Ethical reflection in cognitive behavioral therapy and supervision: Theory and practice.

Ethical reflection is a process that comes from the deeper attitudes and values of the therapist and supervisor. The capability to recognize one's perspectives and ethical dimensions and how they affect own practice is one of the crucial tasks of a responsible therapist. Attitudes and values of an individual or a group may significantly influence the therapeutic process and a choice of strategies and behaviour towards the patient, often working at an unconscious, unreflected levels. Ethics is closely connected with psychotherapeutic treatment. Basic principles, such as expediency, honesty, integrity, justice, and respect, apply to all people equally, including psychologists, psychiatrists, psychotherapists, and supervisors. The goal of supervision is to cultivate the therapeutic process in the client's best interest. The supervisor-supervisee relationship is then grounded on principles similar to those in the therapeutic relationship.

Potential ethical pitfalls and dilemmas in the promotion and use of American Psychological Association-recommended treatments for posttraumatic stress disorder.

A variety of potential unrecognized ethical concerns arise from the American Psychological Association's (APA, 2017) Clinical Practice Guideline for the Treatment of PTSD in Adults. In privileging short-term treatments that underscore symptom reduction as the predominant index of outcome, such as cognitive processing therapy and prolonged exposure, there is a susceptibility to mislead mental health professionals and clients alike to believe that lasting improvements in socioemotional well-being, and a time-intensive approach, are unrealistic, rather than realistic psychotherapy expectations. There are ethical implications to incompletely addressing clients' preferences and clinicians' judgments on matters such as preferred socioemotional outcomes, and desirable qualities in a therapist and therapy. As regard combat veterans, treating trauma-related guilt and shame as symptoms to be eliminated, rather than moral feelings to be acknowledged, expressed, and self-forgiven, warrants special ethical consideration. The high dropout rates of cognitive processing therapy and prolonged exposure raise questions as to whether their protocol-driven methods alienate substantial numbers of traumatized clients. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

An Aristotelian view of therapists' practice in multifamily therapy for young adults with severe eating disorders.

BACKGROUND: Eating disorders are serious conditions which also impact the families of adult patients. There are few qualitative studies of multifamily therapy with adults with severe eating disorders and none concerning the practice of therapists in multifamily therapy. OBJECTIVES: The aim of the study is to explore therapists' practice in multifamily therapy. RESEARCH DESIGN AND PARTICIPANTS: A grounded theory approach was chosen. Data were collected through participant observation in two multifamily therapy groups and qualitative interviews with the therapists in those groups. ETHICAL CONSIDERATIONS: The study conforms to the principles outlined in the Declaration of Helsinki. All participants in the multifamily therapy groups received information about the research project and signed consent forms. The data are treated confidentially and anonymised. FINDINGS: The core category was identified as 'having many strings to one's bow', consisting of three subcategories: 'planning and readjusting', 'developing as therapist and team' and 'regulating the temperature of the group'. This article discusses the empirical findings in the frame of Aristotelian virtue ethics.

Reviewing outcomes of psychological interventions with torture survivors: Conceptual, methodological and ethical Issues.

BACKGROUND: Torture survivors face multiple problems, including psychological difficulties, whether they are refugees or remain in the country where they were tortured. Provision of rehabilitation varies not only with the needs of survivors and resources available, but also with service models, service provider preferences and the local and country context. Despite increasing efforts in research on effectiveness of psychological interventions with torture survivors, results are inconclusive. METHODS: We undertook a Cochrane systematic review of psychological, social and welfare provision, with meta-analysis to best estimate efficacy. The process raised conceptual, methodological and ethical issues of relevance to the wider field. FINDINGS: We searched very widely, but rejected hundreds of papers which recommended treatment without providing evidence. We found nine randomised controlled trials, from developed and under-resourced settings. All conceptualised survivors' problems in psychiatric terms, using outcomes of post-traumatic stress symptoms, distress, and quality of life, by self-report, with or without translation or unstandardised interpretation, and with little mention of cultural or language issues. None used social or welfare interventions. Four related studies used narrative exposure therapy (NET) in a brief form, and without ensuring a safe setting as recommended. Five used mixed methods, including exposure, cognitive behavioural therapy, and eye movement desensitisation. Combined, the studies showed no immediate improvement in PTSD, distress, or quality of life; at six months follow-up, a minority showed some improvement in PTSD and distress, although participants remained severely affected. CONCLUSIONS: While applauding researchers' commitment in running these trials, we raise ethical issues about exposure in particular, and about the effects of shortcomings in methodology, particularly around assessment using unfamiliar cultural frameworks and language, and the lack of concern about dropout which may indicate harm. The issues addressed aid interpretation of existing research, and guide clinical practice as well as future studies evaluating its effectiveness.

