The Artificial Third: A Broad View of the Effects of Introducing Generative Artificial Intelligence on Psychotherapy

Unlabelled

This paper explores a significant shift in the field of mental health in general and psychotherapy in particular following generative artificial intelligence's new capabilities in processing and generating humanlike language. Following Freud, this lingo-technological development is conceptualized as the "fourth narcissistic blow" that science inflicts on humanity. We argue that this narcissistic blow has a potentially dramatic influence on perceptions of human society, interrelationships, and the self. We should, accordingly, expect dramatic changes in perceptions of the therapeutic act following the emergence of what we term the artificial third in the field of psychotherapy. The introduction of an artificial third marks a critical juncture, prompting us to ask the following important core questions that address two basic elements of critical thinking, namely, transparency and autonomy: (1) What is this new artificial presence in therapy relationships? (2) How does it reshape our perception of ourselves and our interpersonal dynamics? and (3) What remains of the irreplaceable human elements at the core of therapy? Given the ethical implications that arise from these questions, this paper proposes that the artificial third can be a valuable asset when applied with insight and ethical consideration, enhancing but not replacing the human touch in therapy.

Statement on conversion therapy

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is practiced in every region of the world by health professionals, religious practitioners, and community or family members often by or with the support of the state. Conversion therapy is performed despite evidence that it is ineffective and likely to cause individuals significant or severe physical and mental pain and suffering with long-term harmful effects. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly or without their consent. This medico-legal statement also addresses the responsibility of states in regulating the practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to it.

Ethical considerations for addressing distorted beliefs in psychotherapy

With rising rates of misinformation, psychotherapists are likely to encounter clients with distorted beliefs that are scientifically unsound. In situations where these beliefs are harmful (e.g., vaccination refusal, misunderstanding of sexual consent), psychotherapists may face an ethical dilemma regarding how to proceed with psychotherapy. This is especially true if such beliefs are impairing treatment progress or resulting in safety concerns for the client or society. Questions about whether and how the psychotherapist should address these distorted beliefs are therefore likely to arise. In such cases, psychotherapists are tasked with respecting the client's autonomy, while simultaneously being of maximum benefit to the client and to society at large. Not all distorted beliefs warrant therapeutic intervention, but this judgment requires careful consideration. The current article addresses the relevant ethical considerations for navigating and addressing distorted beliefs in psychotherapy. A vignette is offered, and relevant sections of the American Psychological Association's Ethics Code are discussed, both as they pertain to this scenario and as they apply more generally to the practice of psychotherapy. The article concludes with questions for psychotherapists to consider and recommendations for how to proceed when confronted with harmful distorted beliefs. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Ethical implications of routine outcomes monitoring for patients, psychotherapists, and mental health care systems

Although psychotherapy is generally efficacious, a substantial number of patients fail to improve meaningfully, whereas still others deteriorate. Moreover, psychotherapists have difficulty forecasting which patients are at risk for nonresponse or deterioration, especially when relying predominantly on their judgment. These limitations have implications for the ethical practice of psychotherapy, and they call for remediation strategies. One such strategy involves the use of routine outcomes monitoring (ROM), or the regular collection of core patient progress information that can be fed back to the clinician and patient in real time. ROM-informed analytics outperform clinical judgment in predicting patients who are on or off track for treatment success, which can help psychotherapists plan and responsively adjust their interventions. Additionally, research demonstrates that ROM-generated feedback improves treatment outcomes for the average case who receives versus does not receive it. ROM data can also uncover between-therapist differences in general efficacy, as well as scientifically highlight clinicians' own relative strengths and weaknesses in treating different mental health problems. In light of such evidence, we submit that the research on ROM has matured to the point that it should occupy a central role in discussions of, and guidelines about, the ethical practice of psychotherapy. In this vein, we discuss ROM at patient, psychotherapist, and mental health care systems levels; namely, for each of these stakeholders, we review the extant empirical support before turning to possible ethical implications. Finally, we offer concluding thoughts on the expanding relevance of ROM for helping psychologists fulfill their ethical practice obligations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Competing Ethical Interests Regarding Privacy and Accountability in Psychotherapy

