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Ethics and values in psychotherapy: A guidebook
Book Reviews
520
While many of Rorem’s beliefs and predictions may strike the reader as self-evident, not all have worked out as some may believe they should have. However. it is in the context of these that the most can be gained, for they force the reader to evaluate current assumptions about how health care should be organized and how it in fact is. For example. areawide planning has not been as successful as some of the essays suggest that it should be, partially because of vested interests on the part of providers and limited scope of authority of planning agencies. Have the failures resulted because planning as Rorem describes it is not necessary or because it is necessary but inhibited by systemic structural problems that have to be resolved? Answers to such questions have the potential for increasing our understanding of how policy can be used as a successful intervention. Caution must be taken when criticizing these essays because we have the benefit of “20-20 hindsight” as Herbert Klarman, who writes the comment for the third section. puts it. However, there are still areas which are striking by their absence such as a discussion of the effects of insurance on demand. Rorem does not address moral hazard nor the resulting lack of agreement on what constitutes necessary or minimum level of care. These essays are as fresh today as when they were written. Despite the time that has passed since they were written. they provide an opportunity to get fresh insights and perspectives on the health care system. One comes away with a clearer understanding of what our assumptions are and with a renewed vision-inspired by Rorem’s-of how we can make the health care system’ better. .Sloa,l School 01 Marwgrmwt
BARBARA BIGEL~W
Massuchusetts lmtitutr oj’ Trchr~oloc~y C’rmhridgc MA. U.S.A.
Psychiatric
Ethics.
CHOIXFF. Oxford
edited by SIDNEY BLOTH and PAUL University Press. Oxford, 1981. 341 pp.
Ethics and Values in Psychotherapy:
A Guidebook, edited 1982. 424
by MAX ROSENRAUM.The Free Press. New York, PP.
The result of the approach to studying ethics identified as “applied ethics” is that a number of books have appeared with titles combining a particular discipline with ethics. There are numerous books on “Medical Ethics,” some on others dealing with “Nursing Ethics” “Business Ethics”. and so forth. Now two books have been published which look at the interface between ethics and psychiatry. Although bearing similar titles. the two books. Ps~d~ilrtric Ethics and Ethics ud Vulurs irk Psychothrrupy, are quite diRerent in their approach to the topic. If someone is looking for a tightly woven analysis of a particular ethical issue imbedded in the lield of psychiatry, the nature and role of confidentiality for example. Rosenbaum’s book is not the place to turn. His purpose was other than offering a theoretical examination of the issues. rather more of a “show-and-tell” approach. Each of the IX chapters tells something about the particular tield of expertise being examined and then shows how various ethical issues arise within that field. As one example. Nina Fieldsteel. in her chapter on “Ethical Issues in Family Therapy”, begins by offering a brief justification for discussing ethics and then offers some clarification of what constitutes family therapy. She then focuses on a few ethical issues: (a) the autonomy of the patient and/or family in opposition to the therapist’s perception of what is in the patient’s best inter&: (b) the place of confidentiality when “family secrets” are divulged; and (c) the function of power in the therapeutic relationship with respect to manipulation. The
concluding section offers a suggestion for h’o\v a farnil! therapist might best become atiare of the ethical aspects of her profession. A wide range of settings is examined. Tuo chapters deal with an overview of ethics as it impinges on pskchotherap! as a profession. 6 chapters look at ethlcal Issues which arise in the relation between the patient and the professional.. 