The Relationship between Theoretical Orientation and Countertransference Expectations: Implications for Ethical Dilemmas and Risk Management.

UNLABELLED: Countertransference (CT) awareness is widely considered valuable for differential diagnosis and the proactive management of ethical dilemmas. We predicted that the more practitioners' theoretical orientation (TO) emphasizes insight into the dynamics of subjective mental life, the better they will be at using their CT expectations in differential diagnosis with high-risk patients. To test this hypothesis, we compared psychodynamic therapy (PDT) practitioners who emphasize insight into subjective mental life with practitioners who do not emphasize this epistemology. Results indicated that PDT practitioners expected significantly more CT than practitioners of cognitive-behavioural therapy (CBT) and other practitioners (e.g., family systems, humanistic/existential and eclectic) to patients with borderline personality organization overall. PDT practitioners had significantly more CT expectations to patients with borderline-level pathologies as compared with neurotic-level patients than both CBT and other practitioners. PDT practitioners were significantly more expectant of CT issues than CBT practitioners with respect to the personality disorders most associated with acting out and risk management problems (e.g., paranoid, psychopathic, narcissistic, sadistic, sadomasochistic, masochistic, hypomanic, passive-aggressive, counterdependent and counterphobic). The other practitioners generally had CT expectations between PDT and CBT. These findings suggest that clinical training into CT may be useful in differential diagnoses and in helping to avoid ethical dilemmas regardless of one's theoretical preference. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Insight into countertransference can be used to help with differential diagnoses and to help prevent possible management problems with acting out patients. The Psychodynamic Diagnostic Manual is a useful taxonomy in that it includes countertransference as a diagnostic aid.

Cognitive Enhancement and Beyond: Recommendations from the Bioethics Commission.

Media outlets are reporting that cognitive enhancement is reaching epidemic levels, but evidence is lacking and ethical questions remain. The US Presidential Commission for the Study of Bioethical Issues (Bioethics Commission) has examined the issue, and we lay out the commission's findings and their relevance for the scientific community.

Talking more about talking cures: cognitive behavioural therapy and informed consent.

Cognitive behavioural therapy (CBT) has risen to prominence as an orthodox treatment option which is commonly recommended to patients with anxiety and depressive disorders. Mainstream healthcare institutions (including the National Health Service in the UK (NHS) and National Institute for Mental Health (NIMH)) assume that CBT works by helping patients to challenge and overcome 'faulty cognition'. Even if we accept the empirical evidence which shows that CBT (like other forms of psychotherapy) is a beneficial treatment there are still problems with this therapy: mainstream medicine and psychotherapy are continuing to ignore established research that CBT does not work according to its core theoretical tenets. This paper presents evidence that psychotherapy is entrenched in such conventional 'wisdom' and that practitioners are failing to meet their own codified requirement of informed consent. I examine ethical arguments for and against upholding current informed consent procedures and focus, in particular, on the relationship between respect for patient autonomy and the duty of beneficence. I argue that (so far) there are no strong grounds for the claim that patient autonomy undermines therapeutic outcome. The modest conclusion of this paper is that psychotherapy (including CBT) needs to begin to adapt informed consent procedures to comply with ongoing scientific research into its efficacy.

Opt-outs and upgrades. Ethics and law in the United Kingdom.

