think that free will and determinism can coexist. Some compatibilists even believe that determinism is a prerequisite for free will (e.g., Bieri 2001; Baer 2008; for an overview, see McKenna and Coates 2015b).

Pessimist View of Determinism Let us first consider incompatibilism. A very short and clear argument for incompatibilism is Peter van Inwagen’s “Consequence Argument”: If determinism is true, then our acts are consequences of the laws of nature and events in the remote past. But it is not up to us what went on before we were born, and neither is it up to us what the laws of nature are. Therefore, the consequences of these things (including our present acts) are not up to us.  (Van Inwagen 1983: 16)

We must not ignore the conditionality of the argument. The impossibility of free will just follows if determinism is actually true. The consequence argument only turns pessimistic if we can show that all our thoughts are caused by pre-­existing conditions and the laws of nature. Benjamin Libet’s experiment (Libet et al. 1983; see Haggard 2011 for a careful interpretation) has often been used to show that, indeed, our thoughts and actions are predetermined. Libet instructed participants to press a button at a time of their choice. They were then asked to indicate when they had become consciously aware of their decision to move their finger. Libet was able to show that a change in EEG signals could be measured about 350 milliseconds before the conscious experience of the will. This brain activity, which Libet called “readiness potential,” therefore occurred independently of our control. Since then, Libet’s experiment has been reproduced and improved in several respects (Haggard and Eimer 1999; Kühn and Brass 2009; Schurger et al. 2012). Nevertheless, the interpretation of the experiment is controversial. Libet assumed that the will was only an “epiphenomenon” or “by-­product” of brain activity if determinism was true, but he left open whether the experiment would prove determinism (Libet 1999: 55). If we consider determinism to be true and the consequence argument to be conclusive (if we adopt pessimistic incompatibilism), we would follow the protagonist in Dostoyevsky’s novella Notes from the Underground (Dostoyevsky 1972) who contemplates that it would be completely pointless to feel joy or outrage at the state of the universe—for these emotions also would happen entirely under the power of these laws. And it would also be meaningless to blame oneself and others for anything. Nothing matters anymore: My anger, in consequence of the damned laws of consciousness, is subject to chemical decomposition. As you look, its object vanishes into thin air, its reasons evaporate, the offender is nowhere to be found, the affront ceases to be an offence and becomes destiny, something like toothache, for which nobody is to blame.  (Dostoyevsky 1972: 27)

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concepts of free will   235

The Optimists’ Response From the optimists’ point of view, there are various strategies to escape the agony just described. First, consider the libertarian account. Libertarians claim that, fortunately, determinism is wrong. They further assume that (at least in some cases) human beings are able to create new causes through deliberate actions without these actions having been caused themselves—a capability they call “agent causation” (see Clarke 2003 and O’Connor 2011). In these circumstances, the ultimate control over our will would be independent of determinant factors lying outside ourselves, and without this kind of freedom, “no one can be ultimately in control, ultimately responsible, for this self and its determinations” (Smilansky 2001: 75). Libertarianism, however, faces strong objections. First, the libertarians’ key assumption about the absence of determinism in the process of human decisions that would make “agent causation” or personas as “unmoved movers” possible is unfounded. Balaguer has set out that (so far) this question cannot be decided by physics, and that we simply have no good reasons for or against the assumption of determinism (Balaguer  2010). Neither could “the evidence concerning the readiness potential [in Libet’s experiment] give us any reason at all to reject indeterminism” (Balaguer 2010: 162), which leaves the question unanswered. A second, even stronger objection addresses the problem of control. Leibniz noted that “nothing is more unsuitable than to want to transform the notion of free choice into I do not know what kind of unheard of and absurd power of acting or not acting without reason—such a power no sane person would select for himself ” (Leibniz 2005: 69). A will that refers to no reasons eliminates freedom instead of creating it. Facing the problems of incompatibilism, the compatibilists do not rely on indeterminacy but try to show that determinism and freedom do not exclude each other. In the following, the basic idea of compatibilism will be explained in more detail, and we then turn to one important contemporary theory. First of all, the compatibilist idea is remarkable for its endorsement by many different philosophical traditions. Jean-­Paul Sartre, for example, has pointed out that our freedom consists in our commitment to the active exercise of our will. Determinism cannot be an excuse to escape this responsibility (Sartre 2007). This interpretation describes freedom as an act of affirmation, or also as a kind of defiance or revolt, as Albert Camus described it and famously demanded we must imagine Sisyphus as being happy in his fatefully determined activity (Camus 1991). Sartre and Camus deny the opposition of freedom and determinacy. However, they do not clearly show why this contradiction does not exist. How could it be that anybody acts freely in a (possibly) deterministic world? Wouldn’t it be accurate to compare ourselves with falling dominoes?

The Compatibilist Approach David Hume has established classical compatibilism. In the chapter “Of Liberty and Necessity” in his Treatise of Human Nature (Hume 2000), Hume argues that causation is not a threat but rather a condition for freedom of will. Hume detects a conceptual confusion in traditional metaphysical theories of determinism. He distinguishes that an action is caused by the fact that someone is forced into an action. This distinction has also been established by analytical philosophers like Moritz Schlick, who, following Hume, mentioned the “pseudo-­problem of the Freedom of the Will” and pointed out the ambiguity of the word

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236   Free Will, Responsibility, and Blame in Psychotherapy “law” (Schlick 1939). Schlick thinks that only normative laws (laws of the state or of morality) would compel our will; laws of nature, on the other hand, would not impose such pressure. Although our desires are caused, it would be nonsensical to say that our desires would force us to want what we want. Compatibilists think that incompatibilistic thinking is exaggerated predominantly by thought experiments in which determinism is metaphorically equated with a powerful person (or will) who controls and manipulates us (Dennett 1984). Now, when do compatibilists think we have free will? The most influential contemporary theory has been established by Harry Frankfurt. Frankfurt’s theory can be classified in the group of internalist theories which have in common that they make freedom dependent on the coherence of the “internal” system of convictions and attitudes. Internally, in this sense, means that free will depends on the individual characteristics of the person such as the structure of her desires or the connection between her desires and her basic personal characteristics or values. According to internalists, it is misleading to make freedom dependent on external conditions, such as the constitution of natural laws or the existence of external values (if any such values existed). According to Frankfurt, we “will freely when what we want is what we want to want” (Frankfurt 2006: 15). Persons are (sometimes but not always) capable of exercising this freedom when they act entirely on behalf of their own reasons. They distinguish themselves from other beings by the fact that they are not only able to have first-­order desires but also second-­order desires. The former relate to actions (e.g., a desire to reduce one’s drinking or to express one’s needs more clearly), while the latter relate to other desires that the person wants or does not want (e.g., a desire to have the desire to reduce one’s drinking or the desire to want to be more communicative). A person has free will when he or she identifies with his or her first-­order wishes that become effective. If he or she succeeds, those wishes are in “volitional unanimity” (Frankfurt 2006: 15). Freedom of will means the lack of serious internal conflict of will. Frankfurt used the term “wholeheartedness,” which means that the wishes of the person are in harmony with each other (Frankfurt 1988). This harmony does not mean that a person no longer has any conflicting desires at all, but only that no desires prevail against the well-­considered will. Let us look at two examples. First, a person who sharpens his pencils over and over again because he cannot escape the immediate urge to do so, although he doesn’t want to show this behavior (and knows that the pencils have long since been sufficiently sharpened), is not free. However, if well-­sharpened pencils are someone’s passion, and she is completely interested in impeccable writing instruments and likes the process of sharpening greatly, the case is different. This person, like the first person, can feel the urgent desire to sharpen the pencils, but it is different in that she approves of this urgent desire. The action expresses what the person actually cares about and what she values. This is the central idea in Frankfurt’s compatibilism: freedom of will is bound to the essential characteristics of the person and what the person cares for. Frankfurt emphasizes that desires relevant to freedom must express (or be in accordance with) what the person is at heart (Frankfurt 2006). For such a “self-­expression theory,” we have to assume that there are indeed some characteristics that express what is important to the person (Sripada 2017). What is important to us depends on many circumstances that are beyond our control; what we love may just happen to us. But determinism does not threaten our freedom, because it does not make it impossible for us to reflect upon our desires, or to appropriate or reject

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free will and mental disorder   237 them, and identify with what is valuable to us. Many influential theories of recent decades share this basic compatibilist concern and focus on “character traits” (Dworkin 1988) and “long-­term plans” (Bratman  2007), which are concepts that bear resemblance to Frankfurt’s theory.

