ETHICS IN PSYCHOTHERAPY

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18 ETHICS IN PSYCHOTHERAPY

NORMAN ABELES AND GERALD P. KOOCHER

In the first 60 years after the founding of the American Psychological Association (APA) in 1892, no formal code of ethics existed (Pope & Vetter, 1992). Not until 1938 did APA establish a Committee on Scientific and Pro- fessional Ethics and begin dealing with ethical complaints on an informal basis (Golann, 1969). In 1948, development of a formal ethical code began under the leadership of Nicholas Hobbs (1948). The first provisional Ethical Standards of Psychologists ultimately won adoption by the APA Council of Representatives in 1952 for a 3-year trial period (APA, 1953).

The standards originated using a critical incident methodology (Flanagan, 1954). APA encouraged its members to critique the 1953 publication and provide additional incidents leading to a vote of the membership principle by principle, with formal adoption by the Council to follow in 1955. The APA has revised its code a number of times in ensuing years, but not until the 2002 revision did it again use a critical incident survey. In the 5 years leading to adoption of that revision, APA invited both critiques and case examples that did not seem well addressed in prior versions. During that revision APA members and the public could submit comments and cases via the APA web- site for electronic review by the Ethics Code Revision Task Force. The APA

http://dx.doi.org/10.1037/12353-048 History of Psychotherapy: Continuity and Change (2nd Ed.), edited by J. C. Norcross, G. R. VandenBos, and D. K. Freedheim Copyright © 2011 American Psychological Association. All rights reserved.

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approach proved more relevant to actual practice than codes developed by other professional associations by virtue of the early reliance on actual incidents, and the resulting document became a model for the ethical codes of other health professions.

As the practice of psychotherapy bloomed, and as more psychologists and other professions entered the field, attention to the unique ethics of psychotherapy broadened. Other professional groups added their own per- spectives, and the major professions of psychotherapists have all evolved distinct ethical codes. These include the American Association for Marriage and Family Counseling (2001), American Counseling Association (2005), American Psychiatric Association (2006), and National Association of Social Workers (1999). Many more specialized psychotherapy ethical codes exist, and one can easily locate these via Web searches (Pope, 2008).

An important survey of ethical dilemmas encountered by APA members (Pope &Vetter, 1992) yielded categories of ethically troubling incidents closely tied to psychotherapy. The prominent categories involved confidentiality; blurred, multiple, and/or conflicted relationships; and payment for services. Reports of the APA Ethics Committee describing the nature and incidence of ethical complaints, published annually in American Psychologist, suggest that these three categories remain the most salient bases for complaints in psychotherapy practice. In the pages that follow, we trace the evolution of these three concerns over the past 6 decades and then consider controversial professional and public issues related to psychotherapy.

CONFIDENTIALITY

American history provides many examples of how breaches in confi- dentiality of mental health information have hurt both clients and society. Thomas Eagleton, a senator from Missouri, was dropped as George McGovern’s vice presidential running mate in 1968 following public disclosure that he had previously undergone hospitalization for the treatment of depression. Dr. Lewis J. Fielding, better known as “Daniel Ellsberg’s psychiatrist,” certainly did not suspect that the break-in at his office by federal agents on September 3, 1971, might ultimately contribute to the only resignation of an American president (Morganthau, Lindsay, Michael, & Givens, 1982; G. R. Stone, 2004). Disclosures of confidential information received by therapists also played prominently in the press during the well-publicized murder trials of the Menendez brothers (Scott, 2005) and O. J. Simpson (Hunt, 1999).

