Ethical dimensions of psychotherapy: a personal perspective

A substantial increase in the interest devoted to ethical issues has been a defining feature of my 50 years in psychotherapeutic practice. Reasons include a shift from a paternalistic to a contractual model of the doctor-patient relationship, increased litigiousness, and greater emphasis on the business rather than professional aspects of practice. Many ethical violations stem from misuse of therapist power in the psychotherapeutic relationship. One of the most egregious of these is overt sexual acting out between therapist and patient, a dereliction now viewed much more sternly, largely because of the rise of the women's movement. Therapist power can also be misused for purposes of psychopathological gratification, such as to dominate patients or impose values, and by emphasizing financial rewards over patient needs. A sea change I have observed has been the gradual replacement of a two-party by a three-party system of payment for psychotherapy. Among its most serious consequences in the ethical domain has been the weakening of the therapist's guarantee of absolute confidentiality to the patient. Managed care has further compounded the ethical dilemma by imposing a need to choose between the interests of patients and the organizations from which therapists receive remuneration. In their efforts to ensure parity coverage for psychotherapy, therapists need to respond to certain questions about their claims that their work promotes both individual welfare and the common good. Questions include the professional qualifications for skillful practice of psychotherapy, the evidence for its efficacy, the delimitation of the conditions properly treated by psychotherapy, and the extent to which these conditions fall within the medical model and thus satisfy the criterion of medical necessity. I conclude that, in spite of the efforts needed to maintain ethical standards, the "ethical revolution" that I have witnessed has enhanced the integrity and value of psychotherapy, both for its practitioners and for the public that they serve.