Free Will and Mental Disorder We have seen above that the intrinsic view provides us with a direct ethical reason to respect freedom. Further, the instrumental argument commits us to strive for an increase in freedom in order to improve the success of therapy. Now compatibilism puts forth a theory which affirms free will without relying on uncertain metaphysical assumptions. So, what does it mean to consider free will in psychotherapy? Can we use the compatibilist concept of free will as a resource instead of denying or simply ignoring freedom of will? In the following section we will examine these questions by discussing the significance of free will for various mental disorders. The following section’s aim is not to analyze cases in detail but to highlight some common features. Let us return to Alma, mentioned at the beginning of the chapter. Alma cannot do what she really wants. On the one hand, she wants to hide in the house and not go to work in order to avoid making any efforts. On the other hand, she wants the exact opposite: she wants to overcome her passivity and free herself from its burdens. She does not want to be dominated by her restraining desires. Motivational and (due to pessimistic biases) cognitive obstacles are the reasons why she fails to let her second-­order desires become effective. Frankfurt’s theory also provides us with a practical instrument for determining whether a person’s actions in a hypomanic state are free or not. Anyone who suddenly shows risky behavior or spends a lot of money on unnecessary things without having shown such behavior beforehand—as long as we can exclude other compelling reasons—does not act in accordance with his higher-­level wishes or according to his self-­trajectory. Rather, these actions are based on impulses that may seem strange even to the actor himself. We further find a similar gap between first- and second-­order desires in patients with addictive disorders. For these patients, it is characteristic that their actions undermine their second-­order desires. The freedom of will of the affected person is thus destroyed, regardless of the specific causes that were responsible for the occurrence of these destructive desires. Smeding et al. describe an interesting case in this respect: a man who suffered from Parkinson’s disease and has been treated with deep brain stimulation (DBS) developed symptoms of gambling addiction within a month of therapy. This led to the man gambling away large sums of money, having to sell his house and his wife wanting to divorce (Smeding et al.  2007). Beeker et al. analyze this case according to Frankfurt’s theory of free will: “According to his family, the patient previously was ‘as stingy as a Dutchman.’” The man’s behavior was not free because he continued to gamble and did so contrary to his higher-­order desires to keep enough money for living and to uphold his marriage (Beeker et al.  2017: 8). Obsessive-­ compulsive disorders, too, manifestly threaten free will. If a person fails to counter her obsessive desires, such as washing her hands repeatedly, she wants to do something that she does not really want to do. Her first- and second-­order desires are not in accord with each other. Her repeated washing of her hands is not an expression of her reflected desire, her real

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238   Free Will, Responsibility, and Blame in Psychotherapy intention, or her self. Meynen (2012) gives an example of such a case: a woman who cleans her house for hours every day would experience enormous emotional distress if she did not do so. At the same time, she wishes to be free of this compulsion. She perceives her obsessive thoughts as intrusive and feels alienated from her own actions. The same would apply to the obsessive sharpening of pencils in our example above. For mood and anxiety disorders (including obsessive-­compulsive disorder), we see a tendency that the disharmonic structure of desires, or the weakness of relevant second-­order desires to bring them into action, will make the affected person unfree and consequently not responsible. In the case of personality disorders, the situation is different. In contrast to the person with obsessive-­compulsive disorder, a person with obsessive-­compulsive personality disorder does not necessarily reject the obsessive desires. Persons with personality disorders remind us of Frankfurt’s “willing addict.” Just like the unwilling addict, the willing addict is physically dependent, but unlike the former, the willing addict does not in any way oppose his desire to take the drug. According to Frankfurt, this person “would not have things any other way. If the grip of his addiction should somehow weaken, he would do whatever he could to reinstate it; if his desire for the drug should begin to fade, he would take steps to renew its intensity” (Frankfurt 1971: 19) The willing addict is as free as any willing non-­user. In this example, but even more so in the case of antisocial personality disorder, we see another important aspect of Frankfurt’s theory: the content of desires does not determine the question of freedom. Ben (from the opening example) desires nothing else than what he actually desires. He certainly wants to avoid punishment, but he is at peace with his fundamental desires and with who he is. For Ben there is, as it were, no “external perspective” he could take and from which he could criticize his desires that belong to his illness. Then, if a personality disorder profoundly affects the person, pathological desires may be regarded as “harmonious,” an expression of the person’s self, and therefore their actions can be free and responsible. A cure for this disorder could then look more like the creation of a new self rather than a change of the person him- or herself. In this respect, the aim of therapy is to reveal what the person really cares about and how the person’s actions can be understood according to values and goals that emerge from this care. Therapy aims to restore the harmony of desires by regaining control over the first-­order desires or the coherence of one’s own will. How this purpose is achieved depends on the conditions of the illness and will vary according to the methods used. In the case of depression, it might be—among other things—important to question the validity of depressive thoughts through metacognitive awareness (Biegler  2010: 186) in order to weaken obstructive first-­order desires. Reclaimed freedom then consists in recognizing and perhaps even dissolving contradictions, and thus in actively appropriating freedom, or as Ratcliffe puts it, “in being able to actualize, through our activities, possibilities that are experienced as belonging to the world” (Ratcliffe 2013: 589). In the process of examining the motivational structure of the individual, it may also be necessary for the patient to ask himself moral questions which—if they are urgent and unresolved or if the individual is reluctant to think about them—prevent him from wanting and acting in a wholehearted way (Murray 2017: 501). On the other hand, it is not the objective of therapy to create this harmony by adopting some specific values which the individual has so far neglected. Køster (2013) argues that the aim of therapy is to regain a reflective understanding of the self. We see what affinity this approach has with Frankfurt’s compatibilism. Køster proposes taking a narrative approach and thus takes up an idea that has become increasingly

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free will for responsibility and blame in psychotherapy   239 im­ por­ tant in psychiatry and psychotherapy in the last thirty years (Hamkins  2013). According to narrative approaches, the self that expresses itself in actions can be grasped by giving a description of meaningful connections of diachronic events in a story authored by the patient and people around him. Without having to assess the merits of the narrative approach overall, we see how it matches an internalist theory of free will. The reason for this is that the condition of the narrative self and that of free will are often simultaneously fulfilled (or not). An individual who is able to express his care or his self through his actions is also more likely to have a consistent narration of himself, and vice versa. However, this connection is not necessary. Galen Strawson pointed out that there are people who are not “deeply narrative” and some are even completely “unnarrative” (Strawson 2018). Even one’s own stories can go astray (e.g., by being authored by others or by society), or an “unnarrated” life does not have to be less worth living, as the example of a person with intellectual disability might show. We often have neither the one and true story nor complete self-­ knowledge. This would be beyond human capacity—and neither is it a prerequisite of an internalist theory like Frankfurt’s.

The Importance of Free Will for Responsibility and Blame in Psychotherapy This chapter opened with the description of two short cases, both of which have raised the question of whether the affected persons are free to act responsibly. The same thought is reflected in Laplace’s thought experiment. In fact, the problem of acting responsibly is probably the decisive element in the free will debate. Accordingly, O’Connor and Franklin noted that “the kind of control or sense of up-­to-­meness involved in free will is the kind of control or sense of up-­to-­meness relevant to moral responsibility” (O’Connor and Franklin 2018). With this in mind, the following section will discuss the effects of free will on responsibility and blame in the psychotherapeutic context. The main focus will be on the patient’s responsibility, as this is regularly questioned due to illness. Fundamental objections to free will and responsibility, on the other hand, concern all human actions, including those of the therapist. The opinion that Ben holds in court (in the earlier example) differs fundamentally from the compatibilistic viewpoint. We can reconstruct Ben’s argument as follows: because determinism is true, free will does not exist (pessimistic incompatibility). If free will does not exist, then neither does real responsibility, and therefore no instance of blame is ever justified. If we exclude the possibility of indeterministic freedom, then all that remains is resignation (and the abandonment of all responsibility) or the upholding of a kind of illusion. Saul Smilansky has described this last option as follows: Morality has a crucial interest in confronting what can be called the Present Danger of the Future Retrospective Excuse, and in restricting the influence of the ultimate hard determinist level. To put it bluntly: people as a rule ought not to be fully aware of the ultimate inevitability of what they have done, for this will affect the way in which they hold themselves responsible. (Smilansky 2001: 85)

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240   Free Will, Responsibility, and Blame in Psychotherapy Within this framework, it would be ultimately unfair to blame people, but the practice of ascribing responsibility would increase the likelihood that people would follow rules of morality and would not absolve themselves from blame in advance for everything because every thought and act is inevitable. Praise, blame, and associated practices like punishment would then be justified only instrumentally. Hegel vehemently denounced this kind of attributing responsibility, because it would treat persons not as dignified beings but like dogs (Hegel 1991: 125). The instrumental understanding of attribution of responsibility (holding a person responsible serves a specific purpose) can be distinguished from the view that holding somebody responsible is valuable in itself. In his seminal “Freedom and Resentment,” Peter Strawson argued that our practice of praising and blaming is not dependent on views on determinism or any other assumptions but is valuable to ourselves as a given coherent system of attitudes and practices that express these attitudes (Strawson 2003). In this system, Strawson distinguishes what he called reactive from objective attitudes, which we can only temporarily adopt if we observe people distantly without being personally involved (Strawson 2003: 79). While modifications to individual attitudes and practices are possible, the system as a whole is impossible to abandon: “The existence of the general framework of attitudes itself is something we are given with the fact of human society. As a whole, it neither calls for, nor permits, an external ‘rational’ justification” (Strawson  2003: 78). This understanding of responsibility and blame fits nicely into a compatibilist framework. This point of view acknowledges many instances of responsibility and justified reproach, depending, however, on the specific circumstances. Furthermore, the appropriateness of blame depends on our understanding of what blame is. Tognazzini and Coates (2014) give a taxonomy of the theories of blame and distinguish, among other things, emotional (blame as an expression of emotion) from cognitive (blame as an expression of judgment) approaches. Both approaches share a common trait, namely that blame is essentially communicative. By blaming, we express our attitudes and open the door to reactions, such as apologies, changes in behavior, and possibly even reconciliation. What is the significance of attributing responsibility and blame in a therapeutic context? If we follow a compatibilist understanding of free will, both therapists and patients have a variety of responsibilities, some of which are not limited to this context and others resulting from the circumstances of the professional relationship. This chapter is not intended to give a comprehensive overview of these obligations (they are derived from general ethical obligation as well as from professional duties). The patient’s ability to take responsibility is determined by the characteristics of his or her illness. We have seen in the previous section how various mental illnesses can affect responsibility. Yet we must be aware that responsibility is both a gradual and a contextual concept. Nobody is always fully responsible for everything. In rare cases, the possibility of being responsible can be completely eliminated if, for example, no authentic wishes can be thought of at all, or if a diachronic, accessible self no longer seems to exist—conditions which may be caused by, for example, severe delusions or late-­stage dementia. In the vast majority of cases, however, freedom of will is not completely excluded, so people are still responsible for some of their decisions. A person may offer free and responsible consent to therapy and be willing to participate actively in it, even if the goal of therapy is to identify certain conflicts, to resolve constraints, and to gain greater clarity about pressing questions. For example, the obsessive-­compulsive disorder of the patient makes him unfree with regard to some of his actions, but not with regard to the

