Übersichtsarbeiten / Review Articles. Voreingenommenheiten und Wahrnehmungsverzerrungen (Bias) in der psychiatrisch-psychotherapeutischen Versorgung von Kindern und Jugendlichen mit intellektueller Beeinträchtigung.

Bias in Mental Health Care of Children and Adolescents with Intellectual Disabilities Implicit and explicit bias and distortions of perception are partly responsible for the unequal and significantly deficient psychotherapeutic and psychiatric care situation for children and adolescents with intellectual disabilities and additional behavioral problems. The extent to which these biases influence misdiagnoses and treatment errors, refusals and exclusions from professional care, and grossly hostile rejections of people with disabilities requires empirical evidence (Bartig et al., 2021). The fact that all forms occur - probably to a considerable extent - contradicts the ethical principles of the medical and psychotherapeutic profession. In order to avoid misdiagnosis and treatment as a result of bias, this must be openly addressed. Selfawareness, supervision and second views, the concept of working diagnosis and, above all, the full application of child and adolescent psychiatric standards help to reduce bias.

Does a lack of emotions make chatbots unfit to be psychotherapists?

Mental health chatbots (MHCBs) designed to support individuals in coping with mental health issues are rapidly advancing. Currently, these MHCBs are predominantly used in commercial rather than clinical contexts, but this might change soon. The question is whether this use is ethically desirable. This paper addresses a critical yet understudied concern: assuming that MHCBs cannot have genuine emotions, how this assumption may affect psychotherapy, and consequently the quality of treatment outcomes. We argue that if MHCBs lack emotions, they cannot have genuine (affective) empathy or utilise countertransference. Consequently, this gives reason to worry that MHCBs are (a) more liable to harm and (b) less likely to benefit patients than human therapists. We discuss some responses to this worry and conclude that further empirical research is necessary to determine whether these worries are valid. We conclude that, even if these worries are valid, it does not mean that we should never use MHCBs. By discussing the broader ethical debate on the clinical use of chatbots, we point towards how further research can help us establish ethical boundaries for how we should use mental health chatbots.

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.

[Advance directives and mental disorders: a practice recommendation of the Commission for Ethics and Law of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Patientenverfügungen und psychische Erkrankung ­ eine Praxisempfehlung der Kommission Ethik und Recht der DGPPN.

BACKGROUND: Since the creation of legal requirements for advance directives by the legislator in 2009, special aspects of their application in the treatment of people with mental illnesses have been discussed. GOAL OF THE PAPER: Important questions on dealing with advance directives in everyday life will be answered in a practice-oriented manner. RESULTS: Among other things, this document answers the question of the conditions under which a patient can refuse or consent to hospitalization and treatment in advance, and in particular how to deal with advance directives whose implementation would also affect the rights of third parties. The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has addressed these and other questions in the present document and added practical advice on how to formulate advance directives for people with mental illnesses and how to deal with psychiatric advance directives. DISCUSSION: The DGPPN has developed an advance directive for the area of mental health and published it on its website together with detailed explanations. With the help of this advance directive, people can decide on their treatment in phases of incapacity to consent in the context of a mental crisis or illness.

E-mental health applications for depression: an evidence-based ethical analysis.

E-mental health applications (apps) are an increasingly important factor for the treatment of depression. To assess the risks and benefits for patients, an in-depth ethical analysis is necessary. The objective of this paper is to determine the ethical implications of app-based treatment for depression. An evidence-based ethical analysis was conducted. The material was meta-reviews and randomized control studies (RCTs) on app-based treatment. Based on the empirical data, an ethical analysis was conducted using the 3-ACES-approach by Thornicroft and Tansella. Apps may empower autonomy, offer an uninterrupted series of contacts over a period of time, show evidence-based benefits for patients with subclinical and mild-to-moderate-symptoms, are easily accessible, may be used for coordinating information and services within an episode of care, and are on the whole cost-effective. Their risks are that they are not suitable for the whole range of severity of mental illnesses and patient characteristics, show severe deficits in the data privacy policy, and a big variability in quality standards. The use of apps in depression treatment can be beneficial for patients as long as (1) the usefulness of an app-based treatment is assessed for each individual patient, (2) apps are chosen according to symptom severity as well as characteristics like the patient's level of self-reliance, their e-literacy, and their openness vis-à-vis apps, (3) manufacturers improve their privacy policies and the quality of apps.

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.

The ethical practice of psychotherapy: Clearly within our reach.

