Ethical Dimensions of Psychotherapy:

A Personal Perspective

PAUL CHODOFF, M.D.*

Ethical issues within psychotherapy are reviewed from the perspective of a
fifty-year practice experience. The increased interest in these issues is noted
and some reasons suggested. Misuse of the power inherent in the therapist's
role for sexual, financial, and psych op athological satisfaction can give rise to
ethical derelictions. The shift from a two-party to a three-party payment
system and the effects of managed care have raised questions, with ethical
implications, about confidentiality, and the scope, efficacy, and medicality of
psychotherapy.

INTRODUCTION
As I undertake this review of the ethical issues confronting psychothera-
pists from the standpoint of a practitioner of some 50 years experience, I
am struck by how much more interest there is today in ethical matters and
especially in possible derelictions—both from within and without the
profession—than in the early days of my career. In the post-World War I I
era, when I began my practice, I recall very little discussion of ethical
matters among colleagues, and few articles or books on the subject. The
first edition of the Principles of Medical Ethics with Annotations Especially
Applicable to Psychiatry did not appear until 1973. 1

It seems worthwhile to speculate on reasons for such a marked shift in

what might be called the moral climate within which psychotherapists now
work. I doubt that my colleagues today are intrinsically more righteous
than those in my past. More pragmatically, it seems likely that current
practitioners are increasingly aware that they have to keep track of what
they should and should not do and of what will happen to them if they err.
One factor in the change, at least for psychiatrists, who, of course, are
physicians, has been the movement from the paternalistic model ("father
knows best—you should do what he tells you and not complain") of the

*Clinical Professor of Psychiatry, George Washington University; Past President, American Acad-
emy of Psychoanalysis; Chairman, Ethics Committee, Washington Psychiatric Society. Mailing address:
1904 R Street, NW, Washington, D C 20009.

AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 50, No. 3, Summer 1996

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doctor-patient relationship to a different model, one in which the patient

(and this is also true of the clients of nonmedical psychotherapists) is more
autonomous, and has exchanged the paternalistic mode for what might be
called a contractual relationship with the therapist who will be held
accountable for incompetent or unacceptable behavior. This probably goes
along with a change in the previously prevailing view that science and the
professions were value free and therefore could not be questioned ethically,
and also to a developing attitude that all authority should be questioned.
Also there is no doubt but that today we live in an extremely litigious
society in which dissatisfied patients are likely to take legal action or refer to
ethics committees therapist behavior that might have been passed over
earlier.
A contributing element here is the vast change in the economic under-
pinnings of psychotherapeutic practice, as signaled by third-party payment
and managed care, which have contributed to the increasing perceptions of
the psychotherapeutic practitioner as a business person rather than as a
caring professional worthy of respect and forbearance. Finally, at least for
American psychiatrists, the Principles of Medical Ethics, whether as cause
or effect, now play a significant role in forcing consideration of the ethical
dimensions of psychotherapist behavior. They can be seen as representing a
symbolic emblem of the differences I have noted between today and the
post-World War I I era when the more laissez-faire attitude about ethical
matters then prevalent could itself be seen as an ethical lapse.
I take as my starting point that psychotherapists, whatever their profes-
sional backgrounds, have ethical obligations both to their patients and to
their society. It is clear that in the Western world generally, and especially
the United States, the former obligation far outranks the latter in the minds
of most therapists. If I were writing at an earlier time, I would have
contrasted this situation with that in the former Soviet Union where the
psychiatrist's duty to the state was paramount, far outweighing his or her
obligation to the individual. At any rate, it is inevitable that these two sets
2

of obligations, to the individual and to the community, may at times be

incompatible, and may result in a conflict of loyalties, or what has been
called the double-agent dilemma. 3

A T T I T U D E S : P A S T AND P R E S E N T

In what follows, I shall review some of the common ethical concerns

facing psychotherapists today in the light of how I see them currently and,
in some instances, by contrast with my perceptions of the past. I intend to
make use, although not in any systematic way, of four guiding moral
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principles: nonmaleficence (doing no harm), benevolence, autonomy, and

justice or the common good.
Power Relationship
I want to deal first with the possibly ambivalent consequences of the
power possessed by the therapist in a psychotherapeutic relationship.
Although this power may not always be as potent as psychotherapist hubris
sometimes imagines it to be, it often plays a very important role, for the
therapist without power, although he could do little harm, would also have
little ability to help the patient. There are instances in which psychothera-
pist power may rise to the point of justifying Jonas Robitscher's statement 4

that the psychiatrist, and I believe this to be true also of psychotherapists

generally, "is one of the most important nongovernmental decision-makers
in modern life." If the therapist is a physician, one important source of this
power is the historical role of the healer or priest as custodian of life or
death. But regardless of professional identity, the therapist is often involved
in an intimate and confidential relationship with the patient, the impor-
tance of which is augmented by transferential elements.
Therapist power can be malevolent rather than beneficial whenever it is
used to exploit the relationship for the therapist s own purposes. These
purposes may be to seek sexual gratification, to satisfy certain psychopatho-
logical needs or for financial gain.
Sexual Gratification
Sexual acting out within the therapeutic relationship, usually but not
always between a male psychiatrist and female patient, has been catapulted
into distressing and unwelcome prominence in recent years, both within
the profession and in the eyes of the public. The subject is dealt with fully in
this symposium by Glen Gabbard. (pp. 311-22). However, I do have some
observations, which, although peripheral, may be relevant. My recollection
is that ethical derelictions of this kind were not taken so seriously in the
heady post-World War I I days. Although not condoned, such behavior was
not likely to result in serious difficulties for the therapist—more an
occasion for scandalized gossip than for sanctions. Freud's rather tolerant
attitude about the sexual relationship between Jung and Sabrina Spielrein,
who had been his patient, is a case in point. This attitude seems to have
been particularly true in psychoanalytic circles, at a time when psychoana-
lysts held an almost regal position in the hierarchy of psychotherapists and
could, on occasion, be known to act like demigods rather than fallible
humans. Another, more recent instance is the Anne Sexton case, in which
5

one of the poet's therapists became involved sexually with her without any
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official action or condemnation. It is ironically illustrative of how things

have changed as far as ethical vigilance is concerned that an earlier
therapist, who was therapeutically very helpful to her, recently had to
combat charges, after her death, that he had violated the principles of
confidentiality in his relationship with her.
The vastly more stringent attitude today about sexual offenses of this
kind can be attributed not only to the factors causing greater ethical
diligence earlier outlined, but also to the rise of the women's movement
with its demands for equality and autonomy. My own view is that, in spite
of feeble and disingenuous attempts to justify it on utilitarian grounds,
overt sexual acting out between the two parties in treatment constitutes an
unmistakable and major violation of the principles of nonmaleficence. It is
always to be condemned, ethically, and even at times through legal sanc-
tions.
However, I am not so sure about the ethical need for such an absolute
prohibition in grayer areas such as sexual contact between the two parties
after the psychotherapeutic relationship has been terminated. The recent
change made by the Ethics Committee of the American Psychiatric Associa-
tion (APA) in its previous pronouncement that such encounters are
6

"almost always unethical," to the simple statement that they are unethical,
seems to me to rest on a doubtful assumption that the transference
relationship between therapist and patient is invariably intense and perma-
nently irreducible. Furthermore, a case can be made that this ruling goes
contrary to another ethical-moral principle, that of autonomy, since it
seems to imply that the patient, usually a woman, is always in the thrall of a
dominant male therapist and incapable of making an independent decision.
Applebaum has suggested certain rules, including a year's delay, before
7

such relationships could receive ethical sanction.

A possible similar conflict between the principles of autonomy and
nonmaleficence has been introduced by a recent addition to the APA
Ethical Code stating that sexual involvement between a faculty member or
8

supervisor and a trainee or student may be unethical. Again, whatever we

think of this rule, its promulgation indicates how much more seriously and
(I think, properly so) such relationships are now being taken than they were
in earlier days.
Boundary Violations
What of the so called boundary violations such as other forms of
nonsexual physical contact between the two parties in the therapeutic
transaction? I am well aware of the need to avoid the slippery slope to
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perdition, but I cannot believe that if care and judgment are observed an
occasional hug or hand-holding in emotional moments is always inappropri-
ate and dangerous in the course of psychotherapy. In fact, it is possible that
fear of stepping over an ethical boundary may inhibit therapeutic behavior
unnecessarily.
Psychopathological Gratification
Therapists' power can be misused not only for sexual purposes by the
therapist but also to procure gratification of certain psychopathological
needs. This can result in ethical derelictions that are more subtle and
harder to detect than sexual offenses and, thus, are less likely to be brought
to the attention of ethics committees, but which can do real harm to
patients. Such exploitation can take various forms. Thus, when therapists
guide patients toward certain decisions, are they always really acting in the
latters' best interest or may they be motivated by their need to exert control
and dominance, thus hindering rather than fostering patient autonomy.
Pushing a particular psychotherapeutic method with doubtful clinical
indication may be in support of the therapist's interests rather than the
patient 's benefit. An attempt to extract every last detail of a sexual
encounter may have for its primary purpose voyeuristic or sadistic satisfac-
tion for the therapist.
Although sometimes not acknowledged, patient identification with the
values and behaviors of therapists can be a beneficial therapeutic instru-
ment. However, exploitation rather than benefit will be the result if the
therapists fool themselves and misuse their power to impose their own
particular and possibly inappropriate set of values. We are dealing in an
ambiguous area here since separating such value impositions from useful
therapeutic strategy can be difficult. It has been suggested that this
problem is especially troublesome in what has been called "the ethical mine
field of marital and family therapy." 9

Claims of Sexual Abuse

A particularly glaring example of the exploitation of patients, through
the imposition of the therapist's values, preconceptions, and beliefs, is the
current epidemic of claims of sexual abuse uncovered by the resurrection
of previously unavailable memories of childhood sexual abuse. This subject
is covered fully in this issue by Harold Merskey (pp. 323-35). While
therapists may be acting benevolently toward their patients and in the best
interests of society when their efforts lead to the exposure of real instances
of child abuse, there is also little question that some of these allegations are
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false or exaggerated and that we are dealing with what Richard Gardner has
labeled "sexual abuse hysteria." 10

The current emphasis on abuse occurrence has reinforced my view {see

Ellenbergers The Discovery of the Unconscious ) about the extent to which
11

psychiatry and psychotherapy are subject to waves of fads and vogues. An

earlier example I recall was the allure of the Dianetics craze for even some
reputable psychiatrists. Episodes of this sort raise issues of ethical as well as
clinical relevance.
Professional Standards
I believe that serious attention should be paid to the need for a standard
of care defining competence in psychotherapy and that professional organi-
zations should enunciate and enforce requirements that therapists whose
treatment practices fall below such standards should be considered unethi-
cal. Failing this monitoring device, we are left with the simple rule put
forward by Jeremy Lazarus, "the doctor is obligated to do what is in the
12

patients best interest and not what is in the doctors best interest." To
prevent this kind of exploitation, self-knowledge on the part of the
therapist is required and should be an ethical obligation as long as the
individual is in practice.
Financial Gratification
Harm can be done when a therapeutic relationship is compromised not
only for sexual or psychopathological gratification, but also through the
lure of Mammon. As with the fulfillment of psychopathological needs, the
question of when the legitimate desire for financial security becomes a
dominating rather than a reasonable component of therapeutic decisions is
not easily determined. To cite a couple of opposing instances, ethical
questions arise when an intensive long-term psychotherapeutic program,
individual or group, is undertaken in the absence of adequate indications
or with unclear criteria for termination, or when psychotherapeutic treat-
ment is limited or terminated for purely financial rather than therapeutic
considerations, especially when the real reason is falsified or fudged. Here,
we have a troubling contrast between the therapist as healer and as a
business person, a danger pointed out by Edmund Pellegrino, (speaking of
the medical profession generally but applicable also to psychotherapy):
"Today our profession faces the unenviable choice between two opposing
moral orders, one based on the primacy of our ethical obligations to the
sick, the other, on the primacy of self-interest and the marketplace. These
two orders are not fundamentally reconcilable and, like it or not, the
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profession will be forced to choose between them" (personal communica-

tion).
Effects of Third-Party Payment
The most momentous change in the conditions under which I have
practiced during my long career has resulted from the gradual replacement
of a two-party by a three-party system of payment for psychotherapeutic
services. When I began seeing patients, my practice, in an economic sense,
was similar to that of Sigmund Freud. It was individual, entrepreneurial,
and unregulated by outside agencies as long as fees were for services
rendered in an ethical and legal manner. Payment came from the pocket of
the patient or family member and did not depend on the certification of
medical necessity. Transactions between my patients and myself were no
one's business but our own.
Insurance coverage and the gradual interposition of an uninvolved
third-party fiscal intermediary has produced a sea change in my mode of
practice. ' These changes, of course, are primarily economic, but cer-
13 14

tainly not without ethical implications. With the patient not entirely
responsible for payment, there is an opportunity for unscrupulous thera-
pists to juggle insurance coverage for their own profit. Such actions are
simply illegal and not of primary ethical interest, but ethically more
ambiguous situations can occur. What of therapists who collude with their
patients by accepting as their full payment only the insurance component of
the fee, thus helping patients financially without themselves benefiting?
Though one could plead benevolent motivation here, it could be argued
that such an action is wrong, not only because it envelops therapy in an
ambiguous moral climate but also because, although the patients are
benefiting, the common good is suffering through interference with soci-
ety's efforts to equalize the financial conditions under which people may
seek treatment. What of charging for unused sessions? When third-party
reimbursement is involved, is there an ethical obligation to notify the
insurance company?
However, the more direct and immediate danger posed to ethical
practice by third-party involvement is the threat to that assured confidenti-
ality that has been the cornerstone of the therapeutic relationship. Confiden-
tiality is put into jeopardy because, in order to secure reimbursement,
certain diagnostic and sometimes other information must be released to the
insurance carrier. Caught between the obligation to protect their patients
from the harm that might ensue with the revelation of confidential matters,
on the one hand, and the need to meet insurance requirements so that these
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patients can continue treatment, on the other, the therapist is often placed
in an unpleasant ethical dilemma that produces discomfort and resentment
and is a significant component of the negative attitude many therapists have
toward third-party payers. Clearly this is a situation in which the principle
of nonmaleficence toward their patients has a much higher valence for most
therapists than absolute honesty or theoretical common-good consider-
ations. I believe, however, that it also needs to be said, that although
protecting the patient is paramount, considerations of self-interest may not
be entirely lacking in therapists' behavior in instances when diagnoses are
fudged in order to establish medical necessity.
If third-party payment has upset the apple cart of many psychothera-
pists, particularly those interested in long-term and intensive modes of
treatment, then the various forms of limiting and monitoring treatment
occurring under the heading of managed care, seem to be changing
psychotherapeutic practice so as to render it almost unrecognizable from
what it was in the 1950s. These changes, of course, strike mainly at the
economic health of the psychotherapeutic profession but, as with third-
party payment, are not without ethical implications. Although most psycho-
therapists are outraged when arbitrary limitations and troublesome interfer-
ences are imposed, at least theoretically this Mr. Hyde of managed care may
be balanced by its Dr. Jekyll aspect—the intent to equalize the availability
of care and to eliminate excesses. Relevant to psychotherapy are efforts to
control treatment or to curtail it in certain cases as unnecessarily prolonged
and intensive. Bitterly contested conflicts on this issue between psychia-
trists employed in monitoring capacities by managed care organizations
and treating therapists have come to such a boil that complaints against the
former have been made to APA Ethics Committees.

QUESTIONS ABOUT PSYCHOTHERAPY

However, I believe that the greatest impact that the new economics
underlying psychotherapeutic practice has had in the ethical domain is in
bringing under scrutiny certain questions about the efficacy and scope of
psychotherapy, and what might be called its "medicality," by which I mean
the extent to which psychotherapists are justified in receiving payment
under plans that require medical necessity as a condition for reimburse-
ment.
In the concluding section of this presentation, I shall attempt to explore
facets of these complicated questions that, I believe, can be seen to involve
possible conflicts between common-good considerations and other ethical
values such as benevolence, and that may also invoke elements of self-
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interest. I should say that by contrast with their present-day ubiquity, in the
early days of my career, questions of this sort crossed my mind only
occasionally and vaguely, and played no significant role in my practice.
In advancing their arguments for adequate coverage of their methods,
psychotherapists claim to march under the banner of benevolence and the
common good; they are defending the interests of their patients or clients
who suffer from mental illnesses and who should not be punished because
of the stigma attached to this label. There is a legitimate fear that patients
may be damaged by the current tendency to deal with them as "mindless"
entities, to be treated only with drugs while being deprived of a healing
human experience through psychotherapy. However to justify their claim
to this moral high ground, psychotherapists need to respond to questions
about certain aspects of their practices.
Professional Qualification
First, in view of the large variety of psychotherapies with widely
differing theoretical bases and treatment techniques, what are the param-
eters by which acceptable psychotherapies can be differentiated from
unacceptable ones? What professional and training qualifications should
be required to render a practitioner eligible to receive reimbursement?
Efficacy of Psychotherapy
Second, claims to benevolent motivation and public support can be
justified only if it can be demonstrated that psychotherapy substantially
helps patients. In contrast to earlier years, when there was little interest
among therapists in demonstrating results, partly because of a lack of
consensus on the goals of psychotherapy, we are now witnessing an
increasing effort to validate effectiveness through outcome studies even in
the face of the acknowledged difficulties in applying scientific standards to
this effort. The recent compilation of such studies by Lazar et al. is an
15

encouraging move in this direction. But, as has been pointed out, 16

difficulties are encountered in differentiating the effects of the various

forms of psychotherapy from each other and considerable uncertainty
prevails about the appropriate fit between a particular form of treatment
and a particular condition. Psychotherapists have an ethical obligation to
continue efforts to reach consensus on these questions.
Psychotherapy and the Medical Model
The third question has to do with what might be called the medicality of
psychotherapy, that is whether psychotherapeutic services fall within the
purview of the medical model, so that patients can be defined for
17

payment purposes as suffering from mental illnesses requiring treatment

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because of medical necessity Some third parties and healthcare planners

18

base their reluctance to support psychotherapeutic services more ad-

equately on the belief that psychotherapists may be consulted for reasons
other than illness, if illness is defined in terms of indications for treatment,
degree of disability, duration of treatment, and a clear end point. 19

Although there is a good deal of debate about this issue, some of it

generating more heat than light, it is my belief that serious questions remain
unresolved about the differences between patients seen primarily because
of the presence of a degree of psychopathology, which is universal among
imperfect humankind but who are not "ill" medically, and those who are
seen because they satisfy criteria for illness and qualify for reimbursement
under medical necessity. To the extent that psychotherapy patients fail to
qualify under the "sick" role, but still seek reimbursement, a moral
ambiguity envelops psychotherapeutic practice. The fierce debates about
the size of this practice segment, referred to somewhat disparagingly as "the
worried well" by critics, is an issue that should be dealt with both for the
economic benefit and the moral health of the psychotherapeutic profes-
sions.
One concrete way in which this distinction becomes meaningful can be
seen in the position advocated by organizations like National Alliance for
the Mentally 111 (NAMI), that there should be a differential between
coverage of patients with "severe and persistent mental illnesses," and those
with more doubtful medical indications. The implication here is that
20

those who defend coverage for the latter group are limiting care for the
needy, sicker patients.

Scope of Psychotherapy
In addition to medical-model applicability, there are other questions
about the proper domain of psychotherapy. In my early days in practice, the
Axis I conditions we used to call symptomatic neuroses were grist for the
psychotherapeutic mill, but most of these disorders are treated now either
with drugs or a combination of drugs and psychotherapy. I can also
remember the helpless chagrin I felt, when, armed only with psychoanalytic
psychotherapy, I was confronted with severely ill manic-depressive pa-
tients. But, understanding and accepting appropriate modifications of
criteria for psychotherapy does not mean that a wide range of indications
for psychotherapy is lacking. In fact, I believe it has become an ethical
obligation for psychotherapists to support a proper role for psychotherapy
and to combat the present, almost helter-skelter, rush to create a psy-
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etiological Utopia (dystopia?) by giving every human idiosyncrasy a DSM

label and specific drug treatment.
Thus, to buttress their claim that a harmonious accord between benevo-
lence toward their patients and the common good rather than self-interest
justifies nondiscriminatory or at least greatly expanded coverage of psycho-
therapy, psychotherapists need to add an ethical dimension to their eco-
nomic arguments. They need to continue to produce evidence not only that
their methods help many people, but also to delineate the conditions for
which psychotherapy is indicated and the relationship of these conditions
to the medical domain.

CONCLUSION
I conclude this article on the personal level with which I began, musing
about the worthwhileness of the "ethical revolution" I have witnessed
during my career. It has not been an unalloyed blessing. One can detect a
tendency toward a kind of puritanical nice Nellyism in certain of the ethical
injunctions under which we now operate, such as the absolute rule
prohibiting sexual relationships at any time after the end of a psychothera-
peutic relationship. More seriously, I am troubled by what I see as an
encroachment of cumbersome and expensive legalistic procedures on
ethical debates that has hampered the work and skewed the goals of some
ethics committee deliberations with resultant damage to the collegiality of
colleagues. However, on the whole, I look favorably on the increased
attention being given to whether therapists are acting properly and morally
in their dealings with patients and with the community. To paraphrase
Socrates, "The unexamined profession is not worth trusting." I believe the
care and seriousness with which possible ethical derelictions are being
catalogued and investigated is of inestimable value both to the psychothera-
peutic professions themselves and to the public they serve.

SUMMARY
A substantial increase in the interest devoted to ethical issues has been a
defining feature of my 50 years in psychotherapeutic practice. Reasons
include a shift from a paternalistic to a contractual model of the doctor-
patient relationship, increased litigiousness, and greater emphasis on the
business rather than professional aspects of practice.
Many ethical violations stem from misuse of therapist power in the
psychotherapeutic relationship. One of the most egregious of these is overt
sexual acting out between therapist and patient, a dereliction now viewed
much more sternly, largely because of the rise of the women's movement.
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Therapist power can also be misused for purposes of psychopathological

gratification, such as to dominate patients or impose values, and by
emphasizing financial rewards over patient needs.
A sea change I have observed has been the gradual replacement of a
two-party by a three-party system of payment for psychotherapy. Among its
most serious consequences in the ethical domain has been the weakening of
the therapist's guarantee of absolute confidentiality to the patient. Managed
care has further compounded the ethical dilemma by imposing a need to
choose between the interests of patients and the organizations from which
therapists receive remuneration.
In their efforts to ensure parity coverage for psychotherapy, therapists
need to respond to certain questions about their claims that their work
promotes both individual welfare and the common good. Questions in-
clude the professional qualifications for skillful practice of psychotherapy,
the evidence for its efficacy, the delimitation of the conditions properly
treated by psychotherapy, and the extent to which these conditions fall
within the medical model and thus satify the criterion of medical necessity.
I conclude that, in spite of the efforts needed to maintain ethical
standards, the "ethical revolution" that I have witnessed has enhanced the
integrity and value of psychotherapy, both for its practitioners and for the
public that they serve.

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