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Paternalism and autonomy: psychotherapists’ choices in dilemmas
and their justifications as ethical aspects of the therapeutic relationship
Paternalizm i autonomia: wybierane przez psychoterapeutów rozwiązania dylematów
oraz ich uzasadnienia jako etyczne aspekty relacji terapeutycznej
1 Usługi psychologiczne. Anna Bogatyńska-Kucharska, Kraków, Polska
2 Institute of Philosophy, Faculty of Philosophy, Jesuit University Ignatianum in Kraków, Kraków, Poland
3 Institute of Health Sciences, Collegium Medicum of Jan Kochanowski University in Kielce, Kielce, Poland
Correspondence: Anna Bogatyńska-Kucharska, PhD, Usługi psychologiczne. Anna Bogatyńska-Kucharska, Kochanowskiego 12/8, 31-127 Kraków, Poland, e-mail: anna.bogatynska@terapia-psychologiczna.pl
ORCID iDs
1. Anna Bogatyńska-Kucharska https://orcid.org/0000-0001-7762-9518
2. Jarosław Kucharski https://orcid.org/0000-0001-6129-4477
3. Marcin J. Jabłoński https://orcid.org/0000-0002-3430-5932
Aim: The aim of the study was to analyse solutions to ethical dilemmas based on the criterion of “paternalism-autonomism” in the
context of psychotherapists’ professional experience and therapeutic modality. Another aim was to review the sources of choices
of ethical decisions from the perspective of the “intuitiveness – ethical reflection” dichotomy, and to assess the percentage of ethical,
ambiguous, and non-ethical justifications of solutions preferred in those ethical dilemmas. Method: It was a cross-sectional
qualitative study. An original questionnaire describing three exemplary clinical and ethical dilemmas combined with a multiple-
choice questionnaire containing recommended solutions to the presented dilemmas was employed in the study. The responses were
correlated with the modality of psychotherapy (cognitive-behavioural, psychoanalytic-psychodynamic, psychodynamic-systemic,
systemic, integrated) and the professional experience of therapists. The statistical analysis included questionnaires obtained from
191 respondents. Results: Statistical data indicate the general advantage of autonomous decisions in the entire group of therapists,
regardless of their professional experience. A significant advantage of autonomic solutions over paternalistic solutions was
demonstrated in all analysed therapeutic approaches with the exception of the cognitive-behavioural approach. Moreover,
a statistically significant majority of psychotherapists reported the use of ethical reflection when choosing the solutions to the
discussed dilemmas. A comparison of the total number of selected justifications revealed a significant advantage of ethical
justifications over ambiguous and non-ethical ones, regardless of the professional experience of therapists and in all modalities
except the psychoanalytic-psychodynamic and psychodynamic-systemic types. Conclusions: The principle of respect for autonomy
plays an important role in the professional ethics of psychotherapists, and the preference for ethical considerations and justifications
when choosing solutions to practical ethical dilemmas indicates a potential benefit of incorporating ethics into the professional
training of therapists.
Keywords: psychotherapy, ethical dilemmas, paternalism, autonomy, good of the patient
Celem badania jest analiza rozwiązań dylematów etycznych ze względu na kryterium paternalizm – autonomia wybieranych przez
psychoterapeutów z uwzględnieniem doświadczenia zawodowego oraz modalności respondentów. Ponadto artykuł przedstawia
analizę deklarowanego przez psychoterapeutów sposobu rozstrzygania dylematów (rozwiązania intuicyjne lub namysł etyczny)
oraz uzasadnień wskazanych rozwiązań (uzasadnienia etyczne, niejednoznaczne, pozaetyczne). Na potrzeby badania przekrojowego
stworzono autorski kwestionariusz. Podstawę kwestionariusza stanowią opisy przykładowych dylematów etycznych oraz ich
rozwiązania i uzasadnienia (pytania wielokrotnego wyboru z kafeterią odpowiedzi). Odpowiedzi respondentów zostały skorelowane
z modalnością psychoterapeutyczną (w badaniu wyróżniono podejścia: poznawczo-behawioralne, psychoanalityczno-
-psychodynamiczne, psychodynamiczno-systemowe, systemowe, integrujące) oraz doświadczeniem zawodowym. Do analizy
statystycznej wykorzystano dane zebrane od 191 respondentów. Wyniki wskazują na przewagę rozwiązań autonomicznych
niezależnie od doświadczenia zawodowego psychoterapeutów. Poza tym wyniki badania wskazują na wyraźną przewagę rozwiązań
autonomicznych nad paternalistycznymi we wszystkich badanych podejściach teoretycznych poza poznawczo-behawioralnym.