"Jane" is a mother of two, who was referred for psychotherapy. However, Jane had misgivings about engaging in the offered psychotherapy because of threats made by her domestically violent partner. The therapy sessions are audio recorded for the purpose of professional supervision and clinician reflective practices. Jane's partner had threatened to subpoena the therapy recordings to legally separate Jane from her children. This article focuses on how three different parts of Jane's multidisciplinary care (i.e. clinicians, policy professionals and medico-legal professionals) exhibit different competing ethical priorities. Psychotherapeutic clinicians private use of audio recordings of the therapy enhances patient care and their own professional development but with the risk of concealing possible unethical behaviour by either party. Medico-legal access to the therapy recordings preserves potentially relevant evidence in the pursuit of justice but risks the interpretation of the psychotherapeutic information outside of the therapeutic context. Policies advocating the inclusion of the therapy recordings in the medical record improves clinician (and health service) accountability but risks harming the vulnerable patient due to threats to patient-therapist confidentiality.

Psychotherapy for the 21st century: An integrative, evolutionary, contextual, biopsychosocial approach

Fragmentation of processes and interventions plague the psychotherapies (Gilbert & Kirby, ). Part of the problem is that we have not agreed on a framework that could be the basis for integrating knowledge and the scientific enquiry of processes and interventions. This paper outlines an approach that brings together a variety of different disciplines in the service of consilience (Wilson, , Consilience: The unity of knowledge, Vintage, New York, NY; Siegel, ). It presents the importance of an evolutionary framework for understanding the proclivities and dispositions for mental suffering and antisocial behaviour, and how they are choreographed in different sociodevelopmental contexts. Building on earlier models (Gilbert, , Human nature and suffering, Routledge, London, UK; Gilbert, , Clin. Psychol. Psychother., 2, 135; Gilbert, , Br. J. Med. Psychol., 71, 353; Gilbert, , Case formulation in cognitive behaviour therapy: The treatment of challenging cases, Wiley, Chichester, UK, pp. 50-89) the call is for an integrative, evolutionary, contextual, biopsychosocial approach to psychology and psychotherapy. PRACTITIONER POINTS: Evolutionary functional analysis is part of an evolutionary, contextual, biopsychosocial approach to mental health that can serve as a scientific platform for the future developments of psychotherapy. Therapist skills and training will increasing need to focus on the multidimensional textures of mental states especially the context-social-body linkages. Therapies of the future will also focus more on the moral aspects of therapy and address the need to promote prosocial and ethical behaviour to self and others.

[The contribution of the relationship between therapist-patient and the context of the professional relationship]

The therapeutic relationship is the common place of all medical specialties in therapeutic practice. It is a professional relationship and consists of two components: the work component and the interpersonal component. The focus of the studies aims to show the contribution of the dynamics of the therapist - patient interpersonal relationship as a therapeutic factor in achieving the therapeutic outcome. The issue of doctor-patient relationship has been studied since antiquity, in particular by Socrates and beyond. Hippocrates promotes and systematizes medical philosophy, bioethics and medical ethics, as seen in the well-known "Hippocratic Oath". In the new era, S. Freud continued the work of inductive dialectics of Socrates, while formulating the concept of transference and countertransference. The development of psychotherapies has provided enough evidence for the parameters that interact into a therapeutic relationship, as their techniques were merely dialectical. M. Balint supports the value of counter-transference and transference to the therapeutic relationship. G. Bibring & R. Kahana suggest that psychoanalytic techniques and personality types contribute to the understanding of the physical patient. C. Rogers suggested that the attitudes and the empathic understanding of the therapist, not the techniques, contribute primarily to therapeutic success. G. Engel (1970) promotes the patient's biopsychosocial approach. Since 1980, systematic studies have begun to support the value of the therapeutic relationship, believing that it is itself an autonomous therapeutic factor, confirming the views of M. Balint and C. Rogers. They conclude that the therapeutic effect is a function of the quality of the therapeutic relationship, regardless of any therapeutic technique, and that the therapeutic alliance has a significant effect on the clinical outcome for psychotherapies as well as for pharmacotherapy. Empathy, non-possessive warmth, positive respect and authenticity have a significant effect on the treatment results. The common factor model supports the dynamics of the interpersonal relationship contributing 85% to the therapeutic effect whereas the therapeutic techniques contribute 15%. It therefore seems that the dynamics of the interpersonal relationship, the therapist-patient, is an important therapeutic factor. Studies continue and more questions arise as to whether education is available, the dynamics of interpersonal relationships in the context of therapeutic relationships at undergraduate and postgraduate levels. Also, the development of dialectical techniques, as a response to the empathic therapeutic relationship, which contributes at the clinical level to the patient's approach and information within the general health area and not only to mental health.