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conclusion   241 therapy as such. Psychoanalytic therapy, which assumes the existence of powerful unconscious forces, also offers space for freedom and sets (improved) autonomy as an aim of therapy (Hoff 2013: 42). Responsibility, then, is not fully given or completely denied, but it can be increased. In Frankfurt’s terminology, we can say that the patient becomes his own therapist by better understanding his motivational structure and (whether narrative or not) becoming more aware of himself (Waring 2015: 1405). Given that responsibility is possible in principle, the attribution of responsibility is an expression of respect for the freedom of another person. Angela Smith notes that “being held responsible is as much a privilege as it is a burden. It signals that we are a full participant in the moral community” (Smith 2007: 269). The leading advocate of a communicative theory of punishment, R. A. Duff, has argued extensively for this inclusive aspect of attribution of responsibility: “To remain silent, to let the action pass without criticism, necessarily casts doubt on the sincerity of my declaration that such conduct is seriously wrong” (Duff 2001: 28). Identifying responsibility, on the other hand, means acknowledging and confirming our belonging to the moral community, even if it would be easier for us to exclude other people or treat them in a hostile manner. In the clinical context, Hanna Pickard also emphasizes the recognition of others that is implied in holding responsible and points to the therapeutic benefits of attributing responsibility (Pickard 2013). Although attributing responsibility means respecting somebody as a moral agent, it does not follow that we should express every justified blame. We have to distinguish between the fact that there are reasons to blame and being in the right position to express blame (Cohen  2006). This is especially important in the therapeutic context: the therapist can identify the patient’s responsibility and work with the patient. Nevertheless, as Strawson suggests, he can abandon his reactive attitudes in favor of an objective attitude, perhaps for a moment or for the entire duration of the therapy. Blame can also have destructive consequences. Beyond addressing a wrong, it could indicate anger, rejection, or even hatred and provoke the same with the patient. If we assume that attribution of responsibility is im­por­ tant for the reasons already mentioned, we must ask ourselves by what means it can be adequately communicated. If it is even possible to attribute responsibility without blame, this would certainly be a preferable approach. We should therefore try to find alternative ways of (symbolically) expressing criticism that come without blame but are nevertheless understandable, strong, and unambiguous (see Pickard 2013 for practical implementation).

Conclusion Based on various thought experiments, we have argued that free will is important in general and particularly for psychotherapy. In addition to the fundamental danger that determinism represents for the existence of free will according to the incompatibilists, mental disorders pose a specific threat to freedom and responsibility in therapeutic practice. In this chapter, I have argued that compatibilism offers a theory of free will which is persuasive in two respects: first, it provides an understanding of free will that does not require special (and controversial) metaphysical assumptions and is compatible with our own experience of desires and compulsions. Second, it explains how freedom is threatened by mental illness and how restoring freedom can be defined as a meaningful and resourceful aim of therapeutic

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242   Free Will, Responsibility, and Blame in Psychotherapy work. This is by no means a revisionist theory, but it does not allow the problem of moral justification of decisions and actions to be solved with “technical” solutions or to be ignored altogether. Denying freedom of will has serious effects on the possibility of autonomous action and the attribution of responsibility, and so does its replacement by concepts like competence or capacity. Nevertheless, therapy constitutes a kind of paradox for the therapist and the patient. The activity they engage in together presupposes, in a certain way, what it ultimately wants to achieve, namely freedom and responsibility. It might be part of the art of the good therapist to weigh the presumed freedom (or even the illusion of it) with a genuine participatory sense of belonging to each other. Ludwig Wittgenstein, who understood philosophy itself as a therapeutic activity, said that when a problem is solved, it dissolves like sugar in water, leaving us behind without feeling any resignation (Wittgenstein 2005: 310e). Most people probably do not feel the same way about the problem of free will. However, the analysis of this concept and the description of the phenomenology of freedom, as it is manifested in illness and in everyday life, both suggest that we can act freely and responsibly under many circumstances.

Acknowledgments The author would like to thank Jonathan Erhardt, Anna Van Driel, and Anja Rettich for their comments on this article.

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conclusion   243 Frankfurt, H. (1971). “Freedom of the Will and the Concept of a Person.” Journal of Philosophy 68: 5–20. Frankfurt, H. (1988). “Identification and Wholeheartedness.” In The Importance of What We Care About (ed. H. Frankfurt, pp. 159–176). New York: Cambridge University Press. Frankfurt, H. (2006). “Taking Ourselves Seriously and Getting It Right.” In The Tanner Lectures in Moral Philosophy (ed. D. Satz, pp. 1–54). Stanford, CA: Stanford University Press. Grisso, T. and Appelbaum, P. S. (1998). Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York: Oxford University Press. Haggard, P. (2011). “Neuroethics of Free Will.” In The Oxford Handbook of Neuroethics (ed. J. Illes and B. J. Sahakian, pp. 219–226). Oxford: Oxford University Press. Haggard, P. and Eimer, M. (1999). “On the Relation between Brain Potentials and the Awareness of Voluntary Movements.” Experimental Brain Research 126: 128–133. Hamkins, S. (2013). The Art of Narrative Psychiatry: Stories of Strength and Meaning. Oxford: Oxford University Press. Hegel, G. W. F. (1991). Elements of the Philosophy of Right (ed. Allen W. Wood, trans. H. B. Nisbet). Cambridge: Cambridge University Press. Hoff, P. (2013). “Die autonome Person: Stolperstein psychiatrischen Selbstverständnisses von 1800 bis heute.” Sozialpsychiatrische Informationen 43: 40–46. Hume, D. (2000). A Treatise of Human Nature (ed. D. F. Norton and M. J. Norton). New York: Oxford University Press. Kane, R. (ed.) (2011). The Oxford Handbook of Free Will (2nd ed.). New York: Oxford University Press. Kant, I. (1996). Groundwork of the Metaphysics of Morals. In Practical Philosophy. The Cambridge Edition of the Works of Immanuel Kant (ed. M. Gregor, pp. 37–108). Cambridge: Cambridge University Press. Køster, A. (2013). “Narrative Self-Appropriation: Embodiment, Alienness, and Personal Responsibility in the Context of Borderline Personality Disorder.” Theoretical Medicine and Bioethics 38: 465–482. Kühn, S. and Brass, M. (2009). “Retrospective Construction of the Judgement of Free Choice.” Consciousness and Cognition 18: 12–21. Laplace, P. S. (1951). A Philosophical Essay on Probabilities (ed. F. W. Truscott and F. L. Emory). New York: Dover Publications. Leibniz, G. W. (2005). “Confessio Philosophi.” In Confessio Philosophi: Papers Concerning the Problem of Evil, 1671–1678 (ed. and trans. R. C. Sleigh, Jr.). New Haven, CT: Yale University Press. Libet, B. (1999). “Do We Have Free Will?” Journal of Consciousness Studies 6: 47–57. Libet, B., Gleason, U. A., Wright, E. W., and Pearl, D. K. (1983). “Time of Conscious Intention to Act in Relation to Onset of Cerebral Activity (Readiness-Potential): The Unconscious Initiation of a Freely Voluntary Act.” Brain 106: 623–642. McKenna, M. and Coates, D. J. (2015a). “Compatibilism.” In The Stanford Encyclopedia of Philosophy (ed. E. N. Zalta). Retrieved from https://plato.stanford.edu/entries/compatibilism/ McKenna, M. and Coates, D. J. (2015b). “Compatibilism: State of the Art.” In The Stanford Encyclopedia of Philosophy (ed. E.  N.  Zalta). Retrieved from https://plato.stanford.edu/entries/compatibilism/ supplement.html Meynen, G. (2012). “Obsessive-Compulsive Disorder, Free Will, and Control.” Philosophy, Psychiatry & Psychology 19: 323–332. Morse, S. J. (2007). “The Non-Problem of Free Will in Forensic Psychiatry and Psychology.” Behavioral Sciences & the Law 25: 203–220. Murray, B. (2017). “Clinical Judgment, Moral Anxiety, and the Limits of Psychiatry.” Medicine Health Care and Philosophy 20: 495–501. O’Connor, T. (2011). “Agent-Causal Theories of Freedom.” In The Oxford Handbook of Free Will (2nd ed.; ed. R. Kane, pp. 309–328). New York: Oxford University Press. O’Connor, T. and Franklin, C. (2018). “Free Will.” In The Stanford Encyclopedia of Philosophy (ed. E. N. Zalta). Retrieved from http://plato.stanford.edu/entries/freewill/#Rel