This introductory article to the special section on ethics in psychotherapy highlights the challenges and ethical dilemmas psychotherapists regularly face throughout their careers, and the limits of the American Psychological Association Ethics Code in offering clear guidance for how specifically to respond to each of these situations. Reasons for the Ethics Code's naturally occurring limitations are shared. The role of ethical decision-making, the use of multiple sources of guidance, and the role of consultation with colleagues to augment and support the psychotherapist's professional judgment are illustrated. Representative ethics challenges in a range of areas of practice are described, with particular attention given to tele-mental health and social media, interprofessional practice and collaboration with medical professionals, and self-care and the promotion of wellness. Key recommendations are shared to promote ethical conduct and to resolve commonly occurring ethical dilemmas in each of these areas of psychotherapy practice. Each of the six articles that follow in this special section on ethics in psychotherapy are introduced, and their main points are summarized. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Burnout as an ethical issue in psychotherapy.

Recent studies highlight a range of factors that place psychotherapists at risk of burnout. The aim of this study was to investigate the ethics issues linked to burnout among psychotherapists and to describe potentially effective ways of reducing vulnerability and preventing collateral damage. A purposive critical review of the literature was conducted to inform a narrative analysis. Differing burnout presentations elicit a wide range of ethics issues. High rates of burnout in the sector suggest systemic factors and the need for an ethics review of standard workplace practice. Burnout costs employers and taxpayers billions of dollars annually in heightened presenteeism and absenteeism. At a personal level, burnout has been linked to poorer physical and mental health outcomes for psychotherapists. Burnout has also been shown to interfere with clinical effectiveness and even contribute to misconduct. Hence, the ethical impact of burnout extends to our duty of care to clients and responsibilities to employers. A range of occupational and personal variables have been identified as vulnerability factors. A new 5-P model of prevention is proposed, which combines systemic and individually tailored responses as a means of offering the greatest potential for effective prevention, identification, and remediation. In addition to the significant economic impact and the impact on personal well-being, burnout in psychotherapists has the potential to directly and indirectly affect client care and standards of professional practice. Attending to the ethical risks associated with burnout is a priority for the profession, for service managers, and for each individual psychotherapist. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Toward a psychotherapy science for all: Conducting ethical and socially just research.

Much has been written in recent years regarding the integration of social justice values with psychology and psychotherapy; however, the discourse surrounding social justice perspectives related to conducting psychotherapy research is scant. Psychotherapy researchers are beholden to various professional ethical standards, laws, and policies; however, adhering to these rules and guidelines may make research ethical, but not necessarily socially or politically just. In this article, the authors build on previous work from community, feminist, positive, and multicultural psychology perspectives as well as their own experiences as psychotherapy researchers, to propose a framework for approaching psychotherapy research from an ethical and socially just position. Examples from the authors' experiences conducting psychotherapy research with incarcerated individuals, community- and school-based research with youth, and research with sexual/gender minorities are provided to illustrate theoretical principles and provide practical recommendations. Barriers to implementing such a framework to psychotherapy research, as well as strategies to manage these challenges are also discussed. In addition, the authors propose a model that can be used to develop and evaluate the social justice process and content dimensions of a research study. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Research on the pathophysiology, treatment, and prevention of suicide: practical and ethical issues.

BACKGROUND: Despite decades of research, the rate of death from suicide is rising in the United States. Suicide is a complex and multifactorial phenomenon and, to date, no validated biomarkers that predict suicidal behavior have been identified. Only one FDA-approved drug to prevent suicide exists, and it is approved only for patients with schizophrenia. Although anti-suicide psychotherapeutic techniques exist, treatment takes time, and only preliminary data exist for rapid-acting therapies. DISCUSSION: While more research into suicidal ideation and acute suicidal behavior is clearly needed, this research is fraught with both practical and ethical concerns. As a result, many investigators and bioethicists have called for restrictions on the types of research that individuals with suicidal behavior can participate in, despite the fact that the available empirical evidence suggests that this research can be done safely. This manuscript presents background information on the phenomenology of suicide, discusses the current state of treatment and prevention strategies, and reviews the practical and ethical issues surrounding suicide research in the context of available empirical data. Currently, the causes of suicide are poorly understood, in part due to the fact that very few studies have investigated the acute suicidal crisis. Although some biomarkers for predicting risk have been developed, none have been sufficiently validated. The most successful current interventions involve means restriction. However, while numerous hurdles face researchers, these are not insurmountable. The available evidence suggests that research into suicide can be conducted both safely and ethically.

Psychotherapy in the #MeToo era: Ethical issues.