Film Psychotherapy in the 21st Century

Psychotherapy is commonly depicted in films. Films, then, help to inform the public about the nature of psychotherapy and psychotherapists. Although much has been written about the portrayal of psychotherapy in films, there has been little empirical investigation of films from the 21st century. The current study provides a systematic investigation of the portrayal of therapists and therapy in films released between 2000 and 2013. Trained volunteers coded films with characters identified as psychotherapists. Data are presented for ratings on 22 films in which therapist characters appeared on screen for at least 15 minutes. Therapists were predominantly Caucasian, male, and between ages 40 and 60 years. Their most common characteristics were generally positive-intelligent, caring, knowledgeable, and compassionate. More than half were portrayed as unethical, and more than one-third as manipulative. Therapists were also commonly shown as touching clients in some way, disclosing client information without permission, and becoming involved in social relationships with clients. In addition, it was often unclear whether clients benefitted from their engagement in therapy. The observed portrayals raise serious concerns about their potential impact on viewers. Viewers may be discouraged from seeking help and may have increased vulnerability to exploitation because of a lack of understanding of what is appropriate and inappropriate therapist behavior.

Should Mental Health Screening and Psychotherapy Be Required Prior to Body Modification for Gender Expression?

Some people want to modify their bodies through hormonal and surgical treatments in order to resolve gender dysphoria, the distress they experience when their bodies do not align with their gender identity. The World Professional Association for Transgender Health (WPATH) offers guidelines to clinicians regarding treatment of people wanting to modify their bodies for this reason. Prior to these modifications, WPATH advises that mental health screening is needed and that psychotherapy is recommended though not a requirement. In fact, these advisories allow clinicians some freedom in applying the standards to specific cases. Although some variation from the WPATH Standards of Care can be clinically acceptable, informed consent remains an essential component of clinical encounters involving body modifications.

Disclosure of incidental constituents of psychotherapy as a moral obligation for psychiatrists and psychotherapists

Informed consent to medical intervention reflects the moral principle of respect for autonomy and the patient's right to self-determination. In psychotherapy, this includes a requirement to inform the patient about those components of treatment purported to cause the therapeutic effect. This information must encompass positive expectancies of change and placebo-related or incidental constituent therapy effects, which are as important as specific intervention techniques for the efficacy of psychotherapy. There is a risk that informing the patient about possible incidental constituents of therapy may reduce or even completely impede these effects, with negative consequences for overall outcome. However, withholding information about incidental constituents of psychotherapy would effectively represent a paternalistic action at the expense of patient autonomy; whether such paternalism might in certain circumstances be justified forms part of the present discussion.

Should the century-old practice of psychotherapy defer to science and ignore its foundations in two millennia of ethical thought?

While agreeing with the mainstream view that psychotherapeutic practice must be grounded in science, including research on the effectiveness of psychotherapy, the author advocates giving more weight to the venerable philosophical literature on ethics that bears directly on what patients bring to therapists: problems in living. These problems have been the domain of ethics since Socrates, who--like psychotherapists--promoted reflective dialogue. This article reviews some contemporary thought regarding the importance of reflection and the limits that patients and therapists face in promoting it. Relying on attachment theory and the process of mentalizing, the author identifies a convergence of science and ethics in the therapeutic aspiration to cultivate epistemic trust and illustrates this convergence with a case example.

