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 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

T h e Ox f o r d H a n d b o o k o f

PSYC HOT H E R A PY
ET H IC S
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

Oxf ord
H a ndb o ok s
in Philo sophy
a nd P sychiat ry

Series editors: K.W.M. Fulford, Lisa Bortolotti, Matthew R. Broome,

Katherine Morris, John Z. Sadler, and Giovanni Stanghellini

Volumes in the Series:

The Oxford Handbook of Philosophy and Psychiatry

Edited by K.W.M. Fulford, Martin Davies, Richard Gipps, George Graham, John Sadler,
Giovanni Stanghellini, and Tim Thornton

The Oxford Handbook of Psychiatric Ethics

Edited by John Z. Sadler, Werdie (C.W.) Van Staden, and K.W.M. Fulford

The Oxford Handbook of Philosophy and Psychoanalysis

Edited by Richard Gipps and Michael Lacewing

The Oxford Handbook of Phenomenological Psychopathology

Edited by Giovanni Stanghellini, Matthew R. Broome, Anthony Vincent Fernandez,
Paolo Fusar-­Poli, Andrea Raballo, and René Rosfort

The Oxford Handbook of Psychotherapy Ethics

Edited by Manuel Trachsel, Jens Gaab, Nikola Biller-­Andorno, Şerife Tekin, and
John Z. Sadler
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

the oxford handbook of

PSYCHOTHERAPY
ETHICS
Edited by
MANUEL TRACHSEL,
JENS GAAB,
NIKOLA BILLER-ANDORNO,
ŞERIFE TEKIN
and
JOHN Z. SADLER

1
OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

1
Great Clarendon Street, Oxford, ox2 6dp,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
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© Oxford University Press 2021
The moral rights of the authors have been asserted
First Edition published in 2021
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
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for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

To all those who seek help and support through psychotherapy, and to those
who seek to provide it to the best of their knowledge and ability.
OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

Foreword
Bruce E. Wampold, Ph.D.
Madison, WI, USA
Professor Emeritus, University of Wisconsin—Madison
and Senior Researcher, Research Institute, Modum
Bad Psychiatric Center, Vikersund, Norway

In an evidence-based world, the emphasis in health services is on finding the most effective
treatment for a particular disorder. In the latest iteration of the application of evidence to
improve health, the notion of personalized medicine has been introduced, turning the
focus on what is the most effective treatment for this particular patient with this particular
disorder. In many ways this has been a technological endeavor, with attempts to increase
longevity by days, it seems, and mortality by minute percentages. In this technological
effort to make incremental advances by focusing on treatments, or even for treatments for
individual patients, the patient and their context are secondary, if not ignored. Lip service
is paid to patient preferences and the “psycho” and “social” aspects of the biopsychosocial,
but the person as an agentic participant is too frequently ignored.
If health service is to retain the essence of healing practices, with a respect for the patient,
health care ethics must be central to all aspects of health systems. Ethical considerations are
not simply “add-ons” to satisfy society’s demands for such services—rather they should be
endemic to the study of services, to the training of clinicians, to the delivery of services, to
the evaluation of quality—all aspects of health services must be saturated with a consider-
ation of ethics. This is an imperative for an effective health care system—one that not only
demonstrates caring and respect for the patient, but one that is sustainable, is utilized by
those who need services, and effective. Too many mistakes in health care have been com-
mitted by ignoring ethics.
Much has been written about ethics generally and, despite the focus on treatments, in
health care specifically. Indeed, there is a name for the field in health care—bioethics. There
are bioethics academic programs (usually in medical schools), graduate degrees, and pro-
fessors of bioethics. There is a plethora of experts to comment on thorny problems in bio-
ethics that are raised in public.
Although bioethics is ubiquitous, the ethics of psychotherapy is neglected. This is quite
surprising, and frankly disturbing, because the practice of psychotherapy raises ethical
issues by its very nature. Psychotherapy is an intimate relationship between two persons but
a very specialized one—and this raises a host of ethical issues. Moreover, each type of ther-
apy creates a different type of relating. In each, the therapist takes a different stance.
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

viii   Foreword

The psychotherapy field desperately needs a comprehensive volume dedicated to psycho-

therapy ethics. The editors of The Oxford Handbook of Psychotherapy Ethics Manuel
Trachsel, Jens Gaab, Şerife Tekin, Nikola Biller-Andorno, and John Z. Sadler, collectively
have thought and written about this subject to a greater extent that the remainder of the
field, most likely. The volume they have created and edited covers the ground comprehen-
sively, with sections and topics as follows:

• Why Ethics Matter in Psychotherapy

• The Historical Context
• Concepts and Theories for Psychotherapy Ethics
• Common Ethical Challenges in Psychotherapy
• Ethical Issues with Specific Psychotherapy Approaches
• Ethical Challenges of Specific Settings and Populations
• Ethics of Psychotherapy Education, Training, Quality Assurance, and Research

This volume is a must read for everyone in the psychotherapy field: clinicians, educators,
trainees, researchers, policy makers, and managers of mental health care. Unless this
­material is read and understood, we are “flying blind” when it comes to becoming ethical
professionals.
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

Acknowledgements

An Oxford Handbook requires strong leadership as well as an integrated, smoothly func-

tioning team. We, the editors, have enjoyed both of these through the support Oxford
University Press has provided. Senior Commissioning Editor Martin Baum has provided
steady guidance, extraordinary liberty of content, and practical wisdom for each step in
developing the Oxford Handbook of Psychotherapy Ethics. Senior Assistant Commissioning
Editor Charlotte Holloway provided prompt and thorough assistance in every practical
detail and question we could send her way, with encouragement and cheer. We’re also grate-
ful to Assistant Commissioning Editor Janine Fisher for stepping in for Charlotte when the
demands of a growing family pulled her away from us. We thank Project Manager Sandhiya
Purushothaman and Senior Project Manager Ramani Venkatesan from SPi Global for their
guidance in the production stage of the manuscripts. We are much obliged to the authors of
the Oxford Handbook of Psychotherapy Ethics who provided substance, patience, and flexi-
bility in responding to our editorial demands, even when on short notice.

Dr. Manuel Trachsel would like to thank his great fellow editors for their constant engage-
ment, support, and hard work in developing the present Oxford Handbook of Psychotherapy
Ethics over the last four years. I have very much enjoyed all the excellent discussions and
creative exchanges with them that made it such a pleasure to work on this groundbreaking
volume. I am also indebted to the members of my research group at the Institute of
Biomedical Ethics and History of Medicine (IBME) at the University of Zurich, where lively
debate on issues of medical ethics with my colleagues and my PhD and MD students has
been a source of ongoing delight. I am especially grateful to my mentor and role model
Nikola Biller-Andorno, who has provided constant and trustful support in shaping my
career. I am also grateful to the Swiss Academy of Medical Sciences for supporting my
research.
I could not have brought this work to fruition without tapping into the intellectual inspi-
ration provided by some great earlier thinkers, including Aristotle, Epicurus, Marcus
Aurelius, Michel de Montaigne, David Hume, John Stuart Mill, Søren Kierkegaard,
Arthur Schopenhauer, Friedrich Nietzsche, Jean-Paul Sartre, Albert Camus, William James,
Carl R. Rogers, and Irvin D. Yalom.
I thank my family and friends for their emotional support over the years, among them
my parents Elsbeth and Kurt, my sister Rahel, my nephews Joshua and Aaron, my parents-
in-law Elisabeth and Hansueli, my friends Gieri Maissen, Simon Lieberherr, Sebastian
Haas, Tobias Krieger, and Tobias Zürcher.
Finally, my wholehearted thanks to my wonderful wife Barbara, and to my children Liv,
Jon, May, and Eli.
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x   Acknowledgements

Dr. Biller-Andorno would like to thank the wonderful administrative team of the Institute
of Biomedical Ethics and History of Medicine of the University of Zurich, who has been
tremendously helpful with the many searches, mails and calls that were needed to bring this
volume together. Special thanks to my children – Sophia, Leticia and Luca – , who are at the
same time relentless critics and a wonderful source of inspiration.

Dr. Tekin would like to thank her fellow editors.

Dr. Sadler would like to thank his fellow editors for their creativity, collegiality, and hard
work. I also want to thank my steadfast and highly competent assistant, Ruth Vinciguerra,
for her help with this book and all the other goings-on in our office in the four years that
went into developing the Oxford Handbook of Psychotherapy Ethics. I am also grateful
for my department chair, Carol Tamminga, MD for her encouragement and commitment
to a strong ethics presence in our department and our field. As always, my family is a source
of renewal and joy, making affairs private and professional more glorious: Abbie, Evan,
and Cole.
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