No discussion of confidentiality in the mental health arena can occur without reference to the Tarasoff case (Tarasoff v. Board of Regents of the

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University of California, 1976) and the family of so-called progeny cases that followed in its wake (see Quattrocchi & Schopp, 2005; A. A. Stone, 1976; VandeCreek & Knapp, 2001), as these contributed to significant changes in how psychotherapists deal with confidentiality. The case began in fall 1969, when a student at the University of California’s Berkeley campus killed Ms. Tarasoff, a young woman who had spurned his affections. The perpetrator had sought psychotherapy at the university’s student health facility and gave his psychologist cause to seek civil commitment by notifying police about fears that his client posed a danger to Ms. Tarasoff. The police concluded that the patient did not pose a danger and secured a promise that he would stay away from Ms. Tarasoff. After his release by the police, the man understandably never returned for further psychotherapy, and 2 months later killed Tarasoff. California courts determined that the psychologist had a duty to protect Ms. Tarasoff and awarded damages. With respect to risk to public safety, little hard data exist to demonstrate that warnings effectively prevent harm, although reasonable indirect evidence does suggest that treatment can pre- vent violence (Douglas & Kropp, 2002; Otto, 2000). Obviously, ethical prin- ciples preclude direct empirical validation of management strategies that may or may not prevent people at a high risk from doing harm to others (Koocher & Keith-Spiegel, 2008).

In addition, many states had already begun passing legislation mandat- ing that certain professionals, including psychologists, report knowledge of physical or emotional abuse of vulnerable persons (e.g., children, older people, people with disabilities). APA subsequently amended its Ethics Code to reflect authorized breaches to prevent imminent harm to self or others, or as mandated by law.

In 1996, Congress enacted Public Law 104-191, better known as the Health Insurance Portability and Accountability Act or HIPAA. Regulations and implementation took several years, but many focus on protecting the privacy of personal health information (PHI). HIPAA specifies that health care providers, including psychotherapists, must give clients specific notices about the confidentiality of records and standards for authorizing the release of PHI. It is interesting to note that the APA Ethics Code already addressed most of the key principles mandated under HIPAA, albeit with less specificity (e.g., the need to alert clients about limits of confidentiality at the outset of the professional relationship, releasing information to third parties only with a client’s consent). As a result of these cases and statutes, psychotherapists in the United States must ethically give all clients information on the limits of confidentiality at the outset of a professional relationship and must breach confidentiality in certain circumstances to protect the client or other vulner- able parties.

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MULTIPLE RELATIONSHIPS

The APA (2002) “Ethical Principles of Psychologists and Code of Conduct” defines multiple role relationships as occurring when a psychologist stands in a professional role with a person and also (a) holds another role with the same person, (b) has a relationship with someone closely associated with or related to the person with whom the psychologist has the professional relationship, or (c) makes promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. One often cannot avoid such role overlap, and the APA Ethics Code recognizes this by noting that not all multiple role relationships with clients are necessarily unethical so long as no risk of harm can be reasonably expected. The code admonishes psychologists to refrain from entering a multiple role relationship when their objectivity, competence, or effectiveness in performing their professional functions could be impaired or if a risk of exploitation exists.

Some mental health professionals decry the concept of professional boundaries, asserting that they promote the conduct of psychotherapy as a mechanical technique rather than relating to clients as unique human beings. Such critics call attention to boundaries’ rigid, cold, and aloof “cookbook therapy,” harmful to the natural process of psychotherapy (Koocher & Keith- Spiegel, 2008). Lazarus (1994) put it bluntly: “Practitioners who hide behind rigid boundaries, whose sense of ethics is uncompromising, will, in my opinion, fail to really help many of the clients who are unfortunate enough to consult them” (p. 260).

The evolution of strong concern about boundaries appeared most intensely in the mid-20th century. As described in Chapter 13a, Jean-Marc Itard thought nothing of taking “the wild boy of Aveyron” into his home for treatment in 1799. In 1914, Sigmund Freud sent his daughter, Anna, on a trip to England in the care of one of his patients, Leo Kann. Freud later conducted the psycho- analysis of Anna from 1918 to 1922. Anna in turn analyzed Erik Erikson and allowed him to travel with the family on vacations so that he could continue his treatment. One of the most sensational accounts of multiple role conflicts concerns Henry A. Murray (related by his authorized biographer Forrest Robinson [1992]). In spring 1925 Murray visited Carl Jung in Zurich and told Jung of his infatuation with Christiana Morgan, the wife of a friend, with whom Murray would later create the Thematic Apperception Test. Murray’s story triggered a self-disclosure by Jung of his intimate relationship with his patient Antonia “Toni” Wolff, conducted with the full approval of his wife, Emma Jung. At Murray’s urging, Jung agreed to see Christina in October 1925 and encour- aged her to become Murray’s professional and sexual muse, while both were married to other people.