We report on two areas in which UK law and ethics seem out of step with each other. 2013 saw the passing of the Human Transplantation (Wales) Bill, which will introduce an opt-out system of organ donation in Wales from 2015. In the first section, we discuss the convoluted evolution of the Bill and some potential problems that we consider may prevent it from achieving its intended goal of increasing the number of organs transplanted. The prospect of being able to enhance human cognition through cognitive-enhancing drugs ("smart drugs") also presents a nexus of questions associated with future ambitions, hopes, and concerns as a society. How these drugs might affect the future of work and employment is beginning to generate wide public engagement in the UK and forms the focus of the second section.

[Ethics as the main philosophy of care]. / L'éthique comme philosophie première du soin.

Care is based on ethics, a non-corporatist form of ethics. For the caregiver, clinical refers to the patient and not a profession, a sine qua non condition of not losing sight of the meaning of care. Human nature incites us to escape the formal aspect, but can we necessarily make the informal exclusive to nursing?

Humanistic psychology and contextual behavioral perspectives.

Humanistic psychology historically defined itself in part by its opposition to behavioral psychology, but the conditions now exist for a fundamental reconsideration of the relationship between these two traditions. Behavioral psychology includes contextualistic variants and is no longer limited to principles drawn from animal learning. Behavioral and cognitive therapies commonly address humanistic topics and have developed process accounts that cast new light on them. In that context, a reconsideration of this relationship could prove to be beneficial for both traditions.

Case study: ethical guidance for pediatric e-health research using examples from pain research with adolescents.

OBJECTIVE: The Internet is a frequently used platform for research in pediatric and health psychology. However, there is little pragmatic guidance as to ethical best practice of this research. The absence of guidance is particularly prominent for online research with children. Our objective is to outline ethical issues in e-health research with children and adolescents using two exemplar studies in pediatric pain research. METHODS: The first study is an asynchronous message board discussion amongst teenagers with pain who are frequent internet users.The second study is a web-based behavioral intervention for the management of adolescent pain. RESULTS: Each exemplar study is discussed in the context of specific ethical considerations related to recruitment, informed consent and debriefing, privacy and confidentiality, and participant safety. Ethical issues regarding the evaluation of online psychological interventions are also discussed. CONCLUSIONS: Guidance on optimal ethical practice in e-health research is summarized.

Tratamiento psicológico del trastorno por déficit de atención con hiperactividad en adultos: revisión sistemática / Psychological treatment of attention deficit hyperactivity disorder in adults: a systematic review

Introducción. El trastorno por déficit de atención con hiperactividad (TDAH) es un trastorno del neurodesarrollo de inicio en la infancia y que en la mayoría de los casos persiste en la edad adulta afectando significativamente el funcionamiento del paciente. Aunque el tratamiento farmacológico se considere el tratamiento de primera elección para el TDAH en adultos, los tratamientos farmacológicos no siempre son suficientes. El objetivo de este artículo es revisar sistemáticamente todos los estudios publicados hasta el momento sobre el tratamiento psicológico del TDAH en adultos. Método. El método utilizado fue una búsqueda bibliográfica en las bases de datos MEDLINE y Psych INFO usando los términos psychological treatment OR psychotherapy OR psychosocial treatment AND ADHD. Se limitó la edad, seleccionando los tratamientos de adultos (all adult: 19+ years). Resultados. Cumplieron los criterios de inclusión 18 estudios publicados. Se seleccionaron 15 estudios de eficacia de tratamientos psicológicos (terapia cognitivo-conductual, terapia metacognitiva, terapia dialéctico, conductual, coachingy estudios de rehabilitación cognitiva) y 3 revisiones previas. Conclusiones. Los resultados indican que la terapia cognitivo-conductual es el abordaje más eficaz de tratamiento psicológico del TDAH en adultos y de la sintomatología comórbida de ansiedad y depresión; síntomas que también tienen una importante repercusión funcional en la vida diaria del paciente. No obstante, se requiere mayor investigación para conocer los efectos diferenciales de los distintos abordajes psicológicos en relación a las mejoras de la sintomatología del TDAH en adultos. Finalmente, se sugieren direcciones futuras para los estudios de tratamiento psicológico (AU)