Detailed Table of contents

SE C T ION I : BAC KGROU N D A N D

H I S TOR IC A L C ON T E X T
1. Why ethics matter in psychotherapy 3
Manuel Trachsel, Jens Gaab, Şerife Tekin, Nikola
Biller-Andorno, and John Z. Sadler
Only a few scholars regularly published on psychotherapy ethics from the 1990s
(e.g., Knapp and VandeCreek 2006; Pope and Vasquez 1991; Welfel 1998). The
publication of textbooks for practitioners in the last five to ten years (e.g., Koocher
and Keith-Spiegel 2016), the increasing number of scientific papers (e.g., Curtis
and Kelley 2020; Trachsel et al. 2015), and of article collections and special issues
on psychotherapy ethics (e.g., Barnett 2019) reflect the increase in significance and
scientific knowledge within the field (Gerger et al. 2020). With the present Oxford
Handbook of Psychotherapy Ethics , as with other Oxford Handbooks, our aim is to
provide a definitive resource covering the whole range of ethical issues in the
heterogeneous field of psychotherapy. Although the Oxford Handbook of
Psychiatric Ethics (Sadler et al. 2015) included some chapters on psychotherapy
ethics, we had been convinced and reassured by the submitted chapters that
psychotherapy ethics requires a special volume of its own, because of the scope,
complexity, and various forms of psychotherapy. The present Handbook now
includes 68 chapters from more than 100 authors.

2. A brief moral history of psychotherapy 31

Alan c. Tjeltveit
To grasp its moral history, psychotherapy’s profoundly and pervasively moral
dimensions, its inextricable sociocultural connections, critics’ challenges to moral
claims, the historical origins of moral ideas and practices, and some key historical
trajectories of psychotherapy are addressed. Connections among professions,
professional ethics, and morality (construed broadly); moral understandings of
psychological problems and goals; and moral considerations concerning therapy
techniques and relationship styles are emphasized. Finally, some changing
interrelationships among psychotherapy, the self, society, and morality are
reviewed.
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

xii   Detailed Table of contents

3. What do psychotherapists need to know about ethics?

lessons from the history of professional ethics  47
Carole Sinclair
Behaving ethically is at the core of what it means to be a professional. It is central
to the contract that all professions have with the persons they serve and with the
societies in which they function. This sense of ethical responsibility, and the
practice of articulating the underlying values, principles, and behavioral
manifestations of such a responsibility, both have a long history. By outlining the
history of ethical values and codes, and the meaning of “profession,” from ancient
times to the present, this chapter explores several major components involved in
psychotherapists’ efforts to be ethical practitioners. This includes attention to the
roles of ethics codes, ethical values and principles, moral theory, ethical reasoning,
and moral character. Although there is sometimes a tendency to treat these
components as separate entities (even in competition with each other as
explanatory concepts), the emphasis in this chapter is on how history teaches us
that they need to be seen and treated as an integrated whole in our efforts to be
ethical practitioners.

4. The history and ethics of the therapeutic relationship 65

Ulrich Koch and Kelso Cratsley
This chapter reviews past and present debates about the therapeutic relationship
in order to draw out the ethical implications of relational practices in psychotherapy.
The therapeutic relationship has been understood differently across
psychotherapeutic approaches, with each tradition responding to the attendant
ethical challenges in distinctive ways. Aside from practitioners’ theoretical and
practical commitments, the therapeutic relationship has also been, and continues
to be, shaped by broader societal influences. The chapter discusses the shifting
ethical implications of relational practices, then, as situated in their theoretical
and historical contexts. The historical variability of concerns raised by the
therapeutic relationship, we suggest, calls for continued ethical analysis in order to
confront the diversity and complexity of contemporary clinical practice.

SE C T ION I I : C ONC E P T S A N D T H E OR I E S F OR
P S YC HO T H E R A PY E T H IC S
5. Autonomy as a goal of psychotherapy 87
Paul Biegler
Personal autonomy describes the exercise of self-determination through informed
and rational decisions that reflect an agent’s authentic values. The nexus between
autonomy and psychotherapy is broad, with both respect for client autonomy
through informed consent, and promotion of client autonomy through therapy
itself representing key instances of the significance of autonomy in the consulting
room. While inadequate disclosure of information poses a major threat to personal
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Detailed Table of contents   xiii

autonomy, so too do unjustified paternalism, coercion and the injudicious use of

therapeutic privilege. The capacity of psychotherapy to promote client autonomy,
evidenced by more effective decision making during periods where the risk of
recurrent illness is high, is argued to be a key advantage of psychotherapy over
treatment with medication alone. Ultimately, enhanced autonomy is a goal of
treatment grounded in a more defensible conception of well-being for people with
psychological disorder and, it is concluded, should be sought specifically through
psychotherapy.