Ponadto statystycznie istotnie więcej psychoterapeutów wskazywało, że wybór rozwiązania dylematu etycznego wymagał namysłu
etycznego. Porównanie wskazywanych przez badanych uzasadnień dla rozwiązań dylematów etycznych wykazuje przewagę
uzasadnień etycznych niezależnie od doświadczenia zawodowego oraz wśród przedstawicieli wszystkich podejść z wyjątkiem
psychoanalityczno-psychodynamicznego oraz psychodynamiczno-systemowego. Zasada szacunku dla autonomii odgrywa istotną
Abstract
Streszczenie
Anna Bogatyńska-Kucharska1, Jarosław Kucharski2, Marcin J. Jabłoński3
Received:
20.05.2022
Accepted:
24.11.2022
Published:
13.06.2023
© Psychiatr Psychol Klin 2023, 23(1), p. 3–11
DOI: 10.15557/PiPK.2023.0001
© 2023 Bogatyńska-Kucharska e t al. Th is is an op en-acce ss art icle di stributed under the term s of the Creative Com mons Att ribution-NonCommercial-NoDerivatives Lic ense
(CC BY-NC-ND). Reproduct ion ispermitte d for personal, edu cational, non-c ommercial use , provided that t he origina l article isin w hole, unmodi fied, andprope rly cited.
Anna Bogatyńska-Kucharska, Jarosław Kucharski, Marcin J. Jabłoński
4
© PSYCHIATR PSYCHOL KLIN 2023, 23 (1), 3–11DOI: 10.15557/PiPK.2023.00001
BACKGROUND
The therapeutic relationship is an important and in-
dependent predictor in adult and adolescent psy-
chotherapy (Flückiger et al., 2012). Based on previ-
ous research (Jaworska, 2006), one can assume that among
the processes that are indisputably desirable in the thera-
peutic alliance the most important ones include trust, re-
alness of meeting between persons, individual approach to
a particular patient, honesty, truth as the goal of the thera-
peutic investigation, ethics as the foundation of undertaken
actions, and the benet of the patient as the primary goal of
therapy. Ethics is a critical factor in every helping profession
in which the clients/patients are in trouble and seeking help.
is issue is especially important in psychotherapy, where
the focus of intervention is targeting the most internal, hid-
den, and intimate world of an individual (Treuer, 2008).
e general principles of ethics are intended to guide the
psychotherapist’s decision-making when confronted with
ethical dilemmas. Alternatively, considering the paradigm
of nancialisation dominating in the 21st century, the con-
cept of ethics is an anachronistic construct (Coyle et al.,
2007; Keep, 2003). erefore, questions about the status of
universal ethical values in the therapeutic alliance and pro-
fessional training of psychotherapists, and about their read-
iness to ethical compromises in the therapeutic relationship,
are of great importance. e analysis of ethical issues in the
context of psychotherapy is growing in importance, as there
are now many new therapeutic approaches and simplied
therapeutic platforms for online therapy, without any direct
contact with the patient, and even methods in which arti-
cial intelligence algorithms overtake the role of the thera-
pist altogether (Coyle et al., 2007; Luxton et al., 2016; Stoll
et al., 2020). e principles of the biomedical ethics of Beau-
champ and Childress (2009) cover the most important ar-
eas of the therapeutic relationship compatible with univer-
sal moral norms, and their practical application in ethical
decision-making is obvious. Autonomy is most oen un-
derstood as self-determination (Biegler, 2010). e princi-
ple of respect for autonomy – as the right of an individu-
al to make his or her own choices and, therefore, the need
for informed consent. Benecence – the principle of act-
ing with the best interest of the other in mind, non-male-
cence – the principle that “above all, not harm”, as stated in
the Hippocratic Oath, and justice, a concept that emphasis-
es fairness and equality among individuals (Aldcro, 2012).