Reviewing outcomes of psychological interventions with torture survivors: Conceptual, methodological and ethical Issues

BACKGROUND

Torture survivors face multiple problems, including psychological difficulties, whether they are refugees or remain in the country where they were tortured. Provision of rehabilitation varies not only with the needs of survivors and resources available, but also with service models, service provider preferences and the local and country context. Despite increasing efforts in research on effectiveness of psychological interventions with torture survivors, results are inconclusive.

METHODS

We undertook a Cochrane systematic review of psychological, social and welfare provision, with meta-analysis to best estimate efficacy. The process raised conceptual, methodological and ethical issues of relevance to the wider field.

FINDINGS

We searched very widely, but rejected hundreds of papers which recommended treatment without providing evidence. We found nine randomised controlled trials, from developed and under-resourced settings. All conceptualised survivors' problems in psychiatric terms, using outcomes of post-traumatic stress symptoms, distress, and quality of life, by self-report, with or without translation or unstandardised interpretation, and with little mention of cultural or language issues. None used social or welfare interventions. Four related studies used narrative exposure therapy (NET) in a brief form, and without ensuring a safe setting as recommended. Five used mixed methods, including exposure, cognitive behavioural therapy, and eye movement desensitisation. Combined, the studies showed no immediate improvement in PTSD, distress, or quality of life; at six months follow-up, a minority showed some improvement in PTSD and distress, although participants remained severely affected.

CONCLUSIONS

While applauding researchers' commitment in running these trials, we raise ethical issues about exposure in particular, and about the effects of shortcomings in methodology, particularly around assessment using unfamiliar cultural frameworks and language, and the lack of concern about dropout which may indicate harm. The issues addressed aid interpretation of existing research, and guide clinical practice as well as future studies evaluating its effectiveness.

Prescribing Posttraumatic Growth

This article introduces questions in psychiatric ethics regarding the substantial field of qualitative and quantitative research into 'posttraumatic growth', which investigates how, after devastating experiences, individuals can come to feel that they have developed warmer relationships, increased spirituality, or a clearer vision of their priorities. In one area of this research, researchers of posttraumatic growth outline strategies for clinicians interested in assisting their patients in achieving such growth. In this article, I articulate two ethical concerns about this account of posttraumatic growth and the practice of growth-oriented therapy. The first is a concern about the status and effects of the ideal of posttraumatic health implicit in their account, and the second a concern about the ethical implications of the clinical recommendations for the post-trauma patient. I argue for the need for more attention to the hazardous implications of relating to patients as though they are on their way to, and themselves largely in control of, their own posttraumatic growth.

[Spirituality and ethics in psychosomatic medicine]

A patient has to cope with an illness on a physical, mental and spiritual level. There exists a difference between religiousness and spirituality even though the approach has a common foundation. Nonreligious spirituality relates to an inner experience, transcendent states of consciousness, meaningfulness, responsibility, sympathy, ethics, humanisation, faith. We encounter the spiritual point of view in humanistic psychotherapy, pastoral medicine, work of hospital chaplains, New Age, psychotherapies with religious and alternative aspects, transpersonal psychotherapy, psycho-spiritual crises, unusual states of consciousness, in meditation, Yoga, relaxation, kinesiology, ethicotherapy, reincarnation therapy, positive motivation, holotropic breathing, etc. There is description of different degrees of spiritual development, rational and irrational feeling of spirituality, Quantum Physics, spiritual intelligence, neuro-theology, physiological change, effects on improving adaptation during stress, drugs addiction, etc. Spirituality in relation with ethics is discussed in terms of socio-biology, evolution, emotions, aggressivity, genetics and social influence. The work analyses the effect of stressful situations on the deterioration of moral attitudes: during lack of time, obedience to authority and order. It is described how temperament and personality disorders can affect perception of spirituality, guilt feeling and conscience. Stressful situations, lack of time, relying only on the auxiliary objective methods leads to alienation of physician with a patient. Spirituality can partially improve the doctor-patient relationship, communication and sense of responsibility.