6. Patient protection and paternalism in psychotherapy 99

Marco Annoni
This chapter provides a synthetic overview of the ethics of paternalism in
psychotherapy with a focus on involuntary hospitalization to protect patients
from self-harm. Paternalism entails the intentional overriding of someone’s
preferences or actions on grounds of beneficence and nonmaleficence. After the
emergence of autonomy in medical ethics, paternalism is generally considered
prima facie wrong, as it infringes on patient autonomy, trust, and right to informed
consent. In particular, the use of paternalism in psychotherapy raises a host of
complex and delicate ethical issues due to the nature of the therapeutic relationship
and the difficulty to assess the autonomy of the person who will supposedly benefit
from the paternalistic intervention.

7. Empathy, honesty, and integrity in the therapist: a person-centered

perspective111
Jeffrey H. D. Cornelius-White and Gillian Proctor
Empathy, honesty, and integrity are essential concepts to ensure the quality of the
therapy relationship and the client’s trust in the therapist. This chapter situates
these concepts in relation to the necessary and sufficient conditions for therapy
proposed by Carl Rogers in the late 1950s, and particularly in relation to the
therapist attitudes of empathic understanding, unconditional positive regard, and
congruence. In person-centered therapy (PCT), empathy is a moral, not
instrumental, practice that nondirectively protects the self-determination of the
client. It exemplifies power with others, avoiding power over others, and facilitating
power from within, by providing a conduit for non-possessive love, the active
ingredient in PCT. Honesty in PCT involves the sincerity of the therapist’s
unconditional empathy and the transparence to be a full person in relation to a
client. Integrity refers not only to the disciplined moral practice of empathy, but an
extensional, fully functioning maturation.

8. Fairness, justice, and economical thinking in psychotherapy 122

Marta Herschkopf and Rebecca Weintraub Brendel
Despite a robust and growing evidence-base to support the effectiveness of
psychotherapy in treating mental illness and promoting mental health, funding
and access is often limited. Psychotherapy’s claim on a share of individual and
social resources must compete, on the one, hand with other mental health services
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

xiv   Detailed Table of contents

devoted to treating mental illness, and on the other hand, with a variety of social
services that promote mental health and human flourishing. This chapter focuses
on different theories of justice to consider (a) whether a case might be made for
the unique value of psychotherapy amongst other competing services, and (b) if
not, what criteria might be relevant in assessing its relative cost and value. The
chapter begins by reviewing some relevant concepts of justice and how they might
be applicable to allocation of psychotherapy resources, specifically, Rawlsian,
capabilities, utilitarian, and communitarian theories. It then discusses how these
concepts of justice can be used to navigate research about psychotherapy outcomes
as well as its cost-effectiveness. Decisions about which outcomes to consider are
not value-neutral and can be guided by relevant theories of justice. The chapter
concludes with a brief discussion of lower-income countries.

9. Ethics of care approaches in psychotherapy 140

Anna Magdalena Elsner and Vanessa Rampton
The ethics of care poses a special case for psychotherapy. At first glance, key
elements of care ethics such as acknowledging our dependence on others,
attention to emotions, and creating a supportive environment for healing overlap
substantially with key characteristics of psychotherapy. Care ethics’ emphasis on
attentiveness and empathetic concern, and related acts such as listening and
talking to patients point in the direction of salutary therapeutic relationships,
and also of valorizing psychotherapy as a practice. Yet psychotherapy has a long
history of critical engagement with the therapeutic relationship, using terms and
concepts other than “care.” This chapter shows that while relatively little work
has been done on care ethics approaches in psychotherapy, such approaches
complement traditional attentiveness to the (psycho)therapeutic relationship by
asking to what extent psychotherapists are practicing care and what this entails.
Conversely, because psychotherapy has long been concerned with inter-
subjectivity, as exemplified by the concepts of transference and
countertransference, it offers valuable theoretical and practical resources for
care ethics approaches.

10. Legitimate and illegitimate imposition of therapists’ values

on patients 154
Susana Fehr Lampley and John Z. Sadler
The understanding that psychotherapists should not impose their values on
their patients is a shared belief in the field. However, little has been written about
how not to impose one’s values on patients. Here we diagram an approach to
evaluate justified and unjustified impositions of values in therapy with various
examples. These examples are not intended to be comprehensive, but to provide
an introductory overview. The case discussions will function to: (a) to provide
rough guidance about how to analyze one’s own unique cases, (b) illustrate areas
of consensus within the broad psychotherapy field, (c) to highlight the large
areas of ambiguity and lack of consensus about what constitutes the legitimate
and illegitimate imposition of values on patients and (d) provide sample
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Detailed Table of contents   xv

references from the literature illustrating particular values-imposition

discussions and policies. Our conclusions emphasize the limitations of this
exploratory work, and point to areas where additional analysis would be of
benefit for clarifying ambiguities of practice.