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In the latter part of the 20th century, complaints by patients alleging harmful sexual intimacies with psychotherapists became significant ethical and professional problems. Increasingly, the field became aware of how social and business relationships can compromise the quality of professional ser- vices and integrity (Koocher & Keith-Spiegel, 2008). These factors led to the founding of the interdisciplinary Neuroethics Society, which held its first meeting in November 2008. The society’s president, Steven Hyman, a psychiatrist turned neurobiologist and provost of Harvard University, spoke on “Neuroethics of Pediatric Bipolar Disorder.” He discussed the controversy of assigning the diagnosis of bipolar disorder to hundreds of thousands of American children who never before had signs of major mood disorder, and simultaneously treating these children with powerful drugs in off-label usage (i.e., treatment with drugs neither tested nor approved by the Food and Drug Administration for use in children). Other speakers noted the extremely rare incidence of the same diagnosis outside of the United States.

As new medications abound, adult diagnoses such as bipolar disorder and attendant off-label drug treatments have found their way to children as young as 2 or 3 years old. Such medications pose significant unevaluated risks for children at young ages. How has this ethically risky practice evolved? Recent congressional investigations by Senator Chuck Grassley (R-Iowa) have revealed enormous conflicts of interests involving several of the strongest proponents of such medical applications. Two Boston Globe reporters broke the story of a world-renowned Harvard Medical School professor and child psychiatrist at the Massachusetts General Hospital whose work fueled “an explosion in the use of powerful antipsychotic medicines in children,” earning him at least $1.6 million in consulting fees from pharmaceutical companies between 2000 and 2007. The psychiatrist and two of his colleagues allegedly never reported much of their income from the drug companies, estimated at a combined $4.2 million over 7 years, to university officials (Harris & Carey, 2008). The psychiatrists earned much of the money giving continuing medical education lectures teaching other physicians about prescribing such drugs to children.

Couple these circumstances with long-sought mental health parity legis- lation (i.e., granting fiscal parity to coverage of mental conditions with that afforded physical conditions), and one sees interesting contradictions. The same professionals who support a biopsychosocial model of emotional problems willingly adopted enough focus on “illness” to seek insurance reimbursement parity (i.e., more money to pay providers). Many psychiatrists, who have increasingly eschewed psychotherapy training over psychopharmacology practice (Gabbard, 2005), have flocked to incorporate the new off-label uses into their practices. Just as others have argued against viewing psychological problems as mental illnesses (Szasz, 1960), we now see economic forces aligning

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to promote remedicalization of such difficulties and even create new ones to fit existing or newly created drug protocols (Harris & Carey, 2008). Many years will pass before one can assess whether these shifting roles, trends, and motivations benefit patients or practitioners more.

PAYMENT PROBLEMS

Payment for psychotherapy services has played a significant role in the evolution of service delivery. In particular, the advent of health insurance and coverage for mental conditions influences who practices psychotherapy and how. During the early years of the psychoanalytic movement, few people sought or could afford individual therapy, and professional regulation as we know it today did not exist. So-called lay analysts abounded. From the perspective of psychology, the post–World War II era saw a boom in the training of psychologists and struggles with psychiatry over which profession owned psychotherapy. The key became insurance reimbursement, as psychologists sought licensing recognition, demanded “freedom of choice” laws, and created organizations such as the National Register of Health Service Providers in Psychology to help secure insurance coverage for their services. The 1990s brought managed care and growing ranks of licensed mental health providers who needed to account to third parties (i.e., the client and therapist being the first and second parties) for their therapeutic decisions and treatment plans.

