Ethics surrounding psychotherapy must address a diverse set of situations, ranging from support counseling to new app-based therapies, and recognize the vulnerability of the patient, notes John Z. Sadler, M.D., Professor of Psychiatry, Distinguished Teaching Professor at UT Southwestern, and a member of the Peter O’Donnell Jr. Brain Institute.

What is distinctive about psychotherapy ethics compared with other kinds of medical or clinical ethics?

The field of psychotherapy ethics is distinctive in many ways. First, we have to ask which practices ‘count’ as psychotherapy. What people call psychotherapy represents a huge array of person-to-person helping practices. Some of these are embedded in mainstream mental health care and standard evidence-based treatments; others avoid language such as ‘mental illness,’ ‘diagnosis,’ and ‘treatment’ and operate outside of the formal mental health care system. As opposed to clinical medicine, which is based in the biological sciences, psychotherapies are based broadly in the social sciences, the humanities, narrative theory, and culture-specific healing practices. Psychotherapy is not a profession proper, so psychotherapy ethics has to respond to a host of different practice situations: professional and nonprofessional, clinical and nonclinical, technical and nontechnical. Some psychotherapists are regulated by professional associations and licensure, while others are not. This makes the ethics issues diverse, and therefore, complex and distinctive compared to clinical/medical ethics. Psychotherapy ethics standards for a psychiatrist like me might be quite different compared to those of a peer-support counselor working outside of a mental health setting.

Can you give an example of these distinctive features?

A good example pertains to the core of clinical ethics: people in health-related distress come to us. Because they are in pain and emotional turmoil, they have a situational vulnerability not shared by their would-be helpers, whether a psychotherapist or a surgeon. The person in distress is one-down in the power relationship with the helper.

So how does that relate to ethics?

Appreciation of the vulnerability of the person in distress is what compels clinician-helpers to follow key elements of ethics: not harming the person, not exploiting the person, having a responsibility to provide benefit or a best-effort at benefiting the person, etc. These ethical obligations are encoded in professional ethics standards from either laws, licensure, or professional associations. However, many psychotherapy practice traditions are not bound by these explicit ethical rules, and so for these psychotherapy traditions, the ethics has to be built up in other ways. One guiding principle we used in exploring psychotherapy ethics in nonclinical settings (e.g., peer counseling, philosophical counseling, for instance) was to keep this special vulnerability of the client in mind while respecting the distinctive practice approach of the psychotherapy under consideration.

What are some important emerging ethics issues in psychotherapy?

Some issues have been with us for many years, such as balancing scientific efficacy with tailoring practice to the unique patient; maintaining boundaries and not exploiting patients; and navigating confidentiality in the face of multiclient therapies like group, family, and couples therapy. There are also challenging new areas: computer, internet, virtual, and/or app-based psychotherapy – are these private, effective, safe? Should therapy be provided by robots, even if the science shows efficacy? If the patient has a bad outcome with the robot or app, who is accountable – the manufacturer, the owner, no one? How can psychotherapy be respectful, effective, and serve the diverse intersectional identities of all people today and break free of the image of the practice as a luxury for wealthy white people? Even the standard medical ethics concept, informed consent, is complex in psychotherapy, as what to expect in the course of therapy is very difficult to predict – and without some prediction, how can the psychotherapy patient be informed to participate? We explore these issues at length in the book.

Some of the helping practices you describe may sound to some as being too far away from conventional medical therapies. What made your team include these nonclinical helping practices in a psychotherapy ethics book?

Drawing strict boundaries about what is and isn’t psychotherapy is difficult. However, and more importantly, many of these helping practices are not bound up with regulations, professional associations, and other ways of assuring safety and efficacy. Our decision to include them was ethical in itself. We thought writing about ethical considerations would be a helpful, nonjudgmental way of elevating ethics awareness to practices which might not consider ethics explicitly in their everyday work. Ultimately, we thought some guidance is much better than no guidance at all.