11. Virtue ethics in psychotherapy 177

Michael Laney and Adam Brenner
The ethical pressures on a therapist are great, particularly since effective therapy
demands that we become deeply and affectively involved in a patient’s life as told
to us such that we become part of their stories and conflicts as well. While
deontology and consequentialism provide guidance with respect to a therapist’s
acts in themselves or in their consequences, another ethical perspective focuses
squarely on the character of the therapist him or herself. This chapter reviews
this perspective—called virtue theory—and applies it to the work of therapy,
especially how a virtuous character and the virtuous actions that emanate from
it are more than just moral prescripts but necessary to and partly constitutive of
effective therapy itself.

12. How do people make moral medical decisions? 189

Eleanor Gilmore-Szott and Thomas V. Cunningham
This chapter describes moral decision making in clinical relationships. Section 2
covers the contributions made by bioethics to health care decision making,
including the historical, legal, policymaking, and scholarly background to
contemporary conceptions of moral choice, which culminate in the concept of
informed consent. Section 3 then canvases the contemporary landscape of
ethical decision making by focusing on the important concept of decisional
capacity and empirical approaches for evaluating and supporting the capacity to
make ethical decisions through improvements in health literacy, values
clarification, and shared decision making. Section 4 provides a case analysis to
demonstrate the numerous challenges that come with applying frameworks of
moral medical decision making to actual patient care and possible means for
resolving those challenges by appealing to the concepts defined throughout the
chapter.

13. Existential philosophy and psychotherapy ethics 207

Alexander Noyon and Thomas Heidenreich
This chapter introduces five central concepts of existential philosophy in order
to deduce ethical principles for psychotherapy: phenomenology, authenticity,
paradoxes, isolation, and freedom vs. destiny. Phenomenological perspectives
are useful as a guideline for how to encounter and understand patients in terms
of individuality and uniqueness. Existential communication as a means to search
and face the truth of one’s existence is considered as a valid basis for an authentic
life. Paradoxes that cannot be solved are characteristic for human existence and
should be dealt with to turn resignation into active choices. Isolation is one of
the “existentials” characterizing human life between two paradox poles: On the
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

xvi   Detailed Table of contents

one hand we are deeply in need of relationships to other human beings; on the
other hand we are thrown into the world alone and will always stay like this, no
matter how close we get to another person. Further, addressing freedom and
destiny as two extremes of one dimension can serve as a basis for orientation in
life and also for dealing with the separation between responsibility and guilt.

14. Phenomenological-hermeneutic resources for an ethics of

psychotherapeutic care 219
Giovanni Stanghellini
I will introduce and discuss four concepts that seem to be relevant to develop a
phenomenologically- and hermeneutically-based ethics for psychotherapeutic
care: ‘dialogue’, ‘attunement’, ‘recognition’ and ‘intimacy’. Dialogue is the essential
happening of language, not a mere exchange of information; in it subjectivity is
displaced and something new about the interlocutors is revealed. Attunement is a
modulation of the emotional field in-between myself and the other. Attunement is
also the capacity to coordinate my tempo with that of the other. Attunement—
inter-emotionality—inter-temporality are grounded in corporeality as a form of
intercorporeality. Recognition is the epistemic and ethic capacity to acknowledge
the alterity in myself and of the other person. Self-recognition is the acknowledgement
of the pre-individual elements not yet appropriated by myself; other-recognition is
the acknowledgement of the other person as a fellow man to whom I attribute
value, life and consciousness. Intimacy is an atmospheric experience of aloneness-
togetherness, self- and other-recognition: envelopped in an atmosphere of intimacy
I get in touch with myself via getting in touch with each other.

15. Free will, responsibility, and blame in psychotherapy 230

Tobias Zürcher
Freedom of the will is not only an issue in the attribution of moral and legal
responsibility—it also fundamentally shapes how we look at ourselves and how
we interact with others. This is essential in everyday life but even more so in
psychotherapy. In the debate on freedom of will, the main controversy is
concerned with the relationship between determinism and free will. In this
chapter, different positions will be presented and discussed. The compatibilist
viewpoint, which claims determinism and freedom of will to be compatible, is
defended against competing theories and will be applied to psychotherapeutic
work. Mental disorders affect free will in many ways, as is demonstrated by the
examples. Nevertheless, a compatibilist approach to free will can be used as a
resource to increase the patient’s autonomy. As a result, it is justified and
sometimes appropriate within the therapeutic context to ascribe responsibility
and, within certain limits, to express blame.