Today, newly licensed mental health professionals worry about their ability to secure a listing on overcrowded rolls of approved health insurance providers. And practice patterns have changed dramatically. Most younger psychiatrists have reduced or completely ceased practicing psychotherapy in favor of pharmacotherapy (Gabbard, 2005), and licensed psychotherapists at the master’s degree level abound. This has led to many efforts by psycho- therapists to differentiate themselves with brand-name psychotherapies, discussed below, and has led to a host of ethical problems related to third- party payments. Some of these concern co-insurance (i.e., copayments and deductibles), billing for missed appointments, and other potential contract violations (Koocher & Keith-Spiegel, 2008). The key to ethical conduct in financial matters involves carefully informing clients of fees and other costs in advance and securing their agreement to these prior to billing. In addition, when psychologists sign a contract with a third-party payer, they must honor provisions of that contract by such acts as collecting specified copayments and not billing clients for amounts in excess of contractual agreements.

The modern reality involves ethical dealings with clients, government, and insurers who have a powerful say in what services they will pay for and what data they will demand to process such payments. In every case, obeying

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contractual agreements, clear communication with clients, and accurate billing form the essentials of ethical conduct.

OTHER ETHICAL CHALLENGES IN PSYCHOTHERAPY

Changes in social values also led to changes in the way psychotherapists conceptualize their ethical values and practices. Such issues have included perceptions of mental illness, same-sex attraction, and the rights of individuals to express a preference for rational suicide in cases of painful terminal illness. As society has changed, psychotherapists have found themselves facing situ- ations and client preferences they could not have envisioned during their professional years earlier.

Myth of Mental Illness Debate

In 1960, Thomas Szasz, a psychiatrist, published an article titled “The Myth of Mental Illness.” He argued against the medical or disease model of mental illness, which presumes that underlying biological defects can explain all disorders in thinking and behavior. Szasz differentiated between physical symptoms, such as pain or fever, and mental symptoms, asserting that believing one’s delusion requires a cognitive judgment. He saw mental symptoms as tied to the social and ethical contexts in which they occur.

Szasz objected to claims that any health treatment (including psycho- therapy) could ever become value neutral, noting that it is actually tied closely to cultural and moral values that one often fails to recognize explicitly. He regarded disorders of the brain as falling chiefly under the rubric of neurology and insisted that the psychotherapists of the 1960s dealt primarily with prob- lems in living, not mental illnesses.

The same year Szasz published his article, O. H. Mowrer (1960), a former APA president, published, “‘Sin,’ the Lesser of Two Evils.” He argued that troubled people, described as “neurotics,” experience self-torture and suffer from excessive rigidity. He suggested that confessing one’s sins causes the con- science to loosen its stranglehold, letting society and the superego relax, and allowing the person to become free and well. Mowrer’s assumption: Psychol- ogists could seek to remedy unacknowledged sin with psychotherapy.

Suicide Prevention and the Duty to Protect

Ethical principles across mental health professions clearly emphasize the importance of protecting clients from harm, including self-harm. Most mental health ethics texts (e.g., Koocher & Keith-Spiegel, 2008; Pope & Vasquez, 2007)

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devote significant discussion to suicidal risk assessment and intervention, and rightly so, because failure to prevent suicide often leads to complaints against a deceased patient’s psychotherapist. Thoughtful clinicians will screen all clients for suicidal risk during initial contact and remain alert to possible risks throughout treatment.

A recent New York Times article (Anderson, 2008) described a premeditation–passion dichotomy to explain how some individuals carefully plan their suicide while others act impulsively using any means available to kill themselves. One must consider how people commit suicide rather than primarily focusing on why they attempt it. The article cites the National Institute of Mental Health (NIMH) as reporting that about 90% of all com- pleted U.S. suicides involve people with a diagnosable mental disorder. It seems clear that psychotherapists will continue to encounter suicidal patients and bear a duty to prevent suicide by comprehensive interventions involving psychotherapy and medication, and separating them from the means of harm- ing themselves through hospitalization if necessary.