Introduction. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder of childhood onset. The disorder persists into adulthood in most cases, significantly affecting patient function. Although the firstline choice of treatment for ADHD is pharmacological, drug treatments are not always sufficient. All the published studies on the psychological treatment of ADHD were systematically reviewed for the present article. Method. The MEDLINE and Psych INFO electronic databases were searched using the terms psychological treatment OR psychotherapy OR psychosocial treatment AND ADHD. Patient age was restricted to adults (all adult: 19+years). Results. Eighteen published studies met inclusion criteria for the review. Fifteen efficacy studies of psychological treatment were selected (cognitive behavioral therapy, metacognitive therapy, dialectical behavior therapy, coaching, cognitive remediation) and three previous reviews. Conclusions. The results indicate that cognitive behavioral therapy is the most effective psychological treatment for ADHD symptoms in adults and the comorbid symptoms of anxiety and depression, which have an important functional impact on the daily life of patients. However, more research is needed to know the differential effects of each psychological approach in relation to improved ADHD symptoms in adults. Finally, future directions for the psychosocial treatment of ADHD problems of adults are suggested (AU)

Intervenciones psicosociales en el Trastorno Bipolar: una revisión / Psychosocial interventions in Bipolar Disorder: A review

Introducción. En los últimos años han sido propuestas múltiples intervenciones psicosociales para el tratamiento del trastorno bipolar. Una revisión crítica de los modelos validados empíricamente resultaría de utilidad. Método. Se realizó una revisión bibliográfica de artículos publicados en Medline/Pub Med durante los años 2000-2010 que respondieran al cruce de trastorno bipolar con las siguientes palabras claves: "psychosocial intervention","psychoeducational intervention" y "psychotherapy". Resultados. Cuentan con validez empírica intervenciones provenientes de los modelos cognitivo-conductual, psicoeducativo, cuidado sistemático, interpersonal y familiar. Todas ellas dan cuenta de mejoras significativas en la adhesión a las indicaciones terapéuticas y un incremento en la funcionalidad Conclusiones. Si bien se utilizan diversas intervenciones psicosociales validadas para el abordaje del trastorno bipolar, su nivel de eficacia debería precisarse en base a variables más específicas como ser las formas clínicas, tipo de comorbilidad ,fases o duración de la enfermedad. Estas delimitaciones permitirían seleccionar la intervención más adecuada según las características del paciente (AU)

Introduction. Multiple psychosocial interventions for bipolar disorder have been proposed in recent years. Therefore, we consider that a critical review of empirically validated models would be useful. Methods. A review of the literature was conducted in Medline/Pub Med for articles published during 2000-2010that respond to the combination of "bipolar disorder" with the following key words: "psychosocial intervention", "psychoeducational intervention" and "psychotherapy". Results. Cognitive-behavioral, psychoeducational, systematic care models, interpersonal and family therapy interventions were found to be empirically validated. All of them reported significant improvements in therapeutic adherence and in the patients’ functionality. Conclusions. Although there are currently several validated psychosocial interventions for treating bipolar disorder, their efficacy needs to be specified in relation to more precise variables such as clinical type, comorbid disorders, stages or duration of the disease. Taking into account these clinical features would enable a proper selection of the most adequate intervention according to the patient’s specific characteristics (AU)

[Counter-transference in eating disorder treatment:a systematic review]. / [Le contre-transfert dans le traitement des troubles alimentaires : recension systématique des écrits.]

OBJECTIVE: To identify counter-transference occurrences and causes in therapists treating patients with eating disorders, and to present suggested solutions to overcome counter-transference's negative aspects and to enhance treatment quality. METHOD: Using the major health science and psychology databases, we have identified studies dealing with counter-transference in eating disorder treatment. RESULTS: Many counter-transference occurrences are identified. It seems that therapists often feel negative affects while treating patients with eating disorders. Counter transference seems to be affected by factors related to both the disorder and to the patient and therapist. Further, negative counter-transference can lead to consequences interfering with proper conduct of treatment. The main solutions identified to deal with counter-transference are supervision, consulting with colleagues, and teamwork. CONCLUSIONS: Many factors involved in counter-transference seem hardly modifiable;hence it is important to implement efficient solutions allowing overcoming its negative aspects. Moreover, few empirical studies have focused on counter-transference in eating disorder treatment. That research field is highly pertinent but very rarely exploited, and it deserves the scientific community's attention.

