Ethical Issues in Psychotherapy Research Paper

A good source for information regarding ethical issues in healthcare can be found in the Principles of Biomedical Ethics, by Beauchamp and Childress (1994). These authors take the position that all ethical conduct in healthcare is based upon what they call a four-principled approach to biomedical ethics. They believe that the four primary moral principles that drive ethics in healthcare are: respect for autonomy, beneficence, non malfeasance, and justice. Simply put, healthcare professionals are ethically bound to try to help those they treat (beneficence) while avoiding making things worse (non malfeasance). In addition, healthcare practitioners should have a fundamental respect for the patient’s right to choose (autonomy) and should practice their profession in a system that is equitable and fair (justice). Other authors have argued for the addition of a fifth principle, that of fidelity, to this list (Kitchener 1984; Koocher and Keith-Speigel 1999). As applied to healthcare, fidelity deals with the healthcare provider’s obligation to act in good faith, be honest, keep promises and to fulfill obligations to those they treat. Since these five fundamental principles are generally thought to compose the foundation of ethics in healthcare, they warrant closer scrutiny.

1. Respect For Autonomy

Respect for autonomy is tied to the belief that people have a right to hold views and make choices that reflect their own beliefs and that these beliefs do not need to be shared with, or approved of by, others. Thus, autonomy is a fundamental component of the concept of freedom and, as applied to healthcare, this freedom allows the patient, and not the provider, to control treatment.

Perhaps the best place to find evidence of the principle of autonomy as applied to the practice of psychotherapy is with informed consent to treatment. In its basic form, informed consent requires that the provider tell the patient about the risks and benefits of a specific treatment prior to commencing the treatment itself. In addition, the person consenting must have the capacity to consent and must do so freely (Stromberg et al. 1992). In application, appropriate informed consent serves to level the field in treatment, and allows the patient to become the decision-maker when dealing with his or her well-being. It also places the obligation to fulfill the spirit of autonomy in psychotherapy upon the therapist, who must make sure the decision-maker has enough information to make an informed choice that is free from coercion.

Many authors have argued that good informed consent is not just limited to an exchange that occurs at the outset of therapy but is actually a concept that is applied throughout the treatment process (Pope and Vasquez 1998, Younggren 2000). That is, individuals who find themselves in therapy have a right to understand their treatment, its direction and any changes that occur in its direction. So as the direction of therapy shifts and as the types of interventions used change, the therapist must make sure the patient understands and agrees to these changes. Once again, it is the patient who must be in control of the decision-making process.

Satisfying the requirements of informed consent does not end with fulfilling these obligations to the patient. A good informed consent additionally requires honesty on the part of the psychotherapist regarding comprehensive treatment issues and related matters. If the information shared with the patient is not truthful or complete, then the whole structure of informed consent is threatened since one could not consent to engage in treatment without an honest explanation of that treatment by the therapist.

The requirement of honesty in informed consent raises a number of interesting questions for providers who work in today’s complex healthcare system. For example, a therapist may work with a managed care company whose contract, in application, is more limited than the patient believes. Would it be ethical for this therapist not to inform his or her patients of that reality? Are not a patient’s rights compromised by a therapist’s decision to not tell the patient of the limitations of that insurance when, in fact, the patient might truly not choose to proceed under such circumstances? Is this purposeful lack of clarity unethical? It is clear that the the principle of autonomy requires that the patient understand these types of realities prior to commencing treatment. However, fulfilling this requirement can create serious conflicts of interest for the psychotherapist because the detailed explanation of insurance limitations may be frowned upon by some managed care companies who see such conduct as noncooperative. It goes without saying the providers who are viewed as not being cooperative with the expectations of a managed care company run the risk of losing their provider contracts. All the same the ethical reality remains, that purposefully keeping realities about therapy away from a patient truly violates one of the fundamental tenets of informed consent and that this conduct is unethical. Thus, to conform with the standards of good ethical conduct, therapists must engage in a description of psychotherapy with their patients that is not only detailed, understandable, and noncoercive, but also open, honest and free from conflicts of interest.

