Perspectives: The Struggle to Maintain Neutrality in the Treatment of a Patient With Pedophilia

This article explores the ethical concept of neutrality through use of a psychiatric clinical vignette. In this case a psychiatry resident is faced with the treatment of a patient who was found by the FBI to be in possession of child pornography. Although not accused of any other crimes, the patient was a fugitive from the law and requesting treatment for pedophilia. Faced with the pressures of limited resources and anxiety about the patient's dangerousness to others, the resident and his supervisor tried to strike a balance between the ethical principles of neutrality and beneficence. Through this vignette, the importance of neutrality, as well as how it can be compromised by other pressures such as expediency and anxiety, is explored.     

Attending to diversity in group psychotherapy: an ethical imperative

Ethical issues can arise in dealing with diversity when practicing group psychotherapy. In this paper, a case is presented of a therapist-in-training who is attempting to determine whether a particular psychotherapy group composed exclusively of heterosexual males would be an appropriate and effective treatment venue for a gay male; the clinical vignette is designed to illustrate a process of ethical and culturally competent decision making. The discussion of this vignette articulates the multiple steps through which the group psychotherapist must proceed to successfully resolve ethical dilemmas that are related to diversity.     

Das Wichtigste im Leben – aber nicht in der Psychotherapie?!

Mental health can be substantially impaired by a low partner-relationship quality and nearly all mental disorders are associated with distress. Additionally, couple’s interaction has an impact on parental behavior. Special attention must be paid to family violence. Based on this background, the reciprocity model and the theory of marital stability are described. Detailed suggestions are given for the assessment, treatment planning and couple-oriented as well as parent-orientated interventions. The suggestions are exemplified with a case vignette. Some legal and ethical standards as well as psychotherapeutic conditions may limit the application of these interventions.     

Mother-blaming in family therapy: An empirical investigation

Abstract

This study tested two hypotheses derived from the feminist critique of family therapy in a sample of AAMFT members. The stimulus was a brief vignette of an initial therapy session with a family presenting a teen-aged child as the identified patient. It was hypothesized that family therapists would rate the mothers in the vignette as more dysfunctional than fathers. It was also hypothesized that mothers would be asked to bear more of the burden of change in treatment plans written by subjects. Neither hypothesis was supported. However, respondents did rate the concerned parent, regardless of sex, as more dysfunctional. Since this is a role often occupied by women, this finding may indicate some gender bias.     

Ethical and Legal Considerations in the Training of Mental Health Professionals

Summary

A discussion is provided regarding ethical and legal considerations that relate to the training of mental health professionals. A training program which emphasizes a proactive approach to identifying and resolving potential ethical and legal problems, and their close connection with clinical issues is described, as are the responsibilities of supervisors and supervisees in such a program. For illustrative purposes, a training vignette and a clinical vignette conclude the article.     

Differentiating Two Kinds of Neutrality

Neutrality is a most important concept, yet a controversial one. Theorists of different analytic schools have defined it in their own terms, leaving behind them a legacy of disparate and often contradictory formulations. In this paper, the author reviews briefly some of these ideas about neutrality. Then, from a contemporary interpersonal/relational perspective, the author takes a new look at the idea of neutrality. The author points out how unacknowledged discrepancies among these ideas get in the way of understanding and so complicate analytic discourse, and argues that useful work with this concept requires that analysts differentiate between two aspects of neutrality, specifically operational neutrality and intentional neutrality. The theoretical discussion is followed by a case vignette illustrating the clinical usefulness of this differentiation.     

How does clients' method of payment influence psychologists' diagnostic decisions?

To what extent does payment method (managed care vs. out of pocket) influence the likelihood that an independent practitioner will assign a Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) diagnosis to a client? When a practitioner does diagnose, how does payment method influence the specific choice of a diagnostic category? Independent practitioners responded to a vignette describing a fictitious client with symptoms of depression or anxiety. In half of the vignettes, the fictitious client intended to pay via managed care; in the other half, the fictitious client intended to pay out of pocket. Payment method had a very significant impact on diagnosis such that relative to out-of-pocket clients, managed care clients were much more likely to receive diagnoses and more likely to receive adjustment disorder diagnoses in particular. We discuss implications involving informed consent and other ethical issues.     

