Why Ethics Matter in Psychotherapy

The clinical practice of psychotherapy is 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. The Oxford Handbook of Psychotherapy Ethics aims to provide the most comprehensive reference textbook of psychotherapy ethics; to offer benchmark chapters as go-to guides for a wide variety of practitioners, scholars, policymakers, and patients; to address conceptual, philosophical, cultural, and religious perspectives while also addressing everyday practice concerns; and to identify areas of ethical consensus and convention, while identifying unresolved issues as well as identifying new, problematic areas needing further analysis and research.

Psychotherapy Integration as an Ethical Practice

This chapter aims to analyze which ethical challenges clinicians face when practicing different forms of psychotherapy integration. With this purpose, the authors first define psychotherapy integration and differentiate four types of integrative approaches. Drawing on Beauchamp and Childress’s (2013) principles of biomedical ethics, the chapter highlights important common and particular ethical issues in the four types of integrationist psychotherapy practice. Finally, the authors frame questions for future research into integrative-psychotherapy ethics and consider possible clinical responses to ethics issues raised in integrative therapy.

The Ethics of Placebo and Nocebo in Psychotherapy

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 overestimated 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 this chapter, psychotherapy scholars’ strivings and troubles for specificity will be briefly covered, touching the uncomfortable relationship with placebo and nocebo and finishing with an ethical plea for transparency in psychotherapy and of psychotherapists.

Phenomenological-Hermeneutic Resources for an Ethics of Psychotherapeutic Care

This chapter introduces and discusses 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 acknowledgment of the pre-individual elements not yet appropriated by myself; other-recognition is the acknowledgment of the other person as a fellow man to whom I attribute value, life, and consciousness. Intimacy is an atmospheric experience of aloneness-togetherness, self- and other-recognition: enveloped in an atmosphere of intimacy I get in touch with myself via getting in touch with each other.

The Ethics of Artificial Intelligence in Psychotherapy

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. This chapter discusses the use of chatbots and AI tools as supplements to psychotherapy delivered by persons, and as supervised primary treatments. It presents ethical guidelines and standards for AI and mobile apps in mental health, and discusses 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. The chapter aims to enrich the debate by complementing a perspective of justice with one of care and using both approaches to reflect on the topics of respect of autonomy, access to treatment, non-discrimination, and fulfillment of people’s needs and care. It argues that trustworthy AI tools may help to establish caring relationships between therapist and patient, and contribute to the therapeutic process.

The History and Ethics of the Therapeutic Relationship

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 requires continued ethical analysis in order to confront the diversity and complexity of contemporary clinical practice.

Ethics in Couple and Family Psychotherapy

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 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 presented 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.

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

Resource scarcity forces health care systems to set priorities and navigate trade-offs 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.

Fairness, Justice, and Economical Thinking in Psychotherapy

Despite a robust and growing evidence base to support the effectiveness of psychotherapy in treating mental illness and promoting mental health, funding and access is often limited. Psychotherapy’s claim on a share of individual and social resources must compete, on the one hand, with other mental health services devoted to treating mental illness, and on the other hand, with a variety of social services that promote mental health and human flourishing. This chapter focuses on different theories of justice to consider (a) whether a case might be made for the unique value of psychotherapy amongst other competing services, and (b) if not, what criteria might be relevant in assessing its relative cost and value. The chapter begins by reviewing some relevant concepts of justice and how they might be applicable to allocation of psychotherapy resources, specifically, Rawlsian, capabilities, utilitarian, and communitarian theories. It then discusses how these concepts of justice can be used to navigate research about psychotherapy outcomes as well as its cost-effectiveness. Decisions about which outcomes to consider are not value-neutral and can be guided by relevant theories of justice. The chapter concludes with a brief discussion of lower-income countries.

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

This chapter 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.