Szasz (1986) pointed out that a director of NIMH had in 1967 described suicide as a “disease and public health problem” (p. 806) and reviewed the resulting difficulties in addressing suicide risk by ethicists, if it qualifies as a disease. For example, competent adults have the right to decline treatment, even for fatal illnesses. Szasz argued against suicide prevention (at least coercive prevention), asserting that the mental state of any potentially suicidal indi- vidual has no bearing on instituting coercive action. Szasz did not object to helping suicidal patients in psychotherapy but believed that all people should assume responsibility for their own behavior unless delirium or acute psy- chosis requires physical restraint as an integral part of caring for that patient (p. 810). He insisted, however, that the state should not have the right to pro- hibit or prevent suicide.

Can rational suicide qualify as a valid quality-of-life decision requiring psychotherapists to eschew aggressive intervention? Let’s fast forward to the topic of assisted suicide. In 1997, Oregon enacted the Death With Dignity Act, allowing patients to obtain prescriptions from physicians to achieve a humane and dignified death under specified circumstances (Abeles & Barlev, 1999). Under the Oregon law, such patients must not suffer from impaired judg- ment and must have a terminal disease. Consider that law in the context of a 21-year-old man in Michigan, who had become ventilator dependent as the result of quadriplegia (Abeles & Barlev, 1999). Reportedly, he became depressed and sought to discontinue using the ventilator knowing that doing so would cause his death. He insisted he wanted to die and sought discharge to home. His mother agreed with his decision, but the hospital objected. The courts allowed his discharge, he returned home, and died following a visit from Dr. Kervorkian (Reye, 1998). The courts ruled his death a homicide.

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The ethics codes of both the American Psychiatric Association (2006) and APA (2002) authorize intervention to prevent suicide. The National Asso- ciation of Social Workers (1994), however, provided a position statement authorizing nonintervention in jurisdictions where laws permit assisted suicide. The debate concerning physician-assisted suicide has increased since the U.S. Supreme Court’s holding that physician-assisted suicide remains a state, rather than a federal, matter (Gonzales v. Oregon, 2006).

Many professionals (e.g., Werth, 1996) argue that suicide can constitute a rational act in some circumstances and present several criteria to support the argument. These include the existence of a hopeless condition, circumstances in which the decision constitutes a free choice, and clear indications that the person has engaged in a sound decision-making process. A decision of suicide should include consultation, nonimpulsive consideration of all alternatives, and consideration of the impact the act would have on significant others. The only existing state law on assisted suicide (Oregon) requires evaluation by competent professionals to determine that the patient’s judgment remains unimpaired. The APA (2005) report on the role of psychology in end-of-life decisions and quality of care identified four roles that psychologists play in this area: clinical care, education and training, research, and policy.

Sexual Orientation Conversion or Reparative Therapy

Sexual orientation conversion therapies, once considered a treatment of choice when society deemed homosexuality an illness or form of psycho- pathology, raise a number of ethical challenges. For over a century, medical, psychotherapeutic, and religious practitioners sought to reverse unwanted same-sex attraction or homosexual orientation through a variety of methods, including psychoanalysis, prayer, electric shock, nausea-inducing drugs, hormone therapy, surgery, and a variety of behavioral treatments, including masturbatory reconditioning, visits to prostitutes, and even excessive bicycle riding. The American Psychiatric Association’s 1973 decision to remove homo- sexuality from its seventh printing of the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–II) in 1974 marked the official demise of the illness model of homosexuality. Despite this official “depathol- ogizing” of homosexuality, efforts by both mental health professionals and pastoral care providers to convert lesbians and gay men to heterosexuality have persisted (Greene, 2007).