Breaking Confidentiality to Report Adolescent Risk-Taking Behavior by School Psychologists

School psychologists often break confidentiality if confronted with risky adolescent behavior. Members of the National Association of School Psychologists (N = 78) responded to a survey containing a vignette describing an adolescent engaging in risky behaviors and rated the degree to which it is ethical to break confidentiality for behaviors of varying frequency, intensity, and duration. Respondents generally found it ethical to break confidentiality when risky adolescent behaviors became more dangerous or potentially harmful, although there was considerable variability between respondents. Significant gender effects were found between male and female respondents for alcohol use, and a significant Form Type (i.e., male or female vignette) × Frequency/Duration interaction was observed for antisocial behaviors. School psychologists could benefit from further training in ethical decision making because these ethical dilemmas are not always clear-cut.     

A Survey of Counselor Educators' Ethical Concerns

This survey examined counselor educators' ethical concerns. Responding to a series of vignettes, respondents considered unethical those behaviors that are self-serving (e.g., dating a client or a student and not fulfilling work responsibilities) while perceiving ethical those practices that raise the question of dual relationship. Respondents were also in favor of allowing students with serious mental health problems to become counselors as long as their problems are under control. A significant gender difference was observed in their response to one vignette. The majority of respondents expressed satisfaction with the current ethical standards of the American Counseling Association, although slightly over half indicated that ethical standards specifically applicable to counselor education would be helpful.     

Treatment Parameters and Structural Change: Reflections on the Psychotherapy of a Male Homosexual

Abstract

Shechter R. A. Treatment Parameters and Structural Change: Reflections on the Psychotherapy of a Male Homosexual. Int Forum Psychoanal 1992;1:197-201. Stockholm. ISSN 0803-706X

Sequential highlights from a four-year treatment period demonstrate specific instances when technique parameters, defined as deviations from psychoanalytic neutrality, triggered the emergence of repressed memories. These memories were connected to forbidden impulses and intense annihilation and castration anxiety. Parameters also functioned to keep anxiety at tolerable levels, allowing the working-through and rechanneling of highly charged libidinal and aggressive wishes and fears, and the establishment of a reparative transference. As the patient explored affect and memory, he incorporated a more benign superego. Drive was neutralized, sublimation occurred, and structural change unfolded. Intrapsychic change led to behavior change. The patient moved from a monogamous, sadomasochistic, homosexual lifestyle to a more positively invested and pleasurable heterosexual relationship.

Treatment was not a defense analysis. The patient's ego structure could not have tolerated the anxiety of a transference neurosis that mirrored the abuse of childhood. The treatment dyad was a reparative force. Parameters indirectly functioned as interpretations of repressed longings, surgically cutting through false self-deception.     

Nameless Desire: Alexithymia and the Anorexic Patient

In this article, the author attempts to provide a psychoanalytic understanding of the anorexic patient who is disconnected from her affective experience and is considered to be alexithymic. Through her restrictive food ritual, this type of patient may organize her internal states by repeatedly creating an illusion of what it is that she needs and desires. The author asserts that the task of the therapist working with the anorexic patient with alexithymia is to be aware of his own sensation-based reverie as lived within the intersubjective arena. This will enable the therapist to assist the patient in building an affective vocabulary to accurately identify, differentiate, and label the internal signals of her body. It is suggested that the subjective emotional experience of the patient will continue to be reorganized, expanded, and enriched as the therapist and patient mutually influence one another in this unique relational matrix. A clinical vignette is provided to illustrate intersubjective treatment interventions with a difficult-to-reach anorexic patient.     

Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19

The novel coronavirus (COVID-19) pandemic has caused widespread disruption to our traditional way of life and mental health therapy has not been spared. A combination of increased anxiety, diminished social opportunities, and the shift to telehealth service provision presents particular challenges for the treatment of social anxiety in youth, which relies heavily on exposures to social situations with peers, adults, or other feared social stimuli. The objective of this commentary is to provide guidance to clinicians working with youth with social anxiety on how to maintain ethical, evidence-informed provision of exposure therapy in light of these unusual circumstances. We first present an overview of how COVID-19 may uniquely impact youth with social anxiety and highlight the importance of continuing to provide exposure-based treatments during this time. We then discuss guiding principles for delivering exposure therapy during COVID-19. We focus on providing practical examples of how common social anxiety exposures can be adapted and delivered successfully through telehealth while abiding by COVID-19 social distancing guidelines. Finally, we discuss key recommendations to assist clinicians in moving treatment forward while considering changing safety guidelines pertaining to COVID-19.     