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244   Free Will, Responsibility, and Blame in Psychotherapy Pickard, H. (2013). “Responsibility Without Blame: Philosophical Reflections on Clinical Practice.” In The Oxford Handbook of Philosophy and Psychiatry (ed. K. W. M. Fulford et al., pp. 1134–1152). Oxford: Oxford University Press. Ratcliffe, M. (2013). “Depression and the Phenomenology of Free Will.” In The Oxford Handbook of Philosophy and Psychiatry (ed. K.  W.  M.  Fulford et al., pp. 574–591). Oxford: Oxford University Press. Sartre, J.-P. (2007). Existentialism Is a Humanism (trans. C.  Macomber). New Haven, CT: Yale University Press. Schlick, M. (1939). Problems of Ethics (trans. D. Rynin). New York: Prentice Hall. Schurger, A., Sitt, J.  D., and Dehaene, S. (2012). “An Accumulator Model for Spontaneous Neural Activity Prior to Self-Initiated Movement.” Proceedings of the National Academy of Sciences of the United States of America 109: E2904–E2913. Smeding, H.  M.  M., Goudriaan, A.  E., Foncke, E.  M.  J., Schuurman, P.  R., Speelman, J.  D., and Schmand, B. (2007). “Pathological Gambling after Bilateral Subthalamic Nucleus Stimulation in Parkinson Disease.” Journal of Neurology, Neurosurgery & Psychiatry 78: 517–519. Smilansky, S. (2001). “Free Will: From Nature to Illusion.” Proceedings of the Aristotelian Society 101: 71–95. Smith, A. (2007). “Responsibility for Attitudes: Activity and Passivity in Mental Life.” Ethics 115: 236–271. Sripada, C. (2017). “Frankfurt’s Unwilling and Willing Addicts.” Mind 126: 781–815. Strawson, G. (2018). Things that Bother Me: Death, Freedom, the Self, Etc. New York: New York Review of Books. Strawson, P. F. (2003). “Freedom and Resentment.” In Free Will (ed. G. Watson, pp. 72–93). Oxford: Oxford University Press. Tognazzini, N. and Coates, D.  J. (2014). “Blame.” In The Stanford Encyclopedia of Philosophy (ed. E. N. Zalta). Retrieved from https://plato.stanford.edu/entries/blame/ Van Inwagen, P. (1983). An Essay on Free Will. Oxford: Clarendon Press. Van Inwagen, P. (2008). “How to Think about the Problem of Free Will.” Journal of Ethics 12: 327–341. Waring, D. R., (2015). “Patient Responsibilities in a Psychiatric Healing Project,” In The Oxford Handbook of Psychiatric Ethics (Vol. 2, ed. J. Z. Sadler et al., 1402–1418). Oxford and New York: Oxford University Press. Wittgenstein, L. (2005). Big Typescript, TS 213 (ed. and trans. C. G. Luckhardt and M. A. E. Aue, German–English scholars’ ed.). Oxford: Blackwell. Ziser, K., Resmark, G., Giel, K. E., Becker, S., Stuber, F., Zipfel, S., and Junne, F. (2018). “The Effectiveness of Contingency Management in the Treatment of Patients with Anorexia Nervosa: A Systematic Review.” European Eating Disorders Review 26: 379–393.

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chapter 16

Dign it y i n Psychother a py Roberto Andorno

Introduction Respect for human dignity is generally regarded as the overarching social vaue and as the ultimate foundation of human rights. More specifically, respect for the dignity of patients and research subjects is presented by international documents as the most basic normative principle governing healthcare practice and medical research. Two significant examples of this view are the European Convention on Human Rights and Biomedicine (1997) and the Universal Declaration on Bioethics and Human Rights (2005). Respect for human dignity, not surprisingly, also plays a significant role in the understanding of the psychotherapeutic relationship. References to human dignity can be found in various ethical guidelines for the practice of psychology. For instance, the Universal Declaration of Ethical Principles for Psychologists (IUPsyS and IAAP 2008) states that “respect for the dignity of persons and peoples” is “the most fundamental and universally found ethical principle across geographical and cultural boundaries, and across professional disciplines” (Principle 1). It is very revealing that the Declaration, immediately after having affirmed the principle of dignity, presents some other values that are important for the practice of psychology as if they were derived from the basic premise of dignity: “free and informed consent,” “privacy,” “confidentiality of personal information,” “respect for the diversity among persons and peoples,” “respect for the customs and beliefs” (except when they “seriously contravene the principle of respect for dignity” or “cause serious harm”), and “fairness and justice in the treatment of persons and peoples.” Similarly, respect for dignity embodies the first ethical principle of the Code of Ethics and Conduct of the British Psychological Society, which states that psychologists value the dignity and worth of all persons, with sensitivity to the dynamics of perceived authority or influence over clients, and with particular regard to people’s rights including those of privacy and self-­determination.  (British Psychological Society 2009: 10)

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246   Dignity in Psychotherapy Also, the Model Code of Ethics of the European Federation of Psychologists’ Associations (2015) places “respect for individual rights and dignity” at the top of the principles that should guide the psychological profession (Article 3.1). This document further specifies the meaning of this principle by stipulating that “the psychologist . . . works in such a way that their expertise will not be used to harm, abuse, or oppress.” Similarly, respect for “people’s rights and dignity” is among the five ethical principles put forward by the Ethical Principles of Psychologists and Code of Conduct of the American Psychological Association (2017 [2002]: 4). Interestingly, this principle is directly associated with ensuring respect for privacy, confidentiality, and self-­determination. Furthermore, it is also put in relation with the need to take into account that people’s vulnerabilities may impair their autonomous decision making, and with the importance of avoiding any prejudices regarding people’s diversity. This chapter aims, first, to briefly conceptualize the notion of human dignity in general philosophical and legal terms; second, to stress its central value in the healthcare context; and finally, to consider what factors can jeopardize patients’ dignity in the psychotherapeutic relationship.

Respect for Human Dignity “Dignity” is defined as “the state of being worthy of honour or respect” (The Oxford Encyclopedic English Dictionary). When this concept is associated with the adjective “human,” it denotes that all human beings possess equal and inherent worth and therefore ought to be accorded the highest respect and care, regardless of age, sex, socioeconomic status, physical or mental health, ethnic origin, religion, or any other particular feature. In other words, every human being is worthy of respect simply by virtue of his or her human condition. The concept of “dignity” is very close to that of “respect.” Respecting persons is a consequence of acknowledging the intrinsic worth they possess. Respecting persons involves regarding them as being entitled to make a rightful claim on our conduct, and deserving moral consideration in their own right, regardless of their merit or ability (Feinberg 1973). In modern times, Kant was the first major philosopher to put the notions of respect (Achtung) and dignity (Würde) at the very center of moral theory. According to his famous categorical imperative, we should always treat people as ends in themselves, and never merely as a means to our ends. People should not be instrumentalized because they are not “things,” but “persons” (i.e., rational beings). While things have a price (i.e., the kind of value for which there can be an equivalent), “dignity” makes a person irreplaceable (Kant 1996: 79). In other words, to be a “person” is to have such a status and worth that is incomparable to that of any other being. The point is that respect is the only appropriate attitude towards a “person”. Respect is the acknowledgment, both in attitude and behavior, of the dignity of persons as ends in themselves. Moreover, respect for persons is not only an appropriate attitude but also morally and unconditionally required (Dillon 2018). Although the notion of human dignity has a very long tradition in the history of philosophy, it re-­emerged with great vigor after World War II as an international legal and political concept, which provides the ultimate foundation to human rights. In response to the horrors of

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respect for human dignity   247 that tragic period of history, the international community felt the need to emphasize the idea that every individual has inherent worth and accompanying rights in order to prevent “barbarous acts which have outraged the conscience of mankind” from ever happening again (Preamble of the Universal Declaration of Human Rights 1948, hereafter UDHR). Indeed, the emphasis on human dignity that has dominated ethical and political discourse since 1945 to a large extent can be explained by the horror inspired by the revelations that prisoners of concentration camps, including children, were used by Nazi physicians as subjects of brutal experiments (Baker 2001). In the aftermath of World War II, the member states of the newly created United Nations appealed explicitly to the notion of human dignity when they reaffirmed their “faith . . . in the dignity and worth of the human person” (Preamble of the United Nations Charter 1945). Subsequently, the UDHR, which would become the cornerstone of the new international human rights system, was grounded on the “recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family” (UDHR, Preamble). From the very beginning, the Declaration states that “all human beings are born free and equal in dignity and rights” (Article 1). This provision is the bedrock of all the rights and freedoms set forth in the Declaration and, in particular, the basis for the prohibition of all forms of discrimination (Article 2), of slavery (Article 4), and of torture and any cruel, inhuman, or degrading treatment or punishment (Article 5). In this respect, the statement made in Article 1 has been seen as a “seismic shift in human consciousness” which is “so profound that, paradoxically, its importance may not be fully realized” (Mann 1998: 31). As noted above, human dignity is today regarded by international law as the foundation and source of human rights, that is, as the ultimate rationale for the recognition of equal rights of every human being regardless of ethnic origin, social status, sex, age, health condition, or any other particular feature. This means that human rights are conceived as universal. Indeed, if they were not universal, they could not be called “human” rights at all, but the rights of a particular category of individuals. Moreover, human rights could not even be thought of if they were not understood as universal claims, but as exclusive prerogatives of some individuals.Actually, respect for human dignity and human rights rests upon the belief in the existence of a truly universal moral community comprising all human beings. Philosophers of all times have generally associated the special moral standing we confer to every human individual with the unique rational abilities and moral self-­determination that characterize human beings. Importantly, this intrinsic worth is not conceived as conditioned on the circumstance that the human being actually possesses or is able to exercise such intellectual abilities. Rather, this intrinsic worth is connected to features that characterize human beings as a kind, even if they are not necessarily present in every individual (Sulmasy 2007). In other words, such respect also applies to those individuals who have not yet acquired such rational and moral faculties (such as newborn infants) or to those who have irremediably lost those abilities, either totally or partially (such as persons with serious mental disorders, neurodegenerative diseases, or patients in persistent vegetative state). Dignity is therefore not a privilege of adult, perfectly competent and morally autonomous persons, but a value that we recognize in every human being. Despite the great value attached to dignity by contemporary societies, it must be acknowledged that the concept is inevitably vague and abstract. Very often, its precise meaning and practical implications in concrete situations are not easy to determine. Moreover, the notion of dignity is never defined by the same legal and ethical standards that appeal to it.