Confidentiality principles in psychiatry

Confidentiality stands out in psychiatry through its multiple connotations as an intrinsic necessity in the ethics of professional relationships. Thus it represents an important characteristic of this profession and at the same time a stringent request which, through its specificity, implies a direct contact with persons in need for help. Despite being inserted in professional codes and legislative systems, confidentiality in psychiatry is far from being considered a clarified matter and does not stand aside from ethical controversy. Keeping the professional secret is often a hard task due to the pressure of the law or of other professional groups who can bring multiple justifications, including that of action for the benefit of society. The therapist is often sub- mitted to a tension caused on the one hand by the promise of keeping the professional secret and on the other hand by multiple requests of breaking the confidentiality. So the problem of confidentiality in Psychiatry deserves special attention because in this profession, more than in other branches of medicine, the gain of the patient's trust is essential in the psychotherapeutic relationship.

[Psychosocial rehabilitation and care under constraint]

Psychosocial rehabilitation is a theoretical tools used in psychiatry to fight against the marginalization of chronic patients. In Geneva, the "Tilleuls", a rehabilitation unit located in the psychiatric hospital, provides a range of group and individual interventionsfocusing on recovery for patients with criminal or civil constraints but also patient with severe and debilitating forms of psychotic illness. This article addresses the various types of constraints (medical, civil or criminal) and their impact on for the recovery process. In agreement with other studies, subjective perception of constraints in our clinical setting does not correspond to the legal status of admission. Similarly, the outcome of care is only marginally related to the presence of criminal or civil constraints.

Disclosure of past crimes: an analysis of mental health professionals' attitudes towards breaching confidentiality

Ensuring confidentiality is the cornerstone of trust within the doctor-patient relationship. However, health care providers have an obligation to serve not only their patient's interests but also those of potential victims and society, resulting in circumstances where confidentiality must be breached. This article describes the attitudes of mental health professionals (MHPs) when patients disclose past crimes unknown to the justice system. Twenty-four MHPs working in Swiss prisons were interviewed. They shared their experiences concerning confidentiality practices and attitudes towards breaching confidentiality in prison. Qualitative analysis revealed that MHPs study different factors before deciding whether a past crime should be disclosed, including: (1) the type of therapy the prisoner-patient was seeking (i.e., whether it was court-ordered or voluntary), (2) the type of crime that is revealed (e.g., a serious crime, a crime of a similar nature to the original crime, or a minor crime), and (3) the danger posed by the prisoner-patient. Based on this study's findings, risk assessment of dangerousness was one of the most important factors determining disclosures of past crimes, taking into consideration both the type of therapy and the crime involved. Attitudes of MHPs varied with regard to confidentiality rules and when to breach confidentiality, and there was thus a lack of consensus as to when and whether past crimes should be reported. Hence, legal and ethical requirements concerning confidentiality breaches must be made clear and known to physicians in order to guide them with difficult cases.

What is the place of clinicians' religious or spiritual commitments in psychotherapy? A virtues-based perspective

Value neutrality in psychotherapy is widely acknowledged to be a myth, and a majority of US physicians report that their religious faith influences their practice. Most attention to therapists' religious and spiritual commitments has focused on ethical boundaries, transference/countertransference dynamics and questions about how to relate religious and psychological truth. No consensus exists about the legitimate place in psychotherapy of clinicians' differing value commitments. Therapists' virtues are vitally important in psychotherapy, not least in the relational and aspirational process by which the patient identifies with the therapist as they engage together in confronting obstacles which the patient has been unable to surmount alone. Among the individual and cultural factors that shape a therapist's virtues are spiritual traditions, which encourage preferred or characteristic virtues. Arguably, these include for Jews, communal responsibility and critical thought; for Christians, love and grace; for Muslims, reverence and obedience; for Buddhists, equanimity and compassion; for Hindus, appreciation of Dharma and Karma; and for secularists, respect for scientific evidence and intelligibility. These have differing implications for treatment, as illustrated through the use of a hypothetical case. Attention to differing spiritual and religious virtues in a pluralistic culture offers opportunities for creative dialogue, collaborative teaching and interdisciplinary research.

[Comments on ethical hospital management]

An ethical hospital management will be discussed under the topics (financial) resources, responsibility, quality and focus on patients.