16. Dignity in psychotherapy 245

Roberto Andorno
The notion of human dignity conveys the idea that every human being has
inherent worth and therefore, ought to be accorded the highest respect and
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Detailed Table of contents   xvii

consideration. In health care, dignity provides an overarching moral framework

that is called to guide the physician-patient relationship in a great variety of
issues, and especially in the promotion of the patient’s well-being and self-
determination. Dignity plays also an important role in psychotherapy as the
patient-therapist relationship involves confidences of intimate nature and about
very personal decisions and attitudes, and may lead to a patient’s overdependence
on the therapist. Taking seriously, the patient’s dignity imposes on the therapist
some specific moral duties, such as respecting and promoting patients’ self-
determination, as well as patients’ values, beliefs and life plans. Another direct
consequence of the principle of respect for dignity is the requirement to avoid
exploitative interactions with patients, in particular, any form of sexual
harassment and abuse.

SE C T ION I I I : C OM MON E T H IC A L C H A L L E NG E S
I N P S YC HO T H E R A PY
17. The ethics of informed consent for psychotherapy 259
Alastair J. McKean, Manuel Trachsel, and Paul E. Croarkin
Informed consent, enshrined in many of the codes of conduct of psychology and
psychiatry professional organizations, is an integral component behind the
ethical practice of psychotherapy. Foundationally, informed consent respects
patient autonomy and should be a knowledge sharing process that allows patients
greater agency and improved alliance with their clinician. Psychotherapy differs
from medical and surgical interventions in that it is a longitudinal, collaborative
and interpersonal treatment. As many psychotherapists are not trained in
traditional medical models of care, a medically based framework for informed
consent may not be as familiar and appropriate for psychotherapy. These nuances
do not diminish the need for informed consent but rather emphasize the
distinctiveness of psychotherapy and necessity of adapting to this treatment
modality. In this chapter, the informed consent process for psychotherapy is
examined, detailing its historical development, legal and ethical foundations, as
well as the subtleties and challenges regarding implementation.

18. Ethics of the psychotherapeutic alliance, shared decision

making and consensus on therapy goals 271
Stella Reiter-Theil and Charlotte Wetterauer
The ethics of the psychotherapeutic alliance (a), shared decision making (b), and
consensus on therapy goals (c) is discussed in the context of a legal overview in
three Germanspeaking countries. Particular ethical challenges are identified in
different settings. Clinical Ethics Support (CES) has gained importance beyond
acute medical patient care, but is still new in psychotherapy. Three examples
present ethical issues underlying the basic concepts of psychotherapy (a, b, and
c) that often go unnoticed or remain implicit. Addressing ethical questions in a
practical psychotherapy context may lead to acknowledging more complexity
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

xviii   Detailed Table of contents

than expected. At the same time, meta-level ethical reflection can help to
coordinate previously diverging interests and efforts and remove obstacles
towards problem-solving. Complexity as well as problem solving will be
illustrated by referring to problems with confidentiality concerning sexual
abuse, coercion in treating dependency disorders, and responding to wishes of
assisted suicide.

19. Evidence, science, and ethics in talk-based healing practices 288

James Phillips and John Z. Sadler
This chapter considers the role of knowledge and evidence in comparing and
contrasting the ethics of non-clinical counseling (NCC) and mainstream mental
health care as practiced by psychiatry, clinical psychology, and social work. As
helping traditions which mostly eschew diagnostic categorization and approach
mental distress from different values, practices, and metaphysical standpoints,
the three NCC traditions considered here are found to be prone to errors of
omission, e.g., not knowing what one does not know. While mainstream mental
health is also subject to these errors, the mainstream’s allegiance to evidence-
based practices leaves it prone to neglecting the crucial role of the clinician in
dialogue with the patient. The authors conclude by arguing for wider appreciation
of the contributions of clinical interpretation from the philosophy of psychiatry.

20. Patient information on evidence and clinical effectiveness of

psychotherapy312
Charlotte Blease, John M. Kelley, and Manuel Trachsel
This chapter focuses on what information should be provided to patients about
the evidence base supporting the clinical effectiveness of psychotherapy. In
particular, we consider whether research on the relative efficacy of different
forms of psychotherapy should be provided to patients, as well as whether
patients should be provided with information on the relative importance of
common factors versus specific factors as the causal agents of clinical
improvement. After a critical review and discussion of the relatively few scholarly
papers that have previously addressed this question, we conclude that patients
should be provided with an honest, transparent, and impartial summary of the
evidence related to their treatment options including information about the
common factors. We draw this conclusion even while acknowledging that
considerable controversy persists about how to interpret the psychotherapy
research evidence base. Finally, we strongly support continued research into
these questions, especially given the relatively limited scholarly attention they
have received to date.