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248   Dignity in Psychotherapy The elusiveness of the concept has attracted serious criticisms from some scholars, who see appeals to dignity as purely rhetorical or political statements, which are vague restatements of other more precise notions such as, for instance, “respect for autonomy” or “informed consent” (Caulfield and Chapman 2005; Macklin 2003). Some of these criticisms may make sense when the concept of dignity is just invoked to end an ethical discussion and to avoid the effort of providing substantive reasons about the ethical issues at stake: given that disrespecting dignity is always bad to do, the discussion about a particular topic is over. However, the potential rhetorical misuse of the concept of dignity should not lead us to “throw away the baby with the bathwater.” Appeals to dignity can be meaningful in many cases, in particular when other ethical principles (e.g., autonomy, privacy, etc.) are not able to convey in an equally powerful manner the idea that the intrinsic value of a person should not be disregarded in a given situation. For instance, it is clear that the wrongness of sexual exploitation of a patient by a therapist cannot be adequately grasped just in terms of a lack of “respect for autonomy” or as a “privacy infringement.” Like in this example, the recourse to human dignity is particularly helpful with regard to any practices that involve commodifying human beings, or that entail degrading or humiliating treatment. In this connection, it is noteworthy that the concept of human dignity usually plays a negative role by setting limits to certain practices or banning them altogether. In contrast, dignity is less often used to positively promote certain practices or behaviors. This is due to the fact that the meaning of dignity can be better grasped by considering what is contrary to people’s intrinsic value rather than what is in conformity with it. This ex negativo approach is visible, for instance, in some scholars’ attempts to give an account of what dignity means. According to Ronald Dworkin (1994: 236), dignity embodies the idea that people must “never be treated in a way that denies the distinct importance of their own lives.” Similarly, it has been claimed that human dignity and human rights presuppose that “there are some things that should not be done to anybody, anywhere” (Midgley 1999: 160). It is not by chance that, while most human rights are couched in positive terms (“Everyone has the right to . . .”), those that aim to protect people against the most serious and direct violations of human dignity are formulated in negative terms, as prohibitions: “No one shall be held in slavery or servitude”; “no one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment” (Articles 4 and 5 of the UDHR, respectively). Precisely because these rights and freedoms are more immediately connected with human dignity, they are thought of as absolute, in the sense that they are not subject to any exceptions (Andorno 2013).

Human Dignity in Medical Ethics and Law The notion of human dignity is not only regarded as the foundation and ultimate source of human rights. It also plays a very central role in modern medical ethics and law. The first impact of the notion of dignity on this area took place immediately after World War II and concerned medical research involving human subjects. In 1947, the requirement of free and informed consent of research participants was formally included into the famous Nuremberg

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human dignity in medical ethics and law   249 Code developed by the military court that condemned the Nazi physicians. Although the ten principles for medical research contained in the Nuremberg Code do not explicitly refer to human dignity, they are clearly based on this notion. The categorical nature of the Code principles shows that the judges who formulated them had the idea of unconditional human worthiness in mind. In this respect, it is pointed out that “never before in the history of human experimentation, and never since, has any code or any regulation of research declared in such relentless and uncompromising fashion that the psychological integrity of research subjects must be protected absolutely” (Katz  1992: 227). Interestingly, the only provision relating to medical ethics that appears in the International Covenant on Civil and Political Rights (1966) is the requirement of informed consent for medical research (Article 7). Human dignity also holds a prominent position in the international instruments dealing with bioethics that have been developed since the end of the 1990s, such as the Universal Declaration on the Human Genome and Human Rights (1997) and the Universal Declaration of Human Rights and Bioethics (2005), both adopted by the UNESCO Member States, and the Council of Europe’s Convention on Human Rights and Biomedicine (1997), also known as the Oviedo Convention. The emphasis on human dignity in international instruments dealing with biomedicine over the past few decades is impressive enough to lead scholars to characterize the notion of dignity as “the shaping principle” of international bioethics (Lenoir and Mathieu 2004: 16) or as the “overarching principle” of the global norms governing biomedical issues (Andorno 2009). However, respect for human dignity is not only a general, abstract principle guiding the normative frameworks relating to biomedicine, but also a very concrete moral standard in the patient–physician relationship. It also helps to identify the practices or attitudes of healthcare professionals that contribute—or not—to promote patients’ intrinsic value and self-­determination. In medical ethics, the notion of dignity is often employed to emphasize the importance of promoting patients’ self-­determination and to question autonomy-­denying attitudes of healthcare professionals. The idea of dignity contributes to see every patient not merely as someone suffering from a disorder, disease, or condition, but as a person, that is, a unique, irreplaceable human being with an intrinsic value. This idea compels healthcare professionals to keep in mind that every patient has his or her own rich personal story and life experiences, which make them who they are, and distinct from any other individual. The awareness of the uniqueness and incommensurable worth of every patient is not something merely desirable in medical practice. Rather, dignity is a moral imperative that plays a key, humanizing role in the physician–patient relationship (Andorno 2013). The need to promote patients’ dignity has become especially urgent in the context of time pressure that characterizes modern healthcare practice. This is particularly relevant for psychotherapy as every session is very time consuming and a psychotherapeutic treatment can last for years. The point is that in increasingly bureaucratic and impersonal clinics the risk is high of overlooking that kindness, humanity, and respect for each individual patient are still core values of the practice of medicine (Pellegrino  2008). Hence, emphasizing that every patient, no matter what degree of dependency or disability, possesses intrinsic dignity is probably today more relevant than ever. Undoubtedly, the quality of healthcare depends to a large extent on physicians and nurses paying adequate attention to the distinct worth of every single patient. This is especially the case with hospitalized patients, who are placed in a situation of particular vulnerability as

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250   Dignity in Psychotherapy they are highly dependent on the assistance of others for the improvement of their health condition and for their daily needs. Such patients’ self-­esteem may be affected if they find that certain behaviors or attitudes of healthcare professionals disregard their intrinsic value as “persons” (Andorno 2013). It is worth mentioning that the term “patient” itself, which comes from the Latin verb “patior” and means to endure or suffer, shows this close association with vulnerability. Patients are indeed exposed to suffering, not only as a result of their disease or condition, but also as a consequence of the power and knowledge imbalance that exists between them and healthcare professionals, and of the situation of inescapable dependence in which they are placed. Their sense of dignity and their self-­esteem are therefore challenged by their changing health circumstances. Several surveys show that paying attention to patients’ dignity is of crucial importance to the quality of healthcare, and can contribute to recovery (Baillie  2009; Matiti and Trorey 2008). A number of key themes that help enhancing patients’ dignity include: protecting their privacy, facilitating communication between patients and healthcare providers, assisting patients in their need for information and self-­determination, and ensuring decency and correctness in the forms of address (Matiti and Trorey 2008). Many of these studies point towards the promotion of patients’ self-­determination (or autonomy) as one of the key requirements for ensuring respect for their dignity. Self-­determination (i.e., the ability to govern oneself) is indeed one of the most powerful expressions of human dignity. However, these two notions are not synonymous. The imperative of respect for dignity is far broader and foundational than simply ensuring respect for self-­determination. Let us note that the principle of dignity is not only applicable to adult individuals with full decision-­making capacity, but also covers the respect for those who are not yet, or are no longer, morally autonomous (infants, senile elderly, people with mental disorders, comatose patients, etc.). At this point it is worth stressing that, although respect for autonomy is generally recognized as one of the most important bioethical principles and an expression of dignity, it does not have absolute value. According to principle-­based bioethics, famously developed by Beauchamp and Childress (2009), autonomy is just one of the four ethical principles guiding healthcare practice, together with beneficence, non-­maleficence, and justice. These four principles have prima facie validity which means that they apply as long as there is no conflict between them. If there is, they have to be balanced to determine which one carries more weight in the particular case at hand. According to Beauchamp and Childress (2009: 23), a set of conditions must be met to justify infringing one of the prima facie principles to adhere to another (a sufficient reason for doing so, a realistic chance of success, absence of a morally better alternative available, etc.). In other words, autonomy can be trumped in some contexts and under certain conditions by beneficence and/or non-­maleficence. There are indeed circumstances in which the imperative of promoting a patient’s dignity is better served by upholding beneficence/non-­maleficence instead of autonomy. This can best be illustrated by a simple case example provided by Knapp and VandeCreek (2007: 401): Dr. Rodriguez is treating a patient who has made a serious attempt to harm herself. After a thorough review of the patient and situational factors, Dr. Rodriguez determines that the patient is very intent on killing herself and is resistant to treatment. Dr. Rodriguez then institutes procedures for an involuntary psychiatric hospitalization.

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the importance of dignity in psychotherapy   251 This example shows well that respect for people’s dignity is not reducible to mere autonomy-promoting actions. However, patients’ dignity cannot only be promoted through negative actions (i.e., actions aiming to prevent harm). According to the above-­mentioned studies, patients’ dignity can also be positively promoted by the behavior of healthcare professionals. The ways of preserving patient’s dignity are very diverse and include, among others: “presence” (keeping others company); “concealment” (covering up embarrassing markers of illness); “independence” (facilitating, as far as possible, patients’ self-­sufficiency and moral agency); “leveling” (­minimizing asymmetry); “creativity” (allowing patients to make or share art); “courtesy” (demonstrating common respect); and “authenticity” (honoring individuality and personhood) (Jacobson 2009). It follows from this that the efforts aiming at preserving and promoting patients’ dignity have to take into account very heterogeneous elements such as feelings (feeling comfortable, in control, and valued by others), physical presentation, and staff behavior (Baillie 2009). Consistent with the above-­mentioned studies, the Canadian psychiatrist Harvey Chochinov claims that the concept of dignity offers an overarching conceptual framework that enables physicians, patients, and families to better define the objectives and modalities of any medical intervention (Chochinov 2002, 2007; Chochinov et al. 2008). Based on the results of surveys about the understanding of dignity by patients in a terminal condition, Chochinov developed a model of patient care called the “dignity-­conserving care” model. This approach includes three broad areas of influence of individual perceptions of dignity: illness-­related concerns (i.e., those things that directly result from the illness itself); the dignity-­conserving repertoire (i.e., those aspects of patients’ psychological and spiritual landscape that influence their sense of dignity); and the social dignity inventory (i.e., those social issues or relationship dynamics that enhance or detract from a patient’s sense of dignity) (Chochinov 2002). Chochinov has also developed what he calls the “patient dignity inventory,” which aims to measure various sources of dignity-­related distress among patients nearing the end of life (Chochinov et al.  2008). He stresses, however, that the dignity-­conserving care model applies across the broad spectrum of medicine, and not only in the field of palliative care because “whether patients are young or old, and whatever their health problems, the core values of kindness, respect, and dignity are indispensable” (Chochinov 2007: 185). Similarly, a study conducted in the context of psychiatric nursing practice has identified a number of attitudes and behaviors of nurses that may contribute—or not—to promote patients’ dignity. For instance, dignity is preserved when caregivers take the time to be present for patients and pay empathic attention to their stories and needs; on the contrary, patients’ dignity is offended when caregivers abuse their power, “punish” patients who do not behave as expected, and neglect patients’ requests (Lindwall et al. 2011).