Also inherent in the principle of autonomy is a respect for the rights of patients to control the exchange of private information about themselves and to understand the limitations of that control. Once again, patients must, as a part of informed consent, understand how the psychotherapist is going to deal with their personal and, frequently, very private information. This includes an explanation of what information will be shared with insurance companies, other professionals and other family members, to name a few. The spirit of this principle even extends to minors whose rights, in reality, are limited legally. Psychotherapists who work with children have an ethical obligation to make sure that those children understand what is going to be shared with others and what their legal rights are. While children may not be of the legal age to consent, the philosophy of informed consent clearly demands that minors are asked to give age-appropriate informed consent and the child therapist who fails to fulfill this obligation with his or her patients violates the minor’s autonomy rights.

Interestingly, the implementation of the principle of autonomy in the practice of psychotherapy does not allow the therapist to condone destructive behaviour that may result from patients’ expressing their autonomy. Rights to autonomy exist in balance with other moral principles. Thus, ethical mental health professionals understand that destructive choices that damage oneself, like suicide, or damage another, like homicide or child abuse, become expressed exceptions to autonomy rights. In addition, there are settings, like prisons, where individuals have by definition had their freedom of choice restricted and, consequently, these individuals may not be allowed the full benefit of the principles of autonomy. Regardless of these types of exceptions, the general exceptions to autonomy should be clearly understood by all patients prior to beginning psychotherapy.

2. Beneficence

Fundamental to all healthcare is a belief that the provider is attempting to improve the patient’s condition through the delivery of a professional service. This belief is also key to the practice of psychotherapy. Upon first assessment, the value of this principle seems so obvious that some would say it should stand without explanation. However, when applied to the psychotherapy loosely and without being carefully defined, the implementation of beneficence as a principle can become confusing and complex and can raise many questions. These questions include the following: Is it an expression of beneficence to help a patient gain insight into a very painful, historical reality consistent with an insight-oriented model of therapy, with a risk that such insight will result in psychological distress? Where is beneficence found in an extensive, analytically-oriented psychotherapy that can have no concrete or well-defined goal? Is beneficence evident when the therapist’s intentions are good but when the model of intervention has no scientific merit? The answers to the question are elusive and frequently cause extensive, passionate debate among professionals. Psychotherapists should, at a minimum, have a theoretical rationale that answers these and related questions.

Theoretical debates aside, there are some aspects of beneficence that should universally be found in the ethical practice of psychotherapy. Ethically-based psychotherapists who practice with an eye toward beneficence, practice therapies that are, at a minimum, arguably good treatments for the problems their patients bring to them. This type of therapist does not do the same type of therapy with each person who comes through the door. Implied in this is the corollary that the ethical therapist does not see the same problem in every patient he or she treats. The ethical psychotherapist plans therapy with a respect for the empirical and theoretical support that exists, showing that a specific intervention is the right thing to do for the specific problem being addressed.

Respect for beneficence also requires that the therapist engage in activities that improve the quality of their treatments. That is, they engage in consultation, continuing education and literature reviewing in order to stay current with the changing status of their profession. The ethical therapist also constantly combines the law, current literature, and community standards in using a model of intervention that has the highest probability of success and the ethical therapist is secure in his or her ability to justify their professional conduct. This style of practice assures the ethical psychotherapist that the intervention in a specific case is both consistent with the standard of care for a psychotherapist and in the best interests of the patient. It goes without saying that practicing an outmoded model of intervention, in the face of clear evidence that another treatment could be more effective, would likely be a violation of the principle of beneficence in psychotherapy. There is little justification for a psychotherapist to apply a model of intervention that is less efficient, more costly and less likely to be successful when compared with another treatment, without a clear understanding or rationale for doing so. Once again, the reality of managed care constraints lends itself well to a discussion of the application of the ethical principle of beneficence to psychotherapy. That is, ethical psychotherapists do not allow the constraints placed upon them by insurance benefits or managed care contracts to lead them away from what they believe would be the most effective intervention. The ethical therapist, at a minimum, must make sure that both the patient and the insurance company know that effectiveness of therapy is being administratively threatened by insurance constraints and all parties must know what the recommended treatment is. Most importantly, the ethical psychotherapist attempts to resolve any administrative insurance conflicts with a constant eye toward what is in the patient’s best interest.

Finally, the ethical psychotherapist does not continue a treatment that is no longer benefiting the patient. When faced with an intervention that is leading nowhere, ethical constraints would demand a change in direction that would result in either a change in the type of therapy or, if absolutely necessary, the termination of treatment. To do otherwise is potentially exploitive of the patient, and denies the patient access to other, potentially more effective interventions: a clear violation of the principle of beneficence.