The #MeToo movement has heightened awareness of sexual assault and harassment, causing victims, perpetrators, observers, and loved ones to reflect on what constitutes sexual coercion and what signifies consent. These new conversations have had powerful effects: Survivors who were once silent have raised their voices; hundreds of men in powerful positions across the United States have been dismissed from their jobs; and societal norms related to sex and gender are being reconsidered. It is no wonder that the "national reckoning" enters the world of psychotherapy. This article explores three vignettes that consider therapeutic facilitation of apologies/reconciliations, psychotherapist values and advocacy, and men and #MeToo using the American Psychological Association Ethics Code as the basis to understand coercion and consent in this new cultural zeitgeist. The ethical, legal, and clinical ramifications inherent in these vignettes are highlighted as a way to assist psychotherapists in beginning to deal with #MeToo as it presents in psychotherapy. (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).

Review of "Common Factors," Personal Reflections, and Introduction of the Shaving Brush Model of Integrated Psychotherapies.

This column reviews and updates "common factors" in psychotherapy, as originally described by Saul Rosenzweig in 1936. The author, a psychiatrist who has used multiple modalities of psychotherapeutic treatment over 4 decades, shares personal reflections concerning these "common factors" and introduces a model of integrated psychotherapies named for his grandfather's shaving brush.

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).

Psychotherapists in danger: The ethics of responding to client threats, stalking, and harassment.

The ethics issues involved when clients threaten, stalk, or harass their psychotherapists have generally been neglected in the literature, leaving few psychologists prepared to manage such challenging situations. This article presents 3 clinical vignettes and recommendations resulting from a recent conference in Colorado on this important topic. In essence, the article seeks to address ways psychotherapists can balance the ethical challenges of simultaneously protecting clients and themselves. Each vignette is considered from ethical, clinical, and legal perspectives. Suggestions for the individual practitioner include reference to the principles and standards in the American Psychological Association's Ethics Code, professional consultation, and an increased emphasis on self-care. Recommendations for the profession involve ideas for the American Psychological Association's Ethics Code Task Force as well as a call for further research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

[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.

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.

Your Robot Therapist Will See You Now: Ethical Implications of Embodied Artificial Intelligence in Psychiatry, Psychology, and Psychotherapy.

BACKGROUND: Research in embodied artificial intelligence (AI) has increasing clinical relevance for therapeutic applications in mental health services. With innovations ranging from 'virtual psychotherapists' to social robots in dementia care and autism disorder, to robots for sexual disorders, artificially intelligent virtual and robotic agents are increasingly taking on high-level therapeutic interventions that used to be offered exclusively by highly trained, skilled health professionals. In order to enable responsible clinical implementation, ethical and social implications of the increasing use of embodied AI in mental health need to be identified and addressed. OBJECTIVE: This paper assesses the ethical and social implications of translating embodied AI applications into mental health care across the fields of Psychiatry, Psychology and Psychotherapy. Building on this analysis, it develops a set of preliminary recommendations on how to address ethical and social challenges in current and future applications of embodied AI. METHODS: Based on a thematic literature search and established principles of medical ethics, an analysis of the ethical and social aspects of currently embodied AI applications was conducted across the fields of Psychiatry, Psychology, and Psychotherapy. To enable a comprehensive evaluation, the analysis was structured around the following three steps: assessment of potential benefits; analysis of overarching ethical issues and concerns; discussion of specific ethical and social issues of the interventions. RESULTS: From an ethical perspective, important benefits of embodied AI applications in mental health include new modes of treatment, opportunities to engage hard-to-reach populations, better patient response, and freeing up time for physicians. Overarching ethical issues and concerns include: harm prevention and various questions of data ethics; a lack of guidance on development of AI applications, their clinical integration and training of health professionals; 'gaps' in ethical and regulatory frameworks; the potential for misuse including using the technologies to replace established services, thereby potentially exacerbating existing health inequalities. Specific challenges identified and discussed in the application of embodied AI include: matters of risk-assessment, referrals, and supervision; the need to respect and protect patient autonomy; the role of non-human therapy; transparency in the use of algorithms; and specific concerns regarding long-term effects of these applications on understandings of illness and the human condition. CONCLUSIONS: We argue that embodied AI is a promising approach across the field of mental health; however, further research is needed to address the broader ethical and societal concerns of these technologies to negotiate best research and medical practices in innovative mental health care. We conclude by indicating areas of future research and developing recommendations for high-priority areas in need of concrete ethical guidance.