e problem of paternalism is usually understood as acting
against the will or preferences of the benefactor, motivated
by benecence or protection from harm (also understood
as a preference for benecence over respect for autonomy)
(Beauchamp and Childress, 2009; Dworkin, 1972, 1988).
In the article, paternalism is considered as following the
psychotherapist’s conception of patients’ good which is ba-
sically neutral (Łuków, 2005). e latter denition was cho-
sen because it demands fewer presuppositions than the for-
mer one. Łuków’s denition does not imply the intuitions of
the actor and abstains from determining the “acting against
the will of preferences” (it is possible that the chosen con-
ception of good is consistent with the benefactor’s); there-
fore, it leaves open the question about the conditions of
justication. Merely it is formal, showing that the core of pa-
ternalism lies in abstaining from agreement on the concep-
tion of good rather that acting against the will of the bene-
factor. It diers from typical denitions used in the ethics
of psychotherapy (Annoni, 2021). Many authors argue that
there is no way of avoiding ethics in psychotherapy, “the
only question is whether the psychotherapist will ‘do ethics’
in a professional way” (Urofsky and Engels, 2003, p.121).
New research also indicates that the current ethical deci-
sion-making models do not yield comprehensive answers
or lead to improved ethical decision-making. Consequently,
such models are not theoretically grounded (Barnett et al.,
2007; Cottone and Claus, 2000). To meet this postulate, and
because people state they value these medical ethical prin-
ciples, but they do not use them directly in the decision-
making process, medical ethics has taken a turn towards
empiricism, and empirically measures the ethical principles
(Aldcro, 2012). In this changing therapeutic environment,
the main task is to take care of the patient’s benets and aim
towards client self-reliance and autonomy (Fitzgerald et al.,
2010; Vyskocilova and Prasko, 2013). Also in this study, the
attitude of psychotherapists to ethical dilemmas arising in
the therapeutic relationship with a patient reporting bio-
psychosocial health problems was analysed. e solutions
to the three ethical dilemmas were used to determine their
attitude to the variables being studied. e basic areas of
analysis comprised psychotherapists’ claimed behaviours in
three exemplary ethical dilemmas and the grounds for such
choices. Two types of possible behaviours were considered:
paternalistic and autonomic. Paternalistic actions mean that
the therapist chooses what is good for the patient. In con-
trast, autonomous actions refer to the therapist’s compli-
ance with what the patient him- or herself considers good
for him or her (Łuków, 2005). e ground of these choices,
we divided into ethical, non-ethical, and ambiguous from
the moral perspective. Ethical justications consist of rules
of modality, rules of codes of ethics, care for the good name
of psychotherapy, etc. e psychotherapist’s understanding
rolę w etyce zawodowej psychoterapeutów, a deklaracje respondentów dotyczące namysłu etycznego i znaczna liczba wskazywanych
uzasadnień etycznych przemawiają za korzyściami płynącymi z uwzględnienia zagadnień etycznych w szkoleniu psychoterapeutów.