8 chapters examine the manner in whtch treatment approaches give rise to ethical dilemmas and the final 2 chapters highlight the ethical problems confronting psychotherapists working in situations other than private practice. There is also an appendix containing various codes of ethics which have been established for professionals working in psychiatry. As one might expect. a number of recurrent ethical issues are identified throuehout the book: patient autonomy. truth telling, confidenzality, do no harm. the role of informed consent. labeling of patients, professional competence and so forth. For those who never thought about the ethical ramifications of psychotherapy this book might be helpful. However. identifying a problem. although a needed tirst step. is hardI> the end of the task. It is at this point that Psychitrtric Ethics. by Bloch and Chodoff. enters. They. like Rosenbaum. have included a wide range of topics, from a historical perspective through the ethics of suicide to the political use of psychiatry. The approach taken by the authors in each of the eighteen chapters is issue oriented and theoretically based. For example, Warren Reich in his chapter on “Psychiatric diagnosis as an ethical problem’* cuts to the heart of such ethical issues as “. the technologies of electroconvulsive therapy, behavior modification. medication. psychosurgery ” Underlying all of these behaviors is one sustaining psychiatric act: diagnosis. It is the prerogative to diagnose that enables the psychiatrist to commit. that delineates the populations subjected to his care. and that sets in motion the methods he will use for treatment. And it is this prerogative therefore. that should provoke the most fundamental and the most serious ethical considerations (p. 62). Power, its use and abuse, is a key issue here. A discussion of the positive and very appealing aspects of the use of diagnosis is offset by the dangers inherent in that well established practice. The other authors included in this volume are equalI> adept at centering on the core problem posed by the issue they deal with. The result is an insightful approach to the theoretical components of ethics and psychiatry. Although Rosenbaum’s book needs to be supplemented in order for the reader to gain a comprehensive view of psychiatric ethics. this earlier book could stand alone. Both books. however. are helpful and of interest. Ethics cd C/tr/ue.s it1 P.sychothrropy might best meet the need of the merelq curious: P.s~vhitrtric Ethcx meets the challenge of the curious and serious. Htrhm,,trtr,l,r U~liwrsif~ WILLARD P. GREEN Srctiou 011 Mdicrrl If umrrtitie.\ Phildrlphitr. PA. U.S.A.
How Nurses’ Emotions Affect Patient Care: Self Studies by Nurses. by KATHLIXN M. Cow. Springer. New York. 1982. 336 pp. $24.95 In the helping professions. ncophytcs are acculturated to attitudes and behaviors believed to represent an appropriate professional role. Such professional attitudes and behaviours may be based on ideological rather than tested assumptions. One assumption. formulated hy Parsons ( I95 I. T/IO Soc,itr/ Sr.srcw) out of a functionalist model. is that practitioners’ clfcctivc neutrality is ‘L basic and valid
520
While many of Rorem’s beliefs and predictions may strike the reader as self-evident, not all have worked out as some may believe they should have. However. it is in the context of these that the most can be gained, for they force the reader to evaluate current assumptions about how health care should be organized and how it in fact is. For example. areawide planning has not been as successful as some of the essays suggest that it should be, partially because of vested interests on the part of providers and limited scope of authority of planning agencies. Have the failures resulted because planning as Rorem describes it is not necessary or because it is necessary but inhibited by systemic structural problems that have to be resolved? Answers to such questions have the potential for increasing our understanding of how policy can be used as a successful intervention. Caution must be taken when criticizing these essays because we have the benefit of “20-20 hindsight” as Herbert Klarman, who writes the comment for the third section. puts it. However, there are still areas which are striking by their absence such as a discussion of the effects of insurance on demand. Rorem does not address moral hazard nor the resulting lack of agreement on what constitutes necessary or minimum level of care. These essays are as fresh today as when they were written. Despite the time that has passed since they were written. they provide an opportunity to get fresh insights and perspectives on the health care system. One comes away with a clearer understanding of what our assumptions are and with a renewed vision-inspired by Rorem’s-of how we can make the health care system’ better. .Sloa,l School 01 Marwgrmwt
BARBARA BIGEL~W
Massuchusetts lmtitutr oj’ Trchr~oloc~y C’rmhridgc MA. U.S.A.
Psychiatric
Ethics.
CHOIXFF. Oxford
edited by SIDNEY BLOTH and PAUL University Press. Oxford, 1981. 341 pp.
Ethics and Values in Psychotherapy:
A Guidebook, edited 1982. 424
by MAX ROSENRAUM.The Free Press. New York, PP.