Such efforts, variously described as conversion therapy, reparative therapy, or therapy to eliminate same-sex attraction, span a variety of treatments. So-called reparative therapy emerged in the early 1980s as a “new method of curing” homosexuals. Elizabeth Moberly, a conservative British Christian theologian with a PhD in experimental psychology, became a key proponent of the approach

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after publishing her theory “that the homosexual . . . whether man or woman . . . has suffered from some deficit in the relationship with the parent of the same sex; and that there is a corresponding drive to make good this deficit . . . through the medium of same-sex, or ‘homosexual,’ relationships” (Moberly, 1983, p. 2). Organizations currently promoting psychotherapy for individuals with same- sex attraction often have moralistic or religious underpinnings and include the National Association for Research and Therapy of Homosexuality and Jews Offering New Alternatives to Homosexuality.

The ethical imperative of respect for clients requires psychotherapists to take guidance from and engage clients in goal setting. Some clients present themselves for treatment, describing emotional problems associated with same-sex attraction. In such circumstances the therapist has an obligation to carefully explore how patients arrive at their choices. Some motives may result from social pressures or experiences with homophobic environments. No type or amount of individual psychotherapy will modify societal prejudices. In addition, as part of informed consent to treatment, therapists must help clients understand the potential consequences of any treatment, including those intended to modify sexual orientation. Clients have a right to know that repar- ative treatments lack any validated scientific foundation and may prove harm- ful. Finally, clients have the right to know that organizations representing the mental health professions do not consider homosexuality a mental disorder.

Two additional ethical concerns accompany so-called reparative treat- ments. First, to what extent does offering such treatments comport with therapist responsibility and consumer welfare? Second, given that rigorous empirical studies fail to show that conversion therapies work, do therapists offering such interventions without clear disclaimers and cautions mislead clients (Greene, 2007; Koocher & Keith-Spiegel, 2008)? APA (1998) addressed these concerns with a Resolution on Appropriate Therapeutic Responses to Sexual Orientation, and similar positions have emanated from other profes- sional groups (e.g., American Psychiatric Association, 1998, 2000; National Association of Social Workers, 2000). These standards essentially allow ther- apists to address the stated needs of clients, so long as they fully inform clients regarding known limitations.

Teletherapy

Rapid advances in microelectronics have made portable communication, data, image, sound storage, and transmission devices affordable and readily available in much of the world. A broad array of personal communications and business transactions now occur in cyberspace. Mental health practitioners increasingly face expectations by clients to provide services in the context of their preferred modes of communication. As psychotherapists move away

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from the traditional context of sitting face-to-face with a client across a room, the Greek prefix tele, meaning from a distance, leads naturally to considering the ethics of teletherapy. Telehealth is used in medicine and mental health for a variety of professional services via telephone and other electronic means (e.g., Barnett & Scheetz, 2003; C. B. Fisher & Fried, 2003). Many medical specialties have regularly used these techniques for consultation among professionals, and a number of services now offer such consultation directly to patients for a fee (e.g., http://www.eclevelandclinic.org/eCCHome.jsp). The traditional way of forming alliances and contracts with individual clients and professional standards will certainly require rethinking.

From the perspective of professional ethics, consider the four Cs: contract- ing, competence, confidentiality, and control (Koocher, 2007). In the context of teletherapy, these questions arise: What contracts or agreements for pro- viding distance services will we as psychotherapists make with our clients? What competencies will we need to offer services remotely? What new factors will constrain confidentiality protections? Who will control the practice of teletherapy (i.e., the regulation of practice and data access)?

When psychotherapists agree to work with clients via teletherapy, the nature and terms of how they relate to clients will change. Psychotherapists will need to reach accords on new contracts regarding the nature of psychological services and the manner of providing them. For example, psychotherapists will have to obtain and document clients’ informed consent to communicate with them electronically. Such consent will doubtless require many changes, such as establishing reasonable security and encryption precautions, keeping information posted on professional websites up to date, and providing instruc- tions regarding access and emergency coverage.