Słowa kluczowe: psychoterapia, dylematy etyczne, paternalizm, autonomia, dobro pacjenta
Paternalism and autonomy: psychotherapists’ choices in dilemmas and their justifications as ethical aspects of the therapeutic relationship
5
© PSYCHIATR PSYCHOL KLIN 2023, 23 (1), 3–11 DOI: 10.15557/PiPK.2023.0001
of the patient’s psychopathology was considered a non-eth-
ical justication. Eectiveness and ecacy were considered
an ambiguous justication. e rst study question regard-
ed the type of behaviour ‒ understood as the solutions of
the dilemma – is preferred by psychotherapists (paternal-
istic or autonomic) and what grounds they name for their
choice. So the question was whether therapists follows their
patients’ or their own understanding of the patient’s good,
and how they justify it. Another goal of the analysis was to
identify dierences in the paternalistic and autonomous ap-
proaches and their grounds in dierent therapeutic modal-
ities and according to dierent psychotherapeutic experi-
ence. Benecence was recognised as the principle of acting
in the interests of the other person (seeking their good), and
respecting the patient’s autonomy as recognising the right
of an individual to make his own choice (Beauchamp and
Childress 2009; Suszek et al., 2017). ese variables were
correlated with the modality of psychotherapy, and the
experience of the psychotherapists.
METHODS
Design of the study
e study had a cross-sectional design, used a qualitative
methodology, and was conducted in the period from Feb-
ruary 2019 to February 2020. Data analysed in the paper
are part of a larger research project studying the problem of
autonomy and other goods in psychotherapy. Participation
in the study was anonymous, with recruitment occurring
via psychological social networks (e-survey available on the
website of the Institute of Psychology of the Jesuit Univer-
sity Ignatianum in Kraków) and at scientic conferences
(survey in a printed version). Eight national psychothera-
pists’ associations and two others were asked to cooperate in
the conduct of the research. Among them, there were both
those consociating psychotherapists of dierent modalities
and those consociating psychotherapists of the same mo-
dality. Five national associations and two others agreed to
collaborate by either sending the link (electronic version)
with short information about the research to their mem-
bers or allowing the conduct of the study during their con-
ferences (hard copy). Printed surveys were used during psy-
chotherapeutic conferences. Both versions are almost the
same. e only one dierence is one extra question in the
electronic version: “Are you a psychotherapist?”.
Study group
Inclusion criteria: current active employment in the profes-
sion of a psychotherapist and possession of a psychothera-
pist certicate or participation in a comprehensive certied
psychotherapy course for at least two years. e psychother-
apists’ declaration was used in judging whether the inclu-
sion criteria are met. Two hundred and nine therapists (88
completed the e-questionnaire and 121 the printed version)
were recruited. One hundred ninety-one participants met
the above-mentioned criteria. e study group included
30 men (16%) and 160 women (84%); one participant did
not specify gender. e age of the respondents was 27–70
years (mean 42.6, standard deviation, SD = 9.03). e time
of professional employment ranged from one to 40 years,
with an average of 12.77 years (SD = 7.75 years). Compar-
ing these data with the information from the study on the
population of psychotherapists in Poland, it can be conclud-
ed that in terms of the demographic variables, the struc-
ture of the study group was representative (Suszek et al.,
2017). In terms of professional experience in psychotherapy,
the respondents were divided into three levels: beginners,
advanced, and experts (Tab.1). The category of begin-
ners referred to qualied psychotherapists with less than
10 years of psychotherapeutic experience who have not ob-
tained a psychotherapeutic certicate issued by an appro-
priate professional association. e category of advanced
included practitioners with a psychotherapeutic certifi-
cate and less than 20 years of practice and psychotherapists
without a psychotherapeutic certicate who have practiced
psychotherapy for at least 10, but less than 20 years. e cat-
egory of experts referred to qualied supervisors and psy-
chotherapists who have been practising for at least 20 years.
When qualifying psychotherapists to a modality, two vari-
ables were taken into consideration: the modality of being
trained and the modality used in practice. e psychothera-
peutic modalities of the respondents are presented in Tab.2.
Questionnaire
e survey questionnaire does not measure traits in a psy-
chological sense ‒ or other psychological characteristics.