The Importance of Dignity in Psychotherapy Psychotherapy presupposes regular personal interactions between the therapist and the patient on sensitive and intimate matters. The goal of these regular encounters is to treat emotional and psychological problems by means of talking and understanding, by persuasion and rhetoric. Most therapies assume that the inner landscape of the patient can be

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252   Dignity in Psychotherapy changed (otherwise it would be meaningless to offer therapy at all) (Adshead 2015). This implies, to a greater or lesser extent, an effort by the therapist to influence some particular thoughts, attitudes, or behaviors of patients. When considered from the point of view of the patient’s dignity, the ethical problem of psychotherapy lies precisely here. Indeed, the vulnerable and dependent situation in which patients are placed in the psychotherapeutic relationship creates the conditions for potential threats to their self-­determination, which is a crucial component of their dignity as persons. Consistent with this, it has been advanced that all forms of psychotherapy intend to ­alleviate the patients’ sense of powerlessness to change themselves or their environment in common, a condition that may be termed “demoralization” (Frank and Frank 1991). If this claim is correct, it could perhaps be argued that all psychotherapies ultimately aim to help patients recover their self-­esteem and thereby the awareness of their own dignity. The key ethical dilemma in psychotherapy is to what extent the influence exerted by the therapist on the patient is balanced by a true collaborative relationship between both individuals. The concept of “therapeutic alliance” presupposes that the patient and the therapist work together to promote a therapeutic change. Over the last decades, an egalitarian relationship is gaining in prominence and regarded as more humanitarian and facilitative of exchange than the traditional medical model (doctor–patient) or the behavioral model (teacher–student) (Karasu  2013: 42). However, there are concerns that a friendship-­like relationship involving an excessive familiarity between both individuals may impair the effectiveness of the therapy. Therefore, it seems that a balance has to be found between these two extreme positions. The question here is how to avoid therapists’ misuse of power while maintaining appropriate professional boundaries. What is undeniable is that psychotherapy patients find themselves in a situation of particular vulnerability, not only as direct consequence of their emotional and psychological problems, but also because they are revealing intimate aspects of their lives and exposing their inner weaknesses and fears to another person in a one-­way transaction which is not a peer-­to-­peer relationship (Adshead 2015). Certainly, in any patient–healthcare professional relationship there is an asymmetry of power and knowledge. However, that asymmetry becomes even more pronounced in psychotherapy, since it involves disclosing feelings and thoughts, and this, in regular meetings which generally take place over a long period of time. From the point of view of patients’ dignity, the challenge for psychotherapy consists therefore in helping people overcome their psychological problems, but without making them overdependent on the relationship with the therapist. If self-­determination is a prominent expression of dignity, psychotherapy should encourage patients to remain the main actors of the healing process. For instance, regarding the treatment of depression, it has been suggested that self-­knowledge achieved through psychotherapy has moral value in that it promotes the autonomy of stressor-­related decisions (Biegler 2010). (See also chapter 5 on autonomy as a goal in psychotherapy by Paul Biegler in this volume.) Respect for autonomy also involves being sensitive to the patient’s values, religious beliefs, and life plans, even if they are not shared by the therapist. Of course, values issues arise during treatment. If adequately negotiated, values can contribute to treat the patient’s emotional and psychological problems. The issue is how to resolve value conflicts while preserving the therapeutic mission. In this regard, Bergin has suggested that if therapists disclose, at least implicitly, their own value preferences, they should be extremely careful to do it a non-­directive and respectful manner, so as to preserve patient’s personal views

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conclusion   253 and moral agency (Bergin 1991). (See also chapter 10 on appropriate and inappropriate ­values in this volume.) Respect for patients’ dignity requires not only preserving and promoting their ­self-­determination, but also strictly avoiding any form of patients’ exploitation, in particular, sexual abuse. This latter behavior seriously disregards patients’ inherent worth and misuses the trust they have placed in the therapist. Sexual abuse of patients can indeed be labeled as “exploitation,” since exploiting people means taking unfair advantage of them, or using them exclusively as means to an end rather than as ends in themselves, according to the famous Kantian moral imperative. The misuse by therapists of the professional relationship to advance their sexual interests clearly constitutes a serious violation of patients’ dignity. It should be noted that the possibilities for sexual exploitation are increased by the patient’s dependence on the therapist over a long period of time. In this regard, it has been pointed out that “the inherent intimacy and dependency of the therapeutic relationship makes it more difficult to scrutinize transgression and more likely that the injured patient will remain silent” about the sexual abuse (Holmes and Adshead 2009: 373). Moreover, as Rüger and Reimer (2010) report, patients having been sexually abused by therapists suffer from long-­term psychological harm, which may include depressive developments with suicidal tendencies and drug and alcohol misuse, along with psychological and psychosomatic symptoms. Not surprisingly, ethical guidelines for psychotherapy condemn very explicitly and unconditionally any form of sexual harassment of patients (for sexual abuse in psychotherapy, see also chapter 64 on professional (mis)conduct in psychotherapy in this volume).

Conclusion The notion of dignity plays a crucial role in medical ethics by emphasizing the importance of valuing the patient as a “person,” that is, as a unique and irreplaceable individual who is endowed with intrinsic worth. The relevance of dignity in this context results from the special vulnerability of people suffering from physical or psychological health problems. The idea of dignity requires healthcare professionals to actively promote patients’ intrinsic worth in every encounter, and to avoid any behavior that might hurt patients’ self-­esteem. In psychotherapy, the notion of dignity mainly aims to emphasize the need to promote, as far as possible, patients’ self-­sufficiency and moral agency, and to avoid making them overdependent on the relationship with the therapist. Dignity also requires the therapist to carefully respect the personal values and beliefs of patients, and to absolutely abstain from any behavior that may constitute patient exploitation, such as sexual harassment and other forms of abuse.

References Adshead, G. (2015). “Ethical Issues Common to All Therapies.” In The Oxford Handbook of Psychiatric Ethics (Vol. 2) (ed. J. Sadler, K. W. M. Fulford, and W. V. Van Staden, pp. 1250–1263). Oxford: Oxford University Press. American Psychological Association (2017 [2002]). Ethical Principles of Psychologists and Code of Conduct. Washington, DC: American Psychological Association.

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254   Dignity in Psychotherapy Andorno, R. (2009). “Human Dignity and Human Rights as a Common Ground for a Global Bioethics.” Journal of Medicine and Philosophy 34: 223–240. Andorno, R. (2013). “The Dual Role of Human Dignity in Bioethics.” Medicine, Health Care and Philosophy 16: 967–973. Baillie, L. (2009). “Patient Dignity in an Acute Hospital Setting: A Case Study.” International Journal of Nursing Studies 46: 23–37. Baker, R. (2001). “Bioethics and Human Rights: A Historical Perspective.” Cambridge Quarterly of Healthcare Ethics 10: 241–252. Beauchamp, T.  L. and Childress, J.  F. (2009). Principles of Biomedical Ethics (6th ed.). New York: ­Oxford University Press. Bergin, A. E. (1991). “Values and Religious Issues in Psychotherapy and Mental Health.” American Psychologist 46: 394–403. Biegler, P. (2010). “Autonomy and Ethical Treatment in Depression.” Bioethics 24: 179–189. British Psychological Society (2009). Code of Ethics and Conduct. Leicester: BPS. Caulfield, T. and Chapman, A. (2005). “Human Dignity as a Criterion for Science Policy.” PloS Medicine 2: 736–738. Chochinov, H. M. (2002). “Dignity-Conserving Care: A New Model for Palliative Care. Helping the Patient Feel Valued.” JAMA 287: 2253–2260. Chochinov, H. M. (2007). “Dignity and the Essence of Medicine: The A, B, C, and D of Dignity Conserving Care.” British Medical Journal 335: 184–187. Chochinov, H. M., Hassard, T., McClement, S., Hack, T., Kristjanson, L., Harlos, M., Sinclair, S., and Murray, A. (2008). “The Patient Dignity Inventory: A Novel Way of Measuring Dignity-Related Distress in Palliative Care.” Journal of Pain Symptom Management 36: 559–571. Dillon, R. (2018). “Respect.” In The Stanford Encyclopedia of Philosophy (ed. E. N. Zalta). Retrieved from https://plato.stanford.edu/archives/spr2018/entries/respect/ Dworkin, R. (1994). Life’s Dominion: An Argument about Abortion, Euthanasia and Individual Freedom. New York: Vintage. European Federation of Psychologists’ Associations (2015). Model Code of Ethics. Brussels: EFPA. Feinberg, J. (1973). “Some Conjectures on the Concept of Respect.” Journal of Social Philosophy 4: 1–3. Frank, J. D. and Frank, J. B. (1991). Persuasion and Healing: A Comparative Study of Psychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press. Holmes, J. and Adshead, G. (2009). “Ethical Aspects of the Psychotherapies.” In Psychiatric Ethics (4th ed.; ed. S. Bloch and S. Green, pp. 367–384). New York: Oxford University Press. IUPsyS (International Union of Psychological Science) and IAAP (International Association for Analytic Psychology) (2008). Universal Declaration of Ethical Principles for Psychologists. Jacobson, N. (2009). “A Taxonomy of Dignity: A Grounded Theory Study.” BMC International Health and Human Rights 9: 1–9. Kant, I. (1996). Groundwork of the Metaphysics of Morals. In Practical Philosophy. The Cambridge Edition of the Works of Immanuel Kant (ed. M. Gregor, pp. 37–108). Cambridge: Cambridge University Press. Karasu, T.  B. (2013). “The Ethics of Psychotherapy.” In Applied Ethics in Mental Health Care: An ­Interdisciplinary Reader (ed. D. Sisti, A. Caplan, and H. Rimon-Greenspan, pp. 35–50). Cambridge, MA: MIT Press. Katz, J. (1992). “The Consent Principle of the Nuremberg Code: Its Significance Then and Now.” In The Nazi Doctors and the Nuremberg Code (ed. G. Annas and M. Grodin, pp. 227–239). New York: Oxford University Press. Knapp, S. and Vande Creek, L. (2007). “Balancing Respect for Autonomy with Competing Values with the Use of Principle-Based Ethics.” Psychotherapy: Theory, Research, Practice, Training 44: 397–404. Lenoir, N. and Mathieu, B. (2004). Les normes internationales de la bioéthique. Paris: Presses Universitaires de France. Lindwall, L., Boussaid, L., Kulzer, S., and Wigerblad, A. (2011). “Patient Dignity in Psychiatric Nursing Practice.” Journal of Psychiatric and Mental Health Nursing 19: 569–576.