Still other questions must be answered: Will we as psychotherapists contract to correspond electronically only with existing therapy clients, or will we readily accept new referrals of people whom we have never met for professional services? Will we agree to conduct assessment, consultation, or therapy entirely via telemetry or only a limited range of services? Will we promise real-time electronic access 24/7/365? How will record keeping change, given the ease with which we can record, store, and alter such communications? Will our fees and reimbursement policies differ from office-based services? Will we offer emergency coverage? If so, what backup must we organize for clients who live hundreds or thousands of miles away?

New standards of care and professional competencies will certainly apply when we offer therapy services remotely. APA has not chosen to address teletherapy directly in its Ethics Code (APA Ethics Committee, 1997), and by this intentional omission has created no rules prohibiting such services.

Telehealth brings the obvious potential for mischief. Those offering to provide services and those seeking to obtain them may more easily engage in

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misrepresentation. How can one be certain that the person on the other end of the phone line or computer terminal is the person he or she claims to be? How accurate are the claims of teletherapy practitioners regarding their credentials, skills, and success rates with remote interventions? How will therapists feel when an angry former client posts edited excerpts of their “sessions” on youtube.com or stupidvideos.com? Will teletherapy lead to greater caution and reduced liability (e.g., by reducing the risk of client–therapist sexual intimacy) or greater risk (e.g., reduced ability to respond across dis- tances with suicidal clients)? We will probably have answers to such intriguing questions in the not-so-distant future.

Answers about the control or regulation of teletherapy remain highly fluid. Considerable variability exists across licensing jurisdictions in the United States with respect to electronic practice across state lines. With state, provin- cial, and territorial governments regulating professional practice within United States and Canadian jurisdictions, the Association of State and Provincial Psychology Boards has taken the lead in attempting to foster interstate practice and mobility credentials for psychologists in North America. How- ever, little agreement exists regarding standards for interstate or international telepractice. When a client in Massachusetts enters teletherapy with a psycho- therapist in Michigan, or Mumbai, who regulates the practice? Does the treat- ment take place where the client sits, where the therapist sits, or in cyberspace? If something goes wrong, to whom can one complain? Will telepractice qualify as interstate (or international commerce) exempt from state licensing author- ities? We simply do not know the answers at this time.

Brand-Name or Proprietary Psychotherapies

Many psychotherapies have acquired brand-name status over the years. Psychoanalysis probably qualifies as the first established brand of therapy, even though (as described earlier) the practice of psychoanalysis today differs significantly from treatment at Freud’s Vienna Polyclinic (see Chapter 3, this volume). We have chosen two different proprietary therapies to illustrate the ethical challenges they pose.

Eye Movement Desensitization and Reprocessing.

Eye movement desensitization and reprocessing (EMDR), developed by Francine Shapiro (Shapiro, 1995; Shapiro & Forrest, 2004), is described as a comprehensive method for treating disturbing experiences such as trauma associated with sexual abuse, violence, combat, and grief. The treatment incorporates eight stages (using Shapiro’s terminology): taking the client’s

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history and treatment planning, preparation, assessment, desensitization and reprocessing, installation of positive cognition, body scan, closure, and reevaluation. The treatment asks the client to describe aspects of traumatic memories, including recounting mental images associated with the event, the client’s emotional and physiological responses, and the negative feelings of self contained in the memories The technique repeats the sequence of steps until the client’s subjective units of distress scale (so-called SUDS rating) approaches zero.

EMDR has become one of the fastest growing treatments in the annals of psychotherapy, and its progression has many similarities with the history of mesmerism (McNally, 1999). EMDR as a treatment for posttraumatic stress disorder has received widely divergent reactions from the scientific and professional community. Perkins and Rouanzoin (2002) noted that many points of confusion exist in the published literature on EMDR, including its theoretical and historical foundation, placebo effects, exposure procedures, the eye movement component, treatment fidelity, and outcome studies. They described the charges of “pseudoscience” surrounding EMDR and attributed the controversy to confusion in the published literature focused on five factors: the lack of an empirically validated model capable of convincingly explain- ing the effects of EMDR; inaccurate or selective reporting of research; some poorly designed studies; inadequate treatment fidelity in some of the outcome studies; and multiple biased or inaccurate reviews by a relatively small group of authors.