21. Ethical dimensions of psychotherapy side effects 330

Michael Linden
Side effects are unwanted events caused by appropriate treatment. They must be
discriminated from negative developments which are unrelated to treatment or
which are caused by improper treatment. The assessment of side effects requires
 OUP CORRECTED AUTOPAGE PROOFS – FINALS, 07/06/21, SPi

Detailed Table of contents   xix

several professional but also value decisions: what is negative? What is proper
treatment? What is treatment related? Scientifically there is a lack of generally
accepted instruments and of guidelines on how to assess side effects in clinical
trials. There is growing evidence that about 10% of psychotherapy patients
experience relevant negative consequences of psychotherapy. Therapist should
be aware of the possibility of side effects and inform patients. Acknowledgement
of side effects can improve treatment and also advance the development the field
of psychotherapy.

22. Privacy and confidentiality in psychotherapy: conceptual

background and ethical considerations in the light of
clinical challenges 340
Anke Maatz, Lena E. Schneller, and Paul Hoff
This chapter situates privacy and confidentiality as central ethical, legal and
anthropological concepts for psychotherapeutic practice. It first provides some
conceptual background and clarification of the concepts before considering
their specific relevance in the context of psychotherapy. In particular, it explores
a unique significance that, it is argued, privacy and confidentiality acquire in the
therapeutic process to do with the anthropological dimension of privacy, its
psychological function and the specific dynamics of the therapeutic relationship.
Based on four case vignettes, potential ethical conflicts about privacy and
confidentiality are then discussed. Finally, principles that can guide practitioners
in responding to ethical conflicts about privacy and confidentiality in clinical
practice are provided.

23. Dual and multiple relationships in psychotherapy 352

Kevin S. Doyle
Maintaining appropriate boundaries with clients/patients is a fundamental
ethical obligation of the helping professions. Known as dual relationships or
multiple relationships, holding more than one relationship with a past or current
client/patient can be ethically challenging at a minimum and highly unethical in
certain circumstances. Ethical professionals are aware of the potential risks
associated with having more than one relationship with a client or patient and
consider these both at the onset of therapy and during the therapeutic
relationship. This chapter explores some of the common issues relating to dual/
multiple relationships and presents ways in which the helping professions frame
the appropriate and the inappropriate. Avoiding inappropriate relationships is
balanced with the goal of maintaining access to services in situations such as
those posed by rural areas.

24. Ethics considerations in selecting psychotherapy modalities

and formats 363
John Z. Sadler
Little discussion has appeared in the literature regarding the ethical and value
considerations when clinicians select a psychotherapy modality (e.g., CBT,
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Exploring the Variety of Random
Documents with Different Content
Vanderbilt, Alfred, 194.
Vand der Wonde, Cornelius, 6.
Van Drebel, Cornelius, 4 to 9, 41.
Vendémiaire, 124.
Vereshchagin, 147.
Vickers Sons & Maxim, 80.
Ville de la Ciotat, 205.
Von Weddigen, Lieutenant-commander, 18, 160, 191.
Von Bernstorff, Ambassador, 199.
Von Tirpitz, Admiral, 69, 177, 187, 189.
Vulcan, 132.

Waddington, Mr. J. F., 83, note.

War-head, 47, 52.
War Zone, 30, 179.
Washington, George, 13, 17, 25.
Wheeled submarines, 84.
White mice, 13, 110.
Whitehead, Mr., 44.
Whitney, Secretary, 74.
Wilson, President, 180, 197, 198.
Wright brothers, 71.

X-4, 102 to 123.

Yasaka Maru, 205.

Yenisei, 146.

