In the first 60 years after the founding of the American Psychological Association (APA) in 1892, no formal code of ethics existed (Pope & Vetter

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