Ethics and Psychotherapy – 6

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We are continuing our discussion of Tjeltveit’s book, Ethics and Values in Psychotherapy. In Chapter 7 Tjeltveit discusses the “social context of psychotherapy,” that is, he locates the practice of psychotherapy in the context of how it functions within society. He discusses psychotherapy’s medical heritage including bioethics and medical ethics and the two emphases of “the idea of the professional and a focus on the individual client” (p. 132). Other influences from medicine include reductionism in the form of limiting psychotherapy’s focus to a medical focus of symptom reduction. He seems to suggest that there is much more to biopsychosocial problems than merely what is understood in terms of a “medical issue”.

The other major social context in which psychotherapy occurs is business. Psychotherapy has become a “business relationship” (p. 139) in which there is an exchange of services that occurs in the context of economics (in which resources either contribute or impeded goals being met) and limited financial resources (of third-party payors, including government, insurance companies, employers, and so on). There is a risk of a kind of “ethical reductionism” (p. 141) to the extent that businesses “consider economic considerations alone” (p. 141).

For reflection: Do you agree with Tjeltveit that psychotherapy occurs in the social contexts of its medical heritage and business? How do you see these social contexts shaping the field and the practice of psychotherapy for good or for ill?

5 Comments

  1. I definitely agree that psychotherapy occurs in the social contexts of its medical heritage and business, and I worry that it could be for ill.

    It would seem dangerous for us to lose our identity with the medical
    model for a couple of significant reasons, both driven by business. The first is our reputation in the field. It already suffers a blow from third party payers who are significantly shaping therapy’s ethical character. What will happen to consumer confidence?

    In addition, it seems like breaking away from the medical model may jeopardize our professional standing with the managed care system.
    Psychotherapists are already referred to as service providers, a title you might associate with McDonald’s or Holiday Inn. I fear that psychotherapy will end up on the endangered list of covered expenses.

    I would like to believe that the negative publicity being given to managed care in regards to mental health treatment, will instigate a revamping of the system in a way that will improve patient care, and preserve the dignity of the profession.

  2. A lot of the discussions of these two influencing forces on the field have been on the business aspect – the impact of manage care, etc. on psychotherapy. It makes sense to be concerned about that, although the “devil’s advocate” position might be that therapists brought this on themselves and acted in ways that led to the emergence of managed care.

    The medical influence is also worth reflecting on. The DSM is about individual psychopathology, reflecting one aspect of the medical model that is hard for more systems-focused psychotherapists to appreciate. It has also been suggested that the reductionism associated with the medical model can reduce the person to the cluster of symptoms and that the diagnostic labels themselves – while aiding in communication among professioanls – can come at a cost to the client.

  3. That last line reminded me of another thought: we might take note of the language the field uses to describe those who benefit from mental health services. “Patients” comes from the medical model; “clients” reflects the business influence. Which language is preferred and why? In what ways does the choice of language shape how one thinks about the profession?

  4. I hadn’t thought about the basis for why we are moving away from “patient” to terms such as “client”. I had learned that it was a way of respecting the dignity of the individual. As a matter of fact we referred to the “patients” at the state hospital as “persons in recovery” because it was a way to indicate an active participation. The drive for the change coming from business makes sense though. In regards to language, the one thing that I hear all the time that makes me cringe is when someone is referred to as their diagnosis; they are a schizophrenic, it is difficult working with borderlines. It always makes me uncomfortable to hear people reduced to a diagnosis.

  5. It is interesting to look at how language has changed from calling a person a “patient” to now calling a person a “client”. I beleive this is in part to remind us that we are in a businiess relationship with the client. However, we dare not forget that we are also in a caretaker role with this same client. We are both physicians (or health providers)and business representatives. I believe that as the field expands and evolves, the names that we give the people that come to see us might also change. I agree with you though that our names of patient or client are simply more labels that are applied to the person.

    In undergrad I was taught that calling a person a client was less demeaning than calling him or her a patient. Patient signifies a need for better health, or if you state the current condition instead of the desired condition, patient means unhealthy. On the other hand, client simply connotates a professional relationship wherein a person is seeking the services of a provider.

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