3. Non Malfeasance

It comes as no surprise that ethical psychotherapists are supposed to avoid doing bad or destructive things to and with their patients. In today’s litigious society this has become a very powerful principle and is felt by some authors to take precedence over all other ethical principles (Marsh 1997, Harris 2000). It is obvious that therapy is not supposed to be a damaging process and it is the responsibility of the ethical therapist to minimize risk in order to avoid, at all costs, engaging in a process that is destructive. This prohibition against doing destructive things is very broad and not only applies specifically to the treatment aspects of psychotherapy but can also include administrative aspects of the treatment relationship.

Once again defining exactly what is destructive and damaging about psychotherapy can be quite subtle and elusive. As pointed out earlier, risk can frequently become a matter of theoretical debate among mental health professionals from differing theoretical orientations. Regardless of this lack of consistency and conceptual clarity, in general, therapists should constantly evaluate whether their interventions are potentially damaging to their patients. This is not only in the patient’s best interests but also protects the therapist. However, this does not mean that ethical therapy must be void of risk, since there is probably some degree of risk in all treatments. What it does mean is that therapists do not engage in delivering treatments to patients that have risk without the patient understanding, as much as possible, the nature of those risks. If the term ‘risk’ comes from controversy in the field, and/or the lack of strong empirical support, it becomes all the more important that the patient receive a detailed explanation of these issues.

Non malfeasance principles would also prevent a therapist from engaging in extratherapeutic conduct with a patient that has no theoretical or empirical treatment value whatsoever, or that has even been shown to be potentially destructive. For example, a patient could never give informed consent to have sex with a therapist because research has already shown such conduct to be potentially very destructive to patients and to be of no treatment value. Even if the therapist informed the patient of these risks, agreement on the part of the patient would not reduce the serious nature of this type of ethical violation. A patient also could never give consent to allow the therapist to serve conflicting roles in a case regardless of the rationale for so doing. This prohibition against engaging in anything that is potentially destructive in psychotherapy includes patient exploitation, physical abuse, boundary violations, multiple relationships, and more. The seriousness of these types of violations is only made more obvious by the reality that this type of potentially dangerous conduct usually has nothing to do with psychotherapy and that it is frequently the result of designing the treatment relationship to meet the needs of the therapist, and not the patient.

4. Justice

The ethical principle of justice is the foundation for other very valuable healthcare concepts like fairness and equality. Justice should be evident whenever persons are due benefits from others because of their particular circumstance, as when they are ill or when they are struggling emotionally. The fulfillment of this principle is based upon the professional’s respect for the fair and equal distribution of services regardless of societal differences like race, status, religious orientation, etc. (Kitchener 1984).

The principle of justice, as a concept applied to psychotherapy, takes on differing forms depending upon circumstance. Limited assets, limited time, limited staffing all are variables that have direct impact upon the implementation of justice in a treatment setting. Under some circumstances the lack of justice in the provision of professional services becomes clear; however, in others, it becomes clouded. For example, it would be obvious to most that a therapist who changes services based upon a patient’s race would be unethical. In this circumstance, the lack of justice is easy to evaluate. However, what about when people cannot afford care because of poverty, societal unfairness or when benefits are limited or simply not available? How does the ethical psychotherapist pursue justice under these circumstances? Or, is the ethical therapist even responsible for addressing these types of issues when delivering care? Under these types of circumstances true justice becomes quite difficult to pursue.

In reality, things are not often just, and inequality is a part of the human circumstance. Suffice it to say that ethical psychotherapists are those who work toward justice in treatment but are realistic in so doing. That is, they aim to do the best they can in psychotherapy, to be fairest to the persons they are treating. In fact, this is the psychotherapist’s fiduciary obligation in psychotherapy.

In application, the ethical psychotherapist might pursue justice in therapy by providing a few extra termination sessions to the patient who has lost insurance benefits. He or she could offer a few pro bono visits to the patient who does not have the financial means to continue treatment or the fee for therapy could be reduced so that the patient could afford it. Or he or she could also volunteer to give time to those who do not have the means to pay for the services they receive. Regardless of the actual case, the ethical psychotherapist pursues justice in treatment and makes this one of the key principles in ethical decision-making.