It examines selected solutions to dilemmas (due to the au-
thorship of the patient’s well-being concept), justication
of dilemmas, as well as methods of solving the dilemmas
(based on ethical reection or intuition). e depicted con-
structs are independent of each other. e questionnaire is
Level of experience Number % Mean
[years] SD
Beginners 57 29.8% 4.98 2.66
Advanced 93 48.7% 12.41 3.50
Experts 41 21.5% 23.95 5.98
Tab. 1. Professional psychotherapeutic experience of respondents
Modality Number %
Cognitive-behavioural 26 13.6%
Psychoanalytic/psychodynamic 54 28.3%
Integrated 57 29.8%
Psychodynamic-systemic 39 20.4%
Systemic 11 5.8%
Other 4 2.0%
Tab. 2. Psychotherapeutic modalities of the respondents
Anna Bogatyńska-Kucharska, Jarosław Kucharski, Marcin J. Jabłoński
6
© PSYCHIATR PSYCHOL KLIN 2023, 23 (1), 3–11DOI: 10.15557/PiPK.2023.00001
not a psychometric test. It is a survey questionnaire that al-
lows collecting quantitative data. e researched variables
are qualitative in nature (nominal variables – resolving eth-
ical dilemmas and justifying them) and concern ethics.
To verify the reliability of this tool, the method of com-
petent judges was used twice. e original questionnaire
describing three exemplary clinical and ethical dilemmas
(short case presentations) combined with a multiple-choice
questionnaire containing recommended solutions to the
presented dilemmas was used. Other authors have also used
the short case study method in studies investigating ethi-
cal issues (Bhola et al., 2015; Coverdale et al., 1997; Politis
and Knowles, 2013). e original version of the question-
naire survey was drawn up by Anna Bogatyńska-Kucharska.
It is written in Polish and consists of two versions: elec-
tronic and hard copy. e development of the question-
naire was a multi-stage process. Firstly, a total of 10 ethi-
cal dilemmas were chosen. en, eleven psychotherapists
were interviewed to check the cases by means of a specially
prepared semi-structured interview. Aerwards, four com-
petent judges estimated the dilemmas and questions, tak-
ing into account the answers of interviewees as well. ree
dilemmas meeting a set of criteria (compliance of the com-
petent judges with regard to the conict of pairs of prin-
ciples creating the dilemma, high formal evaluation, dis-
agreement between the patient and the psychotherapist as
to the understanding of the patient’s good and the necessi-
ty to choose the good implemented in psychotherapy be-
tween various competing goods of the patient) were chosen
for compiling the questionnaire. Aerwards, ve competent
judges evaluated the answers to the dilemmas (paternalis-
tic/autonomic) and their justications (ethical-non ethical).
e judges’ assessments were very similar in terms of their
classication of items concerning the solutions to the eth-
ical dilemmas due to the authorship of the implemented
concept of the patient’s good (either from the patient’s or
the psychotherapist’s perspective). e agreement of the
judges as to the assessment of the items was 100% in two
cases; in the third case, it was two out of four cases – 80%,
and another two – 60%. According to the justications, only
those were selected for which the agreement of the judges’
assessments was at least 80%, except for ecacy, for which
an extra category was created (ambiguous). e question-
naire prepared in this way was tested in a pilot study. At the
core of each of the three dilemmas, there is a dierent un-
derstanding of the patient’s good between the psychother-
apist and the patient. e described situations were con-
sidered exemplary in a pilot survey of the questionnaire by
a team of competent judges. e cases also refer to situa-
tions where the patient’s primary autonomy interferes with
his or her current life or health status, such as in the case of
mental problems (1), marriage (2), or pregnancy (3). Case 1:
e mother of 30-year-old Mr. M. would like the psycho-
therapist to provide her with information about her son’s
treatment and prognosis. e patient repeatedly discusses
this issue during therapy. e psychotherapist believes that
his conversation with M.’s mother and providing her with
information will negatively aect the progress of psycho-
therapy and the achievement of goals specied in the con-
tract. Nevertheless, Mr. M. asks the psychotherapist to re-
veal requested information to his mother. Case 2: Mrs. G.
is depressed, plans to start psychotherapy, and attends the
rst meetings. It is immediately evident that the symptoms
of depression are related to her marital situation (dominant
husband, very traditional family model). e therapist be-
lieves that it is impossible to achieve any change benecial
for the patient without a critical overview of her marriage.
e patient wants to participate in therapy but understands
the therapeutic goals differently. She expects emotion-
al support rather than inspiration to change her marriage.