Professional ethics of psychologists and physicians: morality, confidentiality, and sexuality in Israel

Clinical psychologists' and nonpsychiatric physicians' attitudes and behaviors in sexual and confidentiality boundary violations were examined. The 171 participants' responses were analyzed by profession, sex, and status (student, resident, professional) on semantic differential, boundary violation vignettes, and a version of Pope, Tabachnick, and Keith-Spiegel's (1987) ethical scale. Psychologists rated sexual boundary violation as more unethical than did physicians (p less than .001). Rationale (p less than .01) and timing (p less than .0001) influenced ratings. Psychologists reported fewer sexualized behaviors than physicians (p less than .05). Professional experience (p less than .01) and sex (p less than .05) were associated with confidence-violating behavior. Overall, 78% of the sample reported attitudes or behaviors associated with boundary violations. The behavior violations were correlated (r = .49). Actual violators rated vignette violators more leniently than did nonviolators (p less than .01).     

Some ethical issues in feminist-oriented therapeutic groups for women

Review of the origins of group psychotherapy reveals concerns with social as well as with personal "psychopathology." Thus, group processes have been mobilized for curative or change purposes for ideological as well as individual therapeutic goals. Psychopolitical as well as personal change are the goals for some groups. The ethical problem stems from a persistent assumption that the group's processes are inherently benign and curative and beneficial to individual participants. A more sophisticated understanding takes into account their essential neutrality and their potential use (or abuse) for purposes of ideological persuasion that may or may not be personally therapeutic. As in other ethically implicated issues in the psychotherapies, the question becomes one of treatment versus exploitation, or therapy for the individual versus recruitment on behalf of a cause.     

Infertility in the age of technology

Rapid advances in medical and biological technologies are changing the ways we are born, live, and die. Biotechnology is pushing us in our notion of what is possible, and tapping into our most primitive omnipotent fantasies. For the most part these new techniques have not yet been integrated into a shared social consciousness. This paper examines, in a case study of a woman who eventually got pregnant with a donor egg and in a shorter case vignette, how the new technology impacts upon the analytic process. Attention is focused on the permeability of the boundaries between analyst and patient and between fantasy and action. The study shows how analyst and patient, together and often for the first time, must face the difficult moral and ethical issues stimulated by such procedures, as well as the anxieties and underlying fantasies they evoke. It is the uniqueness and the intensity of this experience that permeates boundaries, stimulates emotion in patient and analyst alike, and has the potential to deepen the analytic bond. The study underlines the need for the analyst to be flexible, moving back and forth between interpreting and creating a needed holding environment. Finally, the paper points out the tension between the traditional roles of motherhood, fatherhood, and family and those being created in this high-tech world.     

Alchemy in the image of the analyst

The author aims to demonstrate the activation in the transference relationship of a figure representing 'sameness' in a number of forms. In the first clinical vignette, she shows how a child projects his own difficulty symmetrically on to the analyst, with the aim of creating the conjunction of opposites which the psyche needs for its growth.
During the archetypal reworking which adolescence provides we again find this figure of 'sameness' in the foreground, in the phase of homosexual object choice. A second clinical vignette shows how this figure of 'sameness' can be represented in the fantasy or the desire of becoming an analyst.
The author puts forward the hypothesis that this fantasy represents an imago whose characteristics include being a tool for linking feeling and thinking in the inner world; it is constituted in the entre deux , the space between self and other, and, like Winnicott's transitional object, it facilitates the capacity to symbolize. Being 'off centre' with regard to infantile positions in relation to the parental imagos, this imago offers a vantage point for 'evaluation' ( sich auseinandersetzen ) and 'consideration' ( betrachten ). Finally this imago is transistory, because its destiny is to be deconstructed (as shown in the third clinical vignette which concerns an adult patient), in order to be integrated through the work of analysis.     

The ethics of enforced medical treatment: the balance model

ABSTRACT When is it right to enforce medical treatment on a patient who is refusing that treatment? English law recognises two ethical principles as of paramount importance: the autonomy of the patient; and the consequences of not treating compared with treating. The law, by and large, operates these principles in succession. Thus, in the case of a patient refusing treatment, the law asks first, is the patient competent? Only if the answer is no, are the consequences considered. We criticise the position taken by English law and argue, first, that competence is a graded and not a binary concept, and secondly, that the two ethical principles should be applied not sequentially but at the same time. These two ideas form what we have called the balance model. This model could be used for an empirical study of individuals’ ethical beliefs, and in particular to test the hypothesis that the ethical beliefs of most individuals conform to the balance model rather than to the position taken by English law.     

Toward a definition of psychoanalytic neutrality

The word and concept of neutrality play an important but confusing role in the history of psychoanalysis. Does neutrality imply indifference? The origin of this ambiguity is traced to the fact that Freud himself never used the word "neutrality" (Neutralitaet) in his own writings. (His term Indifferenz was translated as "neutrality" by Strachey.) The essence of the controversy that has simmered in the psychoanalytic literature ever since is contained in the question: "Is remaining true to the concept of neutrality somehow antithetical to the analyst's genuine involvement with the patient?" In this paper, I examine the feeling and power aspects of the word and suggest that the concept of neutrality becomes clinically useful when the analyst asks himself the question, "Neutral to what?" The analyst's awareness of his motives for recognizing and addressing certain conflicts and for overlooking others is heightened. With three clinical vignettes as illustrations, I explore the role of the concept of neutrality in deepening our understanding of (1) the analytic relationship; (2) The influence, on the conduct of the treatment, of the analyst's goals and theoretical persuasion regarding how the goals are to be achieved. As examples, I use the current debates over the relative value of the analyst's focusing his attention on: (a) the patient's mind in the hour rather than his life outside the hour and, (b) transference over nontransference interpretation. Finally, I emphasize the far-reaching implications of adding an explicit concept of "external reality" to A. Freud's exclusively intrapsychic definition of the "objective" analyst's position of neutrality as equidistant from id, ego, and superego. The addition of this fourth point to the analyst's "compass" widens the analytic field toward which the analyst is neutral. The concept of neutrality with respect to specifiable conflicts is thereby also broadened to include (a) interpersonal conflict within the psychoanalytic relationship and (b) conflict within the analyst. With these explicit additions, the concept of neutrality with respect to conflict becomes congruent with the current emphasis on the nonauthoritarian two-persons aspects of the psychoanalytic relationship, without detracting from the primary analytic goal of deeper understanding of intrapsychic conflict.     

7. Guided Group Interaction in a Correctional Setting

Review of the origins of group psychotherapy reveals concerns with social as well as with personal “psychopathology.” Thus, group processes have been mobilized for curative or change purposes for ideological as well as individual therapeutic goals. Psychopolitical as well as personal change are the goals for some groups. The ethical problem stems from a persistent assumption that the group's processes are inherently benign and curative and beneficial to individual participants. A more sophisticated understanding takes into account their essential neutrality and their potential use (or abuse) for purposes of ideological persuasion that may or may not be personally therapeutic. As in other ethically implicated issues in the psychotherapies, the question becomes one of treatment versus exploitation, or therapy for the individual versus recruitment on behalf of a cause.     

Conscientious objection and emergency contraception

This article argues that practitioners have a professional ethical obligation to dispense emergency contraception, even given conscientious objection to this treatment. This recent controversy affects all medical professionals, including physicians as well as pharmacists. This article begins by analyzing the option of referring the patient to another willing provider. Objecting professionals may conscientiously refuse because they consider emergency contraception to be equivalent to abortion or because they believe contraception itself is immoral. This article critically evaluates these reasons and concludes that they do not successfully support conscientious objection in this context. Contrary to the views of other thinkers, it is not possible to easily strike a respectful balance between the interests of objecting providers and patients in this case. As medical professionals, providers have an ethical duty to inform women of this option and provide emergency contraception when this treatment is requested.