The result of the approach to studying ethics identified as “applied ethics” is that a number of books have appeared with titles combining a particular discipline with ethics. There are numerous books on “Medical Ethics,” some on others dealing with “Nursing Ethics” “Business Ethics”. and so forth. Now two books have been published which look at the interface between ethics and psychiatry. Although bearing similar titles. the two books. Ps~d~ilrtric Ethics and Ethics ud Vulurs irk Psychothrrupy, are quite diRerent in their approach to the topic. If someone is looking for a tightly woven analysis of a particular ethical issue imbedded in the lield of psychiatry, the nature and role of confidentiality for example. Rosenbaum’s book is not the place to turn. His purpose was other than offering a theoretical examination of the issues. rather more of a “show-and-tell” approach. Each of the IX chapters tells something about the particular tield of expertise being examined and then shows how various ethical issues arise within that field. As one example. Nina Fieldsteel. in her chapter on “Ethical Issues in Family Therapy”, begins by offering a brief justification for discussing ethics and then offers some clarification of what constitutes family therapy. She then focuses on a few ethical issues: (a) the autonomy of the patient and/or family in opposition to the therapist’s perception of what is in the patient’s best inter&: (b) the place of confidentiality when “family secrets” are divulged; and (c) the function of power in the therapeutic relationship with respect to manipulation. The
concluding section offers a suggestion for h’o\v a farnil! therapist might best become atiare of the ethical aspects of her profession. A wide range of settings is examined. Tuo chapters deal with an overview of ethics as it impinges on pskchotherap! as a profession. 6 chapters look at ethlcal Issues which arise in the relation between the patient and the professional.. 8 chapters examine the manner in whtch treatment approaches give rise to ethical dilemmas and the final 2 chapters highlight the ethical problems confronting psychotherapists working in situations other than private practice. There is also an appendix containing various codes of ethics which have been established for professionals working in psychiatry. As one might expect. a number of recurrent ethical issues are identified throuehout the book: patient autonomy. truth telling, confidenzality, do no harm. the role of informed consent. labeling of patients, professional competence and so forth. For those who never thought about the ethical ramifications of psychotherapy this book might be helpful. However. identifying a problem. although a needed tirst step. is hardI> the end of the task. It is at this point that Psychitrtric Ethics. by Bloch and Chodoff. enters. They. like Rosenbaum. have included a wide range of topics, from a historical perspective through the ethics of suicide to the political use of psychiatry. The approach taken by the authors in each of the eighteen chapters is issue oriented and theoretically based. For example, Warren Reich in his chapter on “Psychiatric diagnosis as an ethical problem’* cuts to the heart of such ethical issues as “. the technologies of electroconvulsive therapy, behavior modification. medication. psychosurgery ” Underlying all of these behaviors is one sustaining psychiatric act: diagnosis. It is the prerogative to diagnose that enables the psychiatrist to commit. that delineates the populations subjected to his care. and that sets in motion the methods he will use for treatment. And it is this prerogative therefore. that should provoke the most fundamental and the most serious ethical considerations (p. 62). Power, its use and abuse, is a key issue here. A discussion of the positive and very appealing aspects of the use of diagnosis is offset by the dangers inherent in that well established practice. The other authors included in this volume are equalI> adept at centering on the core problem posed by the issue they deal with. The result is an insightful approach to the theoretical components of ethics and psychiatry. Although Rosenbaum’s book needs to be supplemented in order for the reader to gain a comprehensive view of psychiatric ethics. this earlier book could stand alone. Both books. however. are helpful and of interest. Ethics cd C/tr/ue.s it1 P.sychothrropy might best meet the need of the merelq curious: P.s~vhitrtric Ethcx meets the challenge of the curious and serious. Htrhm,,trtr,l,r U~liwrsif~ WILLARD P. GREEN Srctiou 011 Mdicrrl If umrrtitie.\ Phildrlphitr. PA. U.S.A.
How Nurses’ Emotions Affect Patient Care: Self Studies by Nurses. by KATHLIXN M. Cow. Springer. New York. 1982. 336 pp. $24.95 In the helping professions. ncophytcs are acculturated to attitudes and behaviors believed to represent an appropriate professional role. Such professional attitudes and behaviours may be based on ideological rather than tested assumptions. One assumption. formulated hy Parsons ( I95 I. T/IO Soc,itr/ Sr.srcw) out of a functionalist model. is that practitioners’ clfcctivc neutrality is ‘L basic and valid