She claims that this relationship model suits her. Case 3:
23-year-old Ms. C., diagnosed with personality disorders,
has been participating in therapy for 2 years. Her therapy
leads to favourable changes. However, Ms. C. continues to
occasionally engage in risky sexual behaviours with random
partners and, as a result, becomes pregnant. Speaking free-
ly during the session, she confesses that she wants an ille-
gal abortion. She does not want to have a baby and look
aer him or her. She believes that having the baby would
also prevent her from achieving her plans (graduation, be-
coming independent). e proposed answers in the ques-
tionnaire (selected by the therapist) reect the dierences
between the patient and psychotherapist in identifying the
best solution for the patient (benecence) and can be inter-
preted in terms of the paternalism-autonomy dichotomy.
e paternalistic choices were understood as following the
psychotherapists’ understanding of the patient’s good, while
autonomic actions are treated as following the patient’s un-
derstanding of his or her own good. ese choices are the
basis for determining the accepted ethical norms in the
event of a disagreement between the psychotherapist and
patient. e competent judges assessed the types of justi-
cation. Due to uctuations in social approval, it makes no
sense to ask people directly about the accepted norms. us,
these norms can be deduced from the choices made (for the
English version of the original Polish questionnaire used in
the study, see the section Supplementary Material).
Statistics
Statistical computations were performed using the statistical
package STATA/SE 14.2 (StataCorp, 2015). Comparisons of
the number of responses in the questions allowing for more
than one answer were made using the Cochran Q statistical
test (Cochran, 1950). e test enables an analysis of depen-
dent data by comparing the proportions of the answers ob-
tained by b subjects in k binary variables. e null hypoth-
esis of the test assumes that the proportions of k variables
are equal, and the alternative hypothesis assumes a dier-
ence in proportions. In the case of comparisons of indepen-
dent data, the Pearson χ2 test was used. Statistical analysis was
performed at the set level of statistical signicance α = 0.05.
Paternalism and autonomy: psychotherapists’ choices in dilemmas and their justifications as ethical aspects of the therapeutic relationship
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© PSYCHIATR PSYCHOL KLIN 2023, 23 (1), 3–11 DOI: 10.15557/PiPK.2023.0001
RESULTS
A general analysis of the solutions to the presented ethical
dilemmas (question A of the questionnaire) in the “pater-
nalism-autonomism” dichotomy in the context of the ther-
apists’ professional experience showed that each of the 191
respondents (100%) chose at least once an answer indicat-
ing an autonomous solution. One hundred y therapists
(78%) additionally chose at least one answer allowing a pa-
ternalistic solution. e result indicates the general advan-
tage of autonomous decisions in the entire group of ther-
apists (χ2(1)=41.00, p<0.0001), regardless of the level of
their professional experience. In situation (1), concerning
the provision of information to the patient’s mother, most
respondents (51%) used the option of choosing their jus-
tification, and among those who marked at least one of
the proposed answer options, paternalistic solutions pre-
vailed (37% vs. 14%). ere were no signicant dierences
in the professional experience of therapists. When present-
ing their responses, the psychotherapists also opted for not
informing the mother, while emphasising the importance
of understanding and discussing the patient’s request in the
context of the therapeutic process. Some psychotherapists
pointed out that the patient’s initial diagnosis (e.g. whether
the patient concerned suers from psychosis) is also impor-
tant in the decision process. e predominance of paternal-
istic decisions was signicant among beginners in the pro-
fession (χ2(1)=8.05, p=0.0046) and among experienced
professionals (χ2(1)=13.09, p=0.0003), but it was not ob-
served in the group of experts (p=0.1444). In situation (2),
regarding the orientation of therapeutic work, more than
half of the respondents (55%) selected both types of re-
sponses simultaneously, both paternalistic and autonomous.