EMDR involves many elements of exposure and cognitive–behavioral therapies, along with the lateral eye movements, causing some to wonder whether the effective component of EMDR actually qualifies as new, and whether the genuinely new aspects of EMDR qualify as effective (McNally, 1999). Shapiro (personal communication, January 17, 2007) argued that EMDR actually integrates many components in addition to cognitive–behavioral elements, including those used in psychodynamic and experiential therapies. In one book, Shapiro (2002) asked experts of the various orientations in experiential, cognitive, and psychodynamic treatment to identify the elements in EMDR that made it effective. Each one identified elements of his or her own orientation as the pivotal factors.

Reviews of the related eye movement research have provided a range of conclusions. Some reviewers (Lohr, Lilienfeld, Tolin, & Herbert, 1999) found no compelling evidence that eye movements contribute to outcome in EMDR, and the lack of unequivocal findings has led some reviewers to dismiss eye movements altogether (e.g., McNally, 1999). Other reviewers (e.g., Chemtob et al., 2000; Perkins & Rouanzoin, 2002) identified method- ological failings (e.g., lack of statistical power, floor effects) and called for

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more rigorous study. Nonetheless, many studies have demonstrated beneficial outcomes for some people using EMDR (e.g., Brown & Shapiro, 2006; Konuk et al., 2006; Raboni, Tufik, & Suchecki, 2006). The Department of Veterans Affairs and Department of Defense (2004) listed EMDR as a potentially effective treatment in their clinical practice guideline for the management of posttraumatic stress.

Although EMDR has clearly proved beneficial for many clients, its aggres- sive marketing, early restrictions on teaching, and resulting aura of secretiveness have contributed to a sense of mystique and controversy. Shapiro had attempted to assure a standard quality in the training of EMDR (Shapiro, 1995; Shapiro & Forrest, 2004). Proponents founded a nonprofit professional organization named EMDR International Association (EMDRIA) as a forum “where prac- titioners and researchers seek the highest standards . . . by promoting training, research and the sharing of the latest clinical information . . . assuring that therapists are knowledgeable and skilled in the methodology” (according to its website: http://www.emdria.org/). Sadly, Shapiro’s work has spawned some creative imitators with questionable rigor who probably cause consternation to well-trained clinicians (Koocher & Keith-Spiegel, 2008).

est

Werner Erhard, the developer of est (Erhard seminar training), was a skilled salesman with no professional training as a psychotherapist. His program evolved to become the “Forum” seminars (Efran, Lukens, & Lukens, 1986; Wistow, 1986) and exists currently as the Landmark Forum, a genre of so-called large group awareness programs (Finkelstein, Wenegrat, & Yalom, 1982). The basic approach challenged participants’ sense of psychological identity or, as one commentator noted, systematic escalation and discount- ing of each participant’s “adapted child,” eventually forcing the participant into their “free child” state, thereby releasing a large amount of “bound energy” (Klein, 1983, p. 178). Other articles have described est as brainwashing (Moss & Hosford, 1983). One of the few careful attempts to study Erhard’s techniques in a rigorous fashion showed no long-term treatment effects and declared claims of far-reaching effects for programs of the Forum as exaggerated (J. D. Fisher et al., 1989).

The ability of skilled salesmen, such as Erhard, to promote and morph their programs in the absence of controlled outcome research and in the face of criticism by behavioral scientists is quite impressive. The central message from an ethical perspective remains the obligation of therapists to have a sound scientific foundation for their work. Rigorous proof of effi- cacy should precede mass marketing of new techniques to the public or to colleagues.

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CONCLUSION

In covering the history of ethics in psychotherapy, we have traversed the emergence of ethical consensus and code of conduct on confidentiality, multiple conflicts, and payment problems. We have selected contentious debates and controversies that had raised significant ethical issues related to psychotherapy. We have no doubt that changes in the health care system, society, and technology will continue to force ethical reexamination about the manner in which psychotherapy is practiced.

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