Zeppelins, 172.
 FOOTNOTES
1
Also spelled Van Drebbel, Drebell, Dreble, and Trebel.
He is the man Ben Jonson calls “Cornelius’ son.”
2
Harsdoffer.
3
“New Experiments touching the Spring of the Air and its
Effects,” by Robert Boyle, Oxford, 1662, p. 188.
4
The only submarine built before this for military
purposes, the Rotterdam Boat, remained private
property, and King James’s “eel-boats” were merely
pleasure craft.
5
Sergeant Ezra Lee’s letter to Gen. David Humphreys,
written in 1815. Published in the “Magazine of American
History,” Vol. 29, p. 261.
6
“General Washington and his associates in the secret
took their stations upon a house in Broadway, anxiously
awaiting the result.” From Ezra Lee’s obituary, New York
“Commercial Advertiser,” November 15, 1821.
7
According to Bushnell, the screw struck an iron bar
securing the rudder.
8
This survivor was examined by the captain of the
Cerberus, who reported that the schooner’s crew had
 drawn the machine on board and by rashly tampering
with its mechanism caused it to explode.
9
See the “Scientific American,” August 7, 1915.
10
Herbert C. Fyfe, “Submarine Warfare,” p. 269.
11
But Fulton’s Nautilus could not possibly have made the
dives with which she is credited except by the use of
the horizontal rudders which she possessed in
conjunction with the push of her man-power propellor.
Holland had carefully studied the plans and letters of
Bushnell and Fulton.
12
Mr. J. F. Waddington used vertical propellers in tubes
through the vessel for keeping her on an even keel or
submerging when stationary, on a small electric
submarine he invented, built and demonstrated at
Liverpool in 1886.
13
Quotations in this chapter are from Mr. Lake’s articles
published in “International Marine Engineering,” and are
here reprinted by his kind permission.
14
Electric current.
15
From an article by Admiral Selfridge in the “Outlook.”
16
The velocity of sound in dry air at a temperature of 32
degrees Fahrenheit is about 1087 feet a second, in
water at 44 degrees, about 4708 feet a second.
17
The sound of the first gun of the salute fired by the
Russian fleet in Cronstadt harbor to celebrate the
coronation of Alexander II in 1855 was the signal for
the crew of the submerged submarine Le Diable Marin
to begin singing the National Anthem. Their voices,
 accompanied by a band of four pieces, were distinctly
heard above the surface. This novel concert had been
planned by Wilhelm Bauer, the designer of the
submarine and one of the earliest students of under-
water acoustics. He succeeded in signaling from one
side of the harbor to another by striking a submerged
piece of sheet-iron with a hammer.
18
“Scientific American,” January 28, 1911, page 87.
19
“Scientific American,” November 23, 1912.
20
Titherington’s History of the Spanish-American War, p.
139.
21
Ibid., page 202.
22
He had done notable work with mines himself, during
the Russo-Turkish War of 1878.
23
This was a very popular type with the Confederate
Torpedo Service in the Civil War.
24
London, Jan. 4.—A British official statement issued to-
day says:
“Sir Edward Grey, secretary for foreign affairs, has
answered the complaint by the Germans through the
American embassies regarding the destruction off the
coast of Ireland of a German submarine and crew, by
the British auxiliary Baralong, by referring to various
German outrages.
“Sir Edward Grey offers to submit such incidents,
including the Baralong case, to an impartial tribunal
composed, say, of officers of the United States navy.
“The Foreign Office has presented to the House of
Commons the full correspondence between Ambassador
 Page and Sir Edward Grey concerning the case. A
memorandum from Germany concerning the sinking of
the submarine includes affidavits from six Americans
who were muleteers aboard the steamer Nicosian and
witnessed the Baralong’s destruction of the submarine.
A further affidavit from Larimore Holland, of
Chattanooga, Tennessee, who was a member of the
crew of the Baralong, was submitted. All the affidavits
speak of the Baralong as disguised and flying the
American flag.”
25
“Scientific American,” October 16, 1915.
26
In “Collier’s Weekly,” August 22, and 29, 1914.
27
This submarine was the U-39. On board her was an
American boy, Carl Frank List, who was taken off a
Norwegian ship and spent eleven days on the U-39,
during which time she sank eleven ships. In each case
the crew were given ample time to take to the boats.
List’s intensely interesting narrative appeared in the
“New York American” for September 3, 5, and 7, 1915.
28
“Von Weddigen, I was told, met his death chasing an
armed British steamer. Commanding the U-29, he went
after a whale of a British freighter in the Irish Sea,
signaled her to stop. She stopped but hoisted the
Spanish flag. As he came alongside, the steamer let
drive with her two four-point-sevens at the submarine,
sinking it immediately.” Statement of Carl Frank List.
29
Statement of Dr. Cecile L. Greil, the only native-born
American on board.
 Transcriber’s Notes
Punctuation, hyphenation, and spelling were made
consistent when a predominant preference was found in
this book; otherwise they were not changed.
Words spelled differently in quoted passages than in
the author’s own text have not been changed.
Simple typographical errors were silently corrected;
occasional unbalanced quotation marks retained.
Chapter II’s footnotes originally skipped number “3”.
The omission is not apparent in this eBook, in which all
footnotes are in a single ascending sequence.
Ambiguous hyphens at the ends of lines were
retained.
For consistency, all occurrences of “bow-foremost”
and “stern-foremost” are hyphenated in this eBook.
Index not checked for proper alphabetization or
correct page references.
*** END OF THE PROJECT GUTENBERG EBOOK THE STORY OF THE
SUBMARINE ***

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