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conclusion   255 Macklin, R. (2003). “Dignity is a Useless Concept.” British Medical Journal 327: 1419–1420. Mann, J. (1998). “Dignity and Health: The UDHR’s Revolutionary First Article.” Health and Human Rights 3: 30–38. Matiti, M. and Trorey, G. (2008). “Patients’ Expectations of the Maintenance of their Dignity.” Journal of Clinical Nursing 17: 2709–2717. Midgley, M. (1999). “Towards an Ethic of Global Responsibility.” In Human Rights in Global Politics (ed. T. Dunne and N. J. Wheeler, pp. 160–174). Cambridge: Cambridge University Press. Pellegrino, E. (2008). “The Lived Experience of Human Dignity.” In Human Dignity and Bioethics (ed. US President’s Council on Bioethics, pp. 513–539). Washington, DC: US Government Printing Office. Rüger, U. and Reimer, C. (2010). “Ethical Problems in Psychotherapy.” In Ethics in Psychiatry (ed. H. Helmchen and N. Sartorius, pp. 281–297). Dordrecht: Springer. Sulmasy, D. (2007). “Human Dignity and Human Worth.” In Perspectives on Human Dignity: A Conversation. (ed. J. Malpas and N. Lickiss, pp. 9–18). Dordrecht: Springer.

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Section III

C OM MON E T H IC A L C H A L L E NGE S I N P SYC HOT H E R A PY

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Chapter 17

The Ethics of I n for m ed Consen t for Psychother a py Alastair J. McKean, Manuel Trachsel, and Paul E. Croarkin

I hold it to be altogether more honorable, and also more expedient, to draw his attention, without alarming him unduly but from the very beginning, to the difficulties and sacrifices involved by analytic treatment; thereby depriving him of the right to assert later on that he had been inveigled into a treatment and implications and extent of which he did not realize. Sigmund Freud (1963)

Introduction Informed consent is an ethical and legal duty that has been an integral part of the practice of medicine and surgery since the early twentieth century. Since the 1980s this process has gradually become an expectation in the delivery of psychotherapy and is incorporated in the ethical codes of conduct of many psychological and psychiatric professional organizations (e.g., American Medical Association 2005; American Psychological Association 2002). Ideally, informed consent respects patient autonomy and the right to self-­determination, it informs patients of potential benefits and harms that may arise in treatment, and provides a foundation to partnering around goals and developing of a therapeutic alliance (Beahrs and Gutheil 2001; Fisher and Oransky 2008). Despite its importance, evidence would suggest that the principles of informed consent are both insufficiently and inconsistently applied to psychotherapeutic treatments with few guidelines to aid in its delivery (Dsubanko-­ Obermayr and Baumann 2010; Trachsel et al. 2015b). As an interpersonal and relationally based longitudinal treatment, psychotherapy is unique when compared to traditional medical procedures and medication prescribing. Further, many psychotherapists are not trained

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260   The Ethics of Informed Consent for Psychotherapy in traditional medical models of care; therefore, a medically based framework for informed consent may not be as familiar. These factors have important implications for how informed consent is communicated at the commencement of therapy and during the course of care, making it a process rather than a well circumscribed event (Trachsel et al. 2015b). In this chapter, we explore the informed consent process in psychotherapy by charting its historical development, legal imperatives, ethical principles, nuances and challenges in execution, as well as the current debates surrounding implementation.

History of Informed Consent in Medicine and the Path to Informed Consent in Mental Health Care Since the origins of Western medicine in Ancient Greece, physicians have wrestled with the responsibility of deciding what information to disclose to patients in their care. In the history of medicine, the attitudes and ethics of Hippocrates have frequently been perceived as paternalistic by modern standards (Beauchamp 2011). More recently, however, this perspective has been rehabilitated and scholarship has pressed the case of Ancient Greek physicians possessing a more straightforward and honest relationship with their patients, with a growing recognition of the importance they placed on disclosing important details to patients in providing care (Miles 2009). However, extant literature is limited and prior writings from Ancient Greek physicians provide no clear evidence of a prescribed ethical framework for the informed consent process. More is written from the eighteenth century onwards concerning what information to share with patients and subsequent obligations physicians and surgeons had in disclosing treatment to patients, yet still there was no formal and consistent approach. A case ruling in English law, Slater v. Baker and Stapleton, from 1767, shows that surgeons had some obligation to gain the patient’s consent (Berg et al. 2001). The pragmatic reason for consent was so that the patient would agree to allow them to perform a procedure, thus increasing the expediency with which they could be treated. Thomas Percival’s Medical Ethics (1803) gives a very paternalistic perspective of the physician’s role recommending guarding against sharing details that the physician determined to be harmful to the patient (Beauchamp 2011). In the twentieth century, development of the ethics of informed consent was propelled by the courts, as medical litigation drove this process to become more formalized. The landmark 1914 malpractice case ruling of Schloendorff v. Society of New York Hospital acknowledged that a patient had a “right to determine what shall be done with his body” (Berg et al. 2001: 43–44). No significant advancement occurred beyond this until after World War II where the Nürnberg trials exposed the atrocities committed by physicians under the Nazi regime and so emphasized the necessity of consent (Beauchamp and Childress 2001). The 1950s and 1960s saw the development of professional peer standards of consent that focused on what a “reasonable” physician would disclose to their patient under similar circumstances (Hall et al. 2012). The term informed consent first appears in the USA in the ruling of Salgo v. Leland Stanford, Jr. University Board of Trustees in 1957 (Berg et al. 2001). This found that physicians not only had to receive a patient’s consent but that this consent had to

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ethical principles and essential components   261 have come after receiving adequate information—although the ruling attempted to balance full disclosure with what was still perceived as physicians’ discretion to withhold information that the patient might find disturbing (Berg et al. 2001). The 1970s saw a shift to more patient-­oriented standards of consent, considering what a “reasonable” patient would want to know in a similar situation (Hall et al. 2012). In 1972, Canterbury v. Spence underscored the right of the patient to self-­decision in medical matters and recognized that this could only fully occur if there is enough information (Beauchamp 2011; Canterbury v. Spence). These rulings were recognized early on as applying to mental health practitioners, with some advocating for early adoption of informed consent in psychotherapy (Beahrs and Gutheil 2001). The imperative for this discussion, however, was not fully recognized until the case of Osheroff v. Chestnut Lodge in the mid-­1980s, which though settled out of court, has since shaped discussions surrounding requirements in psychotherapy (Klerman 1990). In this case, a patient with a prior history of depression that had been partially treated with a tricyclic antidepressant in the outpatient setting experienced deterioration in his functioning and was admitted to Chestnut Lodge, a residential treatment facility. While there, he received psychoanalytic psychotherapy four times weekly as his sole treatment and no further medication options were given to him for his depression. After seven months without satisfactory treatment, his family had him discharged to Silver Hill Foundation where after three months of pharmacotherapy, he improved, was discharged, and was ultimately able to resume his life. The patient sued Chestnut Lodge as he felt that if he had received information regarding his treatment options and had known more about medications, he would have made an alternate treatment selection (Beahrs and Gutheil 2001; Klerman 1990). This raised awareness of the issue and started a course that has led to major professional organizations recommending informed consent as part of the ethical, legal, and administrative obligations of practice (American Medical Association 2005; American Psychological Association 2010).