In situation (3), a signicant predominance of autonomous
decisions was observed, regardless of the professional ex-
perience of the therapists. e results presented above are
summarised in Tab.3.
Analysing the solutions to the ethical dilemmas (cont. ques-
tion A of the questionnaire) in the “paternalism-autono-
mism” dichotomy in the context of the therapeutic modality
of the respondents, a signicant, global (situations 1–3) ad-
vantage of autonomic solutions over paternalistic solutions
was demonstrated in all analysed therapeutic approaches
(integrating, systemic, psychoanalytical-psychodynamic
and psychodynamic-systemic), but not in the cognitive-be-
havioural approach. In situation (1), concerning the provi-
sion of information by the psychotherapist to the patient’s
mother (condentiality), representatives of the psychoan-
alytical-psychodynamic and integrating approach signif-
icantly more commonly chose paternalistic solutions, i.e.
they refused to provide such information to the mother.
In situation (2), concerning the determination of the di-
rection of psychotherapeutic work, people representing the
integrating approach signicantly more frequently chose
autonomous solutions, similarly to representatives of the
systemic approach, accepting the scope of work that the pa-
tient would agree to. In situation (3), concerning abortion,
the autonomous solutions dominated without signicant
dierences among the representatives of all discussed ther-
apeutic approaches. e results discussed above are sum-
marised in Tab.4.
A general analysis of the sources of choices in ethical deci-
sions (question B of the questionnaire) in the “intuitiveness
of choice – ethical reection” dichotomy revealed that a sta-
tistically signicant majority of psychotherapists indicat-
ed the use of ethical reection and less intuitiveness when
Paternalistic solutions Autonomic solutions χ2, p
Case 1 70 (37%)* 26 (14%) χ2(1) = 22.00, p < 0,0001
Case 2 132 (69%) 156 (82%) χ2(1) = 7.38, p = 0,0088
Case 3 21 (11%) 186 (97%) χ2(1) = 157.37, p < 0,0001
The sum 150 (78%) 191 (100%) χ2(1) = 41.00, p < 0,0001
* The results do not sum up to 100% because in each case more than one solution could be chosen.
Tab. 3. Dierentiation of paternalistic and autonomous solutions in specic problem situations (Pearson’s χ2 correlations)
Case 1 Case 2 Case 3
Paternalistic Autonomic p (χ2)Paternalistic Autonomic p (χ2)Paternalistic Autonomic p (χ2)
The modality n%n%n%n%n%n%
Cognitive-
behavioural 3 12 4 15 0.7055 21 81 22 85 0.7389 2 8 25 96 <0.0001
Psychoanalytic-
psychodynamic 33 61 8 15 <0.0001 41 76 40 74 0.8084 6 11 53 98 <0.0001
Integrated 18 32 4 7 0.0017 35 61 47 82 0.0233 7 12 56 98 <0.0001
Psychodynamic-systemic 12 31 8 21 0.3711 28 72 34 87 0.1088 3 8 38 97 <0.0001
Systemic 2 18 2 18 1.0000 4 36 11 100 0.0082 2 18 10 91 0.0114
Other 2 50 2 50 1.0000 3 75 2 50 1.0000 1 25 4 100 1.0000
Tab. 4. Paternalistic and autonomous solutions depending on the modality of the respondents (Pearson’s χ2 correlations)
Anna Bogatyńska-Kucharska, Jarosław Kucharski, Marcin J. Jabłoński
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© PSYCHIATR PSYCHOL KLIN 2023, 23 (1), 3–11DOI: 10.15557/PiPK.2023.00001
selecting the solutions of the discussed dilemmas. ere
was no correlation of this variable either with