Navigating dual relationships in rural communities

The literature examining dual relationships in rural communities is limited, and existing ethical guidelines lack guidelines about how to navigate these complex relationships. This study uses grounded theory to explore rural therapists' perceptions of dual relationship issues, the perceived impact of minority and/or religious affiliation on the likelihood of dual relationships, and the ways rural therapists handle inevitable dual relationship situations. All of the therapists who participated in the study practiced in small communities and encountered dual relationship situations with regularity. The overarching theme that emerged from the data was that of using professional judgment in engaging in the relationship, despite the fact that impairment of professional judgment is the main objection to dual relationships. This overall theme contained three areas where participants felt they most needed to use their judgment: the level of benefit or detriment to the client, the context, and the nature of the dual relationship. Surprisingly, supervision and/or consultation were not mentioned by the participants as strategies for handling dual relationships. The results of this study are compared with established ethical decision-making models, and implications for the ethical guidelines and appropriate ethical training are suggested.

[Ethics as the main philosophy of care]

Care is based on ethics, a non-corporatist form of ethics. For the caregiver, clinical refers to the patient and not a profession, a sine qua non condition of not losing sight of the meaning of care. Human nature incites us to escape the formal aspect, but can we necessarily make the informal exclusive to nursing?

Ethical reflection and psychotherapy

OBJECTIVE

Theories of ethics and ethical reflection may be applied to both theory and practice in psychotherapy. There is a natural affinity between ethics and psychotherapy. Psychotherapy practice is concerned with human problems, dilemmas and emotions related to both one's own and other people's values. Ethics is also concerned with dilemmas in human thinking and with how these dilemmas reflect other individuals' values. Philosophical reflection itself is not a sufficient basis for the ethics of psychotherapy but it may aid in exploring attitudes related to psychotherapy, psychiatry and health care.

METHODS

PubMed, Web of Science and Scopus databases were searched for articles containing the keywords "psychotherapy", "ethics", "therapeutic relationship" and "supervision". The search was conducted by repeating the terms in various combinations without language or time restrictions. Also included were data from monographs cited in reviews. The resulting text is a review with conclusions concerning ethical aspects of psychotherapy.

RESULTS

The ability to behave altruistically, sense for justice and reciprocity and mutual help are likely to be genetically determined as dispositions to be later developed by upbringing or to be formed or deformed by upbringing. Early experiences lead to formation of ethical attitudes which are internalized and then applied to both one's own and other people's behavior. Altruistic behavior has a strong impact on an individual's health and its acceptance may positively influence the pathophysiological mechanisms underlying numerous diseases. Ethical theory and reflection, however, may be applied to both theory and practice of psychotherapy in a conscious, targeted and thoughtful manner. In everyday practice, psychotherapists and organizations must necessarily deal with conscious conflicts between therapeutic possibilities, clients' wishes, their own as well as clients' ideas and the real world. Understanding one's own motives in therapy is one of the aims of a psychotherapist's personal therapy and a frequent goal of supervision interventions. It is a psychotherapist's ethical obligation to do no harm, maintain clear therapeutic borders, not abuse patients, undertake supervision and learn good self-reflection.

CONCLUSION

Knowledge of ethical questions and related issues as well as continuous ethical self-reflection are essential components of high-quality psychotherapeutic management. This requires both good psychotherapy training and systematic supervision.

Differences and similarities in cross-cultural perceptions of boundaries: a comparison of results from two studies

There has been substantial literature on boundary excursions in clinician-patient relationships; however, very little empirical research exists. Even less information exists on how perceptions of this issue might differ across cultures. Prior to this study, empirical data on various kinds of boundary excursions were collected in different cultural contexts. First, clinicians from the U.S. and Brazil were asked to rate 173 boundary excursions for both their perceived harmfulness and their professional unacceptability (Miller et al., 2006). In a second study, colleagues from Qatar administered a slightly modified version to mental health care professional staff of a hospital in Doha, Qatar (Ghuloum et al., 2011). In this paper, the results of these two separate studies are compared. The results showed some similarities and some differences in perceptions of the boundary behaviors. For example, both sets of cultures seem to agree that certain behaviors are seriously harmful and/or professionally unacceptable. These behaviors include some frankly sexual behavior, such as having sexual intercourse with a patient, as well as behavior related to doing business with the patient, and some disclosing behavior. There are also significant cultural differences in perceptions of how harmful some of the behaviors are. Qatari practitioners seemed to rate certain behaviors that within therapy mix disclosing or personal behavior with therapy as more harmful, but behaviors that involved interacting with patients outside of therapy as less serious. A factor analysis suggested that participants in U.S./Brazil saw a much larger number of behaviors as making up a set of Core Boundary Violations, whereas Qatari respondents separated sexual behaviors from others. Finally, a Rasch analysis showed that both cultures perceived a continuum of boundary behaviors, from those that are least harmful or unprofessional to those that are highly harmful or unprofessional. One interpretation is that cultural factors may be most influential on those kinds of behaviors that are perceived as relatively less serious. Implications for training and supervision are also discussed.