How the philosophy of Merleau-Ponty can help us understand the gulf between clinical experience and the doctrine of evidence-based psychotherapy.

OBJECTIVE: The aim of this paper is to examine the gulf between clinical experience and the doctrine of evidence-based psychotherapy from the perspective of the philosophy of Maurice Merleau-Ponty. CONCLUSIONS: Evidence-based psychotherapy, which requires that psychotherapists ignore their thoughts and feelings with individual patients in favour of following standardized manuals and guidelines, is being increasingly promoted as part of evidence-based medicine (EBM). However, this represents an inappropriate extension of logical empiricist philosophy and significance testing methodology, on which evidence-based medicine is founded, to psychotherapy. It sacrifices a search for truth in psychotherapy, for an illusory search for certainty. The inevitable consequence of this is that psychotherapy becomes a commoditised pseudorelationship. Merleau-Ponty provides an alternative ontology, based on the primacy of perception, that gives an epistemological foundation for the search for truth and integration as a basis for psychotherapy. The practice of evidence-based psychotherapy raises serious ethical concerns about pseudorelationships being passed off as authentic, which could lead to missed opportunities to engage mentally ill patients in treatment and to reinforcement of their damaging sense of alienation.

Who needs antipsychotic medication in the earliest stages of psychosis? A reconsideration of benefits, risks, neurobiology and ethics in the era of early intervention.

In recent years, early intervention services have attempted to identify people with a first episode of psychosis as early as possible, reducing the duration of untreated psychosis and changing the timing of delivery of interventions. The logic of early intervention is based partly on accessing people in a more treatment responsive stage of illness in which psychosocial damage is less extensive, and partly on remediating a putatively active process of neuroprogression that leads to pathophysiological, symptomatic and structural changes, hence improving symptomatic and functional outcomes. However, as in other areas of health care, earlier identification of new patients may mean that different treatment approaches are indicated. The corollary of early detection is that the sequence and complexion of treatment strategies for first episode psychosis has been revaluated. Examples include the minimal effective dosage of antipsychotic medication and the content of psychosocial interventions. With the substantial reductions of DUP now seen in many early psychosis services, based on clinical staging and stepped care principles, it is even possible that the immediate introduction of antipsychotic medication may not be necessary for all first episode psychosis cases, but that potentially safer interventions, which may be more acceptable to many patients, such as comprehensive psychosocial intervention, may constitute effective treatment at least for a subgroup of patients. In this paper, we review this theoretical background and describe a randomised controlled trial currently underway at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne designed to test outcomes for first episode psychosis patients in response to two different treatments: intensive psychosocial intervention plus antipsychotic medication versus intensive psychosocial intervention plus placebo. This is a theoretically and pragmatically novel study in that it will provide evidence as to whether intensive psychosocial intervention alone is sufficient for a subgroup of first episode psychosis patients in a specialised early intervention service, and provide a test of the heuristic clinical staging model. By experimentally manipulating duration of untreated psychosis, the study will also provide a methodologically strong test of the effect of delaying the introduction of antipsychotic medication, as well as helping to disentangle the effects of antipsychotic medications and the putative neurobiological processes associated with brain changes and symptom profiles in the early phase of psychotic disorders. The study has been carefully crafted to satisfy critical ethical demands in this challenging research domain.

Autonomy and ethical treatment in depression.

Antidepressant medication and evidence-based psychotherapy have largely equivalent efficacy in the management of the common, less severe grades of depression. As a result, several national guidelines recommend that either can be used in the treatment of this disorder. Psychotherapy, however, differs in that it assists insight into how the depressed person appraises and manages the stressors that frequently trigger depressive episodes. I argue that the self-knowledge achieved through psychotherapy has moral value in that it promotes the autonomy of stressor-related decisions. I further argue that such an effect comprises a compelling moral reason for doctors to see evidence-based psychotherapy not as merely optional, but as a necessary treatment for their patients with depression.