5. Fidelity

The final principle of ethical decision-making is that of fidelity. Fidelity addresses a person’s responsibility to be loyal and truthful in their relationships with others. It also includes promise keeping, fulfilling commitments, and trustworthiness (Welfel and Kitchener 1992). In healthcare, however, the implementation of this principle extends beyond the regular responsibilities of business or contractual fulfillment to the creation of relationship based upon trust: the trust the patient has that the professional will always operate in the patient’s best interests and will always fulfill their professional obligations to operate in his or her best interests. Some authors have taken the position that fidelity, along with non maleficence, are the most legally salient moral principles (Bersoff and Koeppl 1993).

As applied to psychotherapy, fidelity forces the professional to orient toward the patient’s needs and not his or her own. Thus, the therapist who allows a sexual relationship to develop in treatment would be violating this principle. Clearly such a relationship is designed to meet the therapist’s needs and becomes exploitive. This principle also applies to patient abandonment since such conduct would violate the trust the patient places in the psychotherapist, trust that the therapist will see the patient through the treatment process. Finally, fidelity also applies to circumstances where professionals allow administrative factors, like benefits limitations, fee capitation, and contractual rebates to affect their treatment decisions.

Fidelity, as applied to healthcare, is a dynamic process: and the way in which a therapist maintains fidelity in treatment changes as treatment changes. Fidelity also blends with the other principles of ethical decision-making to require that the therapist be open and honest in the treatment relationship and to make sure that the patient’s expectations are consistent with what the therapist can provide. Fidelity requires psychotherapists to make the best choices they can for those that they treat.

6. Summary

The ethical psychotherapist is one who understands the fundamentals of ethical philosophy and knows how to apply them to individual cases. If a psychotherapist is capable of viewing ethical dilemmas from the perspective of ethical philosophy, decisions regarding the correct choice, if you will, become much easier to find. This approach is much more effective than a rule-based system. Rule-based guidance will never give the psychotherapist ethical security because the profession is complex and is fraught with theoretical debate and inconsistency. The search for rules, versus an understanding of principles that generate those rules, will only create a complex, awkward, and laboriously large system that would truly obscure a professional’s ability to evaluate problems and to then choose the best course of action. Therefore, the answers to ethical questions can be found in the thoughtful implementation of the five principles of autonomy, beneficence, non malfeasance, fidelity, and justice in psychotherapy.

Bibliography:

1. American Psychological Association 1992 Ethical principles of psychologists and code of conduct. American Psychologist 47: 1597–611
2. Beauchamp T L, Childress J F 1994 Principles of Biomedical Ethics, 4th edn. Oxford University Press, New York
3. Bersoff D N, Koeppl P M 1993 Ethics and Behavior 3: 345–57
4. Eberlein L 1987 Introducing ethics to beginning psychologists: A problem solving approach. Professional Psychology: Research and Practice 18: 353–59
5. Harris E 2000 Ethical Decision Making and Risk Management in Clinical Practice. A workshop presented by the American Psychological Association Insurance Trust at the meeting of the American Psychological Association, Washington, DC
6. Kitchener, K S 1984 Intuition, critical evaluation, and ethical principles: The foundations for ethical decisions in counseling psychology. The Counseling Psychologist 12(3): 43–55
7. Koocher G P, Keith-Spiegel P 1998 Ethics in Psychology, 2nd edn. Random House, New York
8. Marsh, D T 1997 Ethical issues in professional practice with families. In: Marsh D T and Magee R D (eds.), Ethical and Legal Issues in Professional Practice with families, pp. 3–26 John Wiley, New York
9. Pope, K S, Vasquez M J T 1998 Ethics in psychotherapy and Counseling, 2nd edn. Jossey-Bass, San Francisco
10. Stromberg C D, Haggarty D J, Leibenluft R F, McMillan M H, Mishkin B, Rubin B L, Trilling H R 1988 The Psychologist’s Legal Handbook. The Council for the National Register of Health Service Providers in Psychology, Washington, DC
11. Welfel E, Kitchener K 1992 Introduction to the special section: Ethics education—an agenda for the 90s. Professional Psychology: Research and Practice 23: 179–81
12. Younggren J N 2000 Is managed care really just another unethical Model T? The Counseling Psychologist 28(2): 253–62