[Ethical problems in the treatment of schizophrenia]

The authors present ethical dilemmas in the therapy, particularly family therapy, individual and group psychotherapy of schizophrenia in the context of the specific personality of persons suffering from schizophrenia as well as their experience

Death competence: an ethical imperative

The authors argued that death competence, defined as specialized skill in tolerating and managing clients' problems related to dying, death, and bereavement, is a necessary prerequisite for ethical practice in grief counseling. A selected review of the literature tracing the underpinnings of this concept reveals how a robust construct of death competence evolved. Using the vehicle of a case study, the authors analyzed an example of empathic failure resulting from an apparent lack of death competence on the part of a mental health provider to illustrate the importance of this characteristic in delivering clinically effective and ethically sensitive grief counseling.

Commentary on the treatment of gender variant and gender dysphoric children and adolescents: common themes and ethical reflections

This commentary offers preliminary ethical reflections on the range of treatments for gender variant and gender dysphoric children, adolescents, and young adults described in the preceding five clinical articles. After clarifying the terminology used to discuss these issues, this commentary reviews several common themes of the clinical articles. Focusing on ethical values of informed consent, full disclosure, the minimization or avoidance of harm, and the maximization of life options, the commentary expresses concerns about various treatment options endorsed by some of the articles. In particular, this commentary focuses on how these practices problematically reproduce social prejudices and stereotypes and how they fail to acknowledge and embrace the multiple pathways for expressing one's gender. It also compares and contrasts the ethical issues related to gender variant and gender dysphoric youths and youths who identify as lesbian, gay, bisexual, or queer.

Ethical Issues in the Treatment of Severe Psychopathology in University and College Counseling Centers

Increasing numbers of students with severe personality disorders are presenting for psychological services at college and university counseling centers. The influx of these students poses a number of ethical dilemmas for counseling centers. Clinical decisions about appropriate treatment modalities, philosophical decisions about agency mission, and available resources to carry defined missions converge and influence ethical decisions in this area. It is misguided kindness, as well as being ethically unwise and legally risky, to attempt to carry out a treatment mission with inadequate resources. It is not abandonment to have selection criteria grounded in the treatment literature and executed with fairness if the duty to refer is upheld.

Factors influencing consent to having videotaped mental health sessions

OBJECTIVE

The authors critically reviewed the literature regarding factors influencing consent to having videotaped mental health sessions.

METHODS

The authors searched the literature in PubMed, PsycINFO, Google Scholar, and Web of Science from the mid-1950s through February 2009.

RESULTS

The authors identified 27 studies, of which 19 (73%) examined general practice. Only 4 (15%) were in mental health. Most patients agree to be videotaped when asked. Those who did not consent tended to be female and younger, with previous psychiatric history or psychological distress. The data are mixed about whether psychiatric patients felt inhibited in videotaped sessions.

CONCLUSION

The mental health literature in this area is limited and dated. Implications for practice are drawn inferentially from the general-practice literature. Recommendations for increasing the consent rate include building a relationship with patients before asking them for videotaping and, when asking, explaining the educational value and specific purpose of the recording.

[The therapeutic stay, an "institutional regulator"]

A therapeutic stay acts as a "regulator" of the undesirable effects of the institutional setting. It relies on the commitment of the members of the group who are no longer identified by their status. It is a paradigmatic act of a concept of care inherited from the policy of local sector healthcare and institutional psychotherapy. In the current context, it is an act which advocates patient-centred care.

