Ethical Dilemmas in Psychotherapy: Comparison between Patients, Therapists and Laypersons

Article excerpt

Abstract: Background: The attitudes of patients towards ethical dilemmas in psychotherapy have been reported in only a few studies. Aims of the study: We investigated whether the attitudes of patients undergoing psychotherapy to confidentiality and boundaries are different from those of therapists and laypersons. Methods: Clinical vignettes describing ethical dilemmas of confidentiality and boundaries were presented to 103 patients undergoing psychotherapy (patient group), 93 psychotherapists of different professional backgrounds (professional group), and 55 staff and students from the fields of law and the humanities (lay group). Patients were asked how they think therapists should act in the situations presented and therapists were asked how they should behave in such situations. Results: In general, the patient group showed a greater tendency to view their therapists as breaching confidentiality than the professional and lay groups. Regarding boundaries, the majority of psychotherapists were against initiating any sexual relationship with current patients, former patients, students or supervisees, whereas both patients and laypersons showed a less stringent attitude; these differences were statistically significant. The vast majority of therapists (96.7%) disapproved of accepting money in advance compared to only 31.1% in the patients group and 54.4% of the lay group. Analysis of the patients group by gender did not reveal any significant relationships. Conclusions: (1) Patients have different ethical codes from therapists and laypersons regarding the issues of confidentiality. (2) Patients and lay persons are less strict than therapists regarding issues of boundaries.


An important and hitherto neglected area in psychotherapy is the study of the patients' perception, knowledge and understanding of ethical issues. There have been studies on attitudes of professionals to ethical issues such as confidentiality and boundaries (1-4). The few investigations published have shown that patients have a limited conceptual understanding of confidentiality and its relation to their legal rights (5,6). Hillerbrand and Claiborn (7) compared the ethical knowledge of clients and nonclients, but findings were inconclusive; being in therapy did not seem to significantly increase knowledge.

For psychotherapists to fulfill their ethical responsibilities, it is crucial that patients be properly informed about both confidentiality and boundaries. Psychotherapists have to understand the complexity of the issue of confidentiality and boundaries and learn how to deal with it in therapy. For example, in the case of Tarasoff vs. the Board of Regents of the University of California (8), the California Supreme Court ruled that it is the duty of the therapist to breach a confidence in order to protect the life of a potential victim. Thereafter, professional societies in the U.S. (e.g., The American Psychiatric Association [9], The American Psychological Association, [10]) drafted guidelines for the limits of confidentiality, with specific emphasis on life-threatening crimes and child abuse (11). Harding et al. (12) and others (13, 14) raised the important legal and ethical question of whether the Tarasoff principles apply to HIV-positive clients who refuse to practice safe sex or disclose their medical status to sexual or needle-sharing partners.

Boundaries in psychotherapy are defined as the "edge" of appropriate behavior regarding issues such as the professional role of the therapist, the setting (time, place and space), issues of payment, receiving of gifts and/or services, and physical contact (15). Sexual relationships with current patients are considered taboo by all professional societies; however, the recommended waiting period after termination of treatment differs.

In a previous study we compared the attitude of therapists and laypersons to ethical dilemmas in psychotherapy (16). Realizing the gap in our knowledge of patients' attitudes towards these same dilemmas we decided to extend the study and to add a third group: patients undergoing psychotherapy. …