Ethical Principles and Essential Components of an Adequate Informed Consent In addition to the legal requirements discussed above, informed consent is deeply rooted in the values of medical ethics. It is well acknowledged that informed consent is essential for ensuring patient autonomy—the right to self-­determination of decisions regarding medical care in competent adults that is in keeping with personal beliefs, values, and goals (Barnett et al. 2007; Beahrs and Gutheil 2001; Roberts 2016; Trachsel et al. 2015b). Additionally, as informed consent must speak to benefits and risks inherent in treatment, it also weaves the value of beneficence and non-­maleficence into its purpose in both desiring that the patient has the best available treatment and that choices are offered that balance the risk of harm (Beahrs and Gutheil 2001). As we have seen, prior to the modern process of informed consent, patients were frequently shielded from full clinical details—the consequence of a paternalistic assumption that the physician knew what was best for the patient. Modern medicine developed more patient-­centered approaches, whereby trust and honesty are a

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262   The Ethics of Informed Consent for Psychotherapy framework for the patient–clinician relationship. Fiduciary responsibilities implicit in the doctor–patient relationship require that a reasonable and pertinent amount of information be shared with patients in the consent process. The ethical and legal requirements of incorporating informed consent into care delivery have led to the recognition that there are certain core elements required. For an informed consent to be considered adequate it must contain the essential elements of information sharing, requiring the patient’s adequate decision-­making capacity/competence as well as the voluntarism of the patient (Barnett et al. 2007; Faden and Beauchamp 1986; Gross 2001; Roberts 2016). Patients should receive information regarding the risks and benefits of treatment as well the alternatives that exist to the treatment being recommended. This discussion would include information regarding the diagnosis, the variable course of illness expected, the potential for worsening with or without treatment, duration of treatment as well as the existing treatment alternatives and their empirical evidence (Blease et al. 2018; Fisher and Oransky 2008). It would provide a foundation to partnering around goals and developing a therapeutic alliance (Beahrs and Gutheil  2001). Professional organizations have placed additional recommendations on what should be placed in a psychotherapeutic informed consent. The American Psychological Association encourages sharing further details such as “fees, involvement of third parties, and limits of confidentiality” (American Psychological Association 2002). Assessing a patient’s decision-­making capacity is an important part of the informed consent process. That is, does the patient have the cognitive abilities to receive knowledge and manipulate this information in order to make a decision? The presence of serious psychiatric illness does not preclude the ability to make decisions regarding care (Okai et al. 2007). Rather the patient must have the ability to express a treatment preference, understand relevant information about this treatment preference, consider the choices available to them, and understand the nature of their choice perceiving both its benefits and consequences. These four domains are not binary constructs being either present or absent but rather exist on a continuum of expression that may fluctuate over time based on the patient’s illness and functioning (Appelbaum and Grisso 1988; Roberts 2016; Trachsel et al. 2015a). The final essential component of informed consent is the patient’s voluntarism. This feature resonates with the ethical principle of autonomy in that the patient must be in a position to express their choice freely and without coercion in a manner that is consistent with their values and belief systems. Developmental age of the patient can certainly factor into this with children or those with disabilities still possessing aspects of voluntariness but it may be expressed differently than in a fully functioning adult. Additionally, where the patient is housed can factor into this, with those that are involuntarily hospitalized or committed, or in a residential setting feeling as though they have less choice permitted to them (Roberts 2016). While these are the core attributes of a rigorous informed consent that are part of initiating treatment by surgery or with a medication, there are some nuances in applying this to informed consent in psychotherapy (Trachsel et al. 2015b). There are multiple psychotherapeutic modalities with variable treatment goals. Patients have a wide range of conscious and unconscious needs and perceptions regarding the goal of therapy. These patient needs and perceptions may be at odds with what therapists perceive as treatment goals. A further layer of complexity comes from the fact that therapists have a broad range of backgrounds, training, and credentials. Non-­physician therapists may have alternative views of informed

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the process of informed consent in psychotherapy   263 c­ onsent or treatment contracts. Psychotherapeutic informed consent must be adapted for these realities (see also Sadler, this volume).

The Process of Informed Consent in Psychotherapy Informed consent was historically first linked to the delivery of discrete medical procedures, such as surgeries, which meant that its completion was often practically viewed as a prerequisite of treatment. Psychotherapy, however, as a longitudinal intervention that potentially occurs over multiple sessions occupying a timespan from weeks to years, poses some challenges for how a patient is consented and underscores the importance of viewing informed consent as a process rather than a finite event (Barnett et al. 2007; Blease et al. 2016; Trachsel et al. 2015b). Ideally, this process should commence on the first visit and the American Psychological Association ethics code recommends that it should be integrated into care as soon as possible (American Psychological Association 2002). The phrase “as early as is feasible” indicates that it may not be realistic to accomplish this fully on the first visit (American Psychological Association  2002; Pomerantz  2005). It is recognized that many patients are seeking psychotherapy because of significant personal and interpersonal distress and they may be neither interested in nor in a state of mind to grasp the complexities and gradations of consenting to psychotherapy (Wise 2007). It is also conceivable that the clinician may not have a satisfactory formulation of the patient within the first few visits making the full spectrum of treatment approach and options unclear (O’Neill 1998). For example, a patient may present with mood changes and neuro-­vegetative symptoms initially consistent with a major depressive disorder diagnosis but as the alliance is solidified over a number of sessions the patient is able to share with their therapist a history of trauma that is driving nightmares and hyperarousal. In this situation, the treatment approach taken at first may change as trust is built, the alliance strengthens, and these details flesh out the clinical picture and formulation. Some commentators have noted that an excessively detailed informed consent can be counter-­therapeutic, arguing that presenting the pitfalls of psychotherapy in this initial encounter could undermine the therapeutic alliance or deter further treatment (Beahrs and Gutheil  2001). This concern is not unique to psychotherapy and the same could be said about informed consent discussions surrounding surgery, procedures, or pharmacotherapy. This concern does not mitigate the responsibility to share details that the patient requires in order to make an informed decision and the risks are certainly part of this process. Surveys of therapists have indicated that clinicians also have a varying degree of comfort in what they perceive as being appropriate to share with patients on the first few visits (Pomerantz 2005). Discussing more basic details concerning fees, confidentiality, or general structure are generally viewed as being more natural to share in the first visit than more personalized elements of treatment such as duration (Pomerantz  2005). Realizing these complexities, clinicians should be aware that informed consent may need to be presented in a step-­wise fashion over time and revisited as context and capacity allow. The patient’s changing capacity for receiving information should also prompt clinicians to be mindful of

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264   The Ethics of Informed Consent for Psychotherapy a patient’s treatment options. Patients that are significantly impaired may struggle with receiving, manipulating, or holding new information and the clinician should factor this into consent. As decision-­making capacity is a foundational part of informed consent, so too should clinicians have knowledge of the evidence for use of psychotherapies in particular disorders and their likelihood of success when severe impairment is present. All of these complexities reduce the feasibility of a thorough informed consent in a singular encounter when the treatment relationship may last for many visits. Beyond the initial session, further discussions regarding informed consent need to occur at other points in treatment depending on the patient’s progress or clinical material encountered. This may be particularly germane depending on the psychotherapy employed. For example, this necessity may be different between a manualized brief-­psychotherapy (e.g., cognitive behavioral therapy or interpersonal psychotherapy) with a more predictable course versus a long-­term, more open-­ended treatment (e.g., insight-­oriented psychodynamic therapy) that may be more likely to take an unanticipated direction (Trachsel et al. 2015b). Patients may need to have both written and verbal sharing of information about their care to make this process more efficient and to ensure that they understand the benefits, risks, and alternatives that may come up at certain points in care. Certainly, if the patient’s condition were to change and treatment course were altered the patient should be informed of additional treatment alternatives that may exist, including for example other psychotherapies or pharmacotherapies that may apply. In meeting the requirement of having an adequate informed consent in psychotherapy and recognizing that this is more of a process than an event, the therapist should consider how this information is communicated with the patient. There are no clear guidelines regarding whether informed consent should be given verbally, with a written document or both, though given the case for informed consent being a process, a combinational approach should be entertained (Barnett et al. 2007). Many patients have a preference in how they receive information and this should be explored with them. Using a verbal consent process allows space for interaction and question answering and as noted, could strengthen the therapeutic alliance. It has been recommended that therapists document the patient’s interest in these discussions and their capacity for comprehending the information shared (Beahrs and Gutheil  2001). The sharing of written information in addition would allow patients to reference details between sessions and come prepared with questions about their care if need be. These forms might also better meet legal obligations but should not use language that alienates the patient or confuses the therapeutic intent (Beahrs and Gutheil  2001). As has been noted, the written consent also is tangible proof that can be called upon if either party were to disagree or have trouble recalling details of a discussion (Barnett et al. 2007).

Therapeutic Benefits of Informed Consent Aside from the legal and ethical imperative of performing an informed consent for psychotherapy there is also evidence that there are therapeutic benefits for the patient as well. Including informed consent as part of treatment has the potential to improve the patient’s

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Psychotherapists’ Challenges in Implementing Informed Consent   265 self-­efficacy, empowerment in facilitating change, the therapeutic alliance, and ultimately improve the outcome of psychotherapy (Beahrs and Gutheil 2001; Trachsel et al. 2015b). In the past, some have expressed concern that the insertion of informed consent into psychotherapy may promote passivity in patients and enable them to take a victim role and damage the therapeutic alliance (Beahrs and Gutheil 2001; Guthiel 1994). This perspective seems to be very much rooted in viewing informed consent as an event rather than a process. Informed consent as a process within psychotherapy has the potential to help shift the therapy from the passive to the active—that is, rather than therapy being something done to the patient by the therapist, it encourages the patient to be an active participant in a therapeutic relationship where their input is required. By expecting information sharing from the clinician and eliciting patient input on these details, a collaboration around identifying and working toward goals can be fostered. By having a forthright discussion about treatment goals, expectations, pitfalls, and treatment options available to them, the therapist grounds the treating relationship in honesty and adheres to their fiduciary role. In a recent large-­scale survey examining the negative effects of psychotherapy, Crawford and colleagues had two crucial findings that speak to the process of educating patients about their treatments (Crawford et al. 2016). They observed that patients who could not describe what therapy they had been given were more likely to have experienced negative effects than those who could clearly state the type of therapy received (Odds Ratio (OR) = 1.51, 95 percent Confidence Interval (CI) 1.22–1.87, P