[Calamitous moments: rethinking the ethics of post disaster psychological reconstruction programs]

This article points out firstly that disaster and traumatic events resulting from calamitous moments must be the focus of dedicated long term research and of ontological caring in practice. Ethical issues related to the post disaster psychological reconstruction program represent an important agenda. Therefore, in the execution of serial programs and nursing care, it should not be taken for granted that sufferers are destined to be pathological clients. Rather, each sufferer should be attended to in a humanistic manner. In other words, the elimination of symptoms cannot be our only focus. Secondly, the author discusses the ethical dimensions of post-disaster psychological intervention within a "Five T" framework (namely, tears, time, talk, transformation, and trauma). The author then explores the meaning of posttraumatic psychological growth, which is relevant to the resilience that coexists with suffering. Finally, it is important to practice ontological care from the context of being "within" the relationship, rather from a rigid cognition regarding program efficiencies. 'Being' provides much greater depth than 'doing'.

Teaching professional boundaries to psychiatric residents

OBJECTIVE

The authors demonstrate that the teaching of professional boundaries in psychiatry is an essential component of training to prevent harm to patients and to the profession.

METHODS

The authors illustrate overarching principles that apply to didactic teaching in seminars and to psychotherapy supervision.

RESULTS

The teaching of boundaries must be based in sound clinical theory and technique so that transference, countertransference, and frame theory are seen as interwoven with the concept of boundaries and must use case-based learning so that a "one-size-fits-all" approach is avoided.

CONCLUSION

The emphasis in teaching should be on both the clinician's temptations and the management of the patient's wish to transgress therapeutic boundaries.

Ethical issues in child and adolescent psychotherapy: a clinical review

Child and adolescent psychotherapy has made great progress in recent years. With this progress, ethical issues have emerged that need to be addressed in the Indian setting. This article looks at various ethical issues in child and adolescent psychotherapy specific to Indian practitioners. The involvement of parents in psychotherapy often blurs therapeutic boundaries and issues related to confidentiality. Practitioners working in hospital and school settings are faced with similar problems. The advent of the internet and e-mail has resulted in new concerns for psychiatrists, related to communication via those media. Issues related to parenting, culture and development patterns, along with personal issues for the therapist, have been discussed.

Offender rehabilitation as a value-laden process

This article investigates some of the primary assumptions and values that underpin correctional practice in the area of offender rehabilitation. It is suggested that values are reflected in offenders' and clinicians' fundamental beliefs about the rehabilitative process and as such underlie their various actions. This article identifies three areas in which values may be important (organisational values about crime and punishment, professional values, and personal values) and discusses each in relation to its relevance for rehabilitative practice. It is concluded that despite the apparent role of values in the correctional domain, very little is known about the values of those who deliver rehabilitative programs and how these might influence rehabilitative outcomes.

Autonomy and ethical treatment in depression

Antidepressant medication and evidence-based psychotherapy have largely equivalent efficacy in the management of the common, less severe grades of depression. As a result, several national guidelines recommend that either can be used in the treatment of this disorder. Psychotherapy, however, differs in that it assists insight into how the depressed person appraises and manages the stressors that frequently trigger depressive episodes. I argue that the self-knowledge achieved through psychotherapy has moral value in that it promotes the autonomy of stressor-related decisions. I further argue that such an effect comprises a compelling moral reason for doctors to see evidence-based psychotherapy not as merely optional, but as a necessary treatment for their patients with depression.

Ethics in the practice of clinical psychology

The paper presents an overview of ethical issues in clinical psychology. Specifically, it addresses the broad philosophical ideas and views on mental illness on which ethical principles are based, including Greek philosophy and Christianity. It goes on to describe the ethical code of the American Psychological Association as it pertains to general principles, psychological assessment or psychometry, education or training and psychological interventions. The principles of the code and research on the same are discussed with relevance to issues and challenges to ethical practice in India, and suggestions for ethical conduct are made. The paper emphasises the need to consider different viewpoints and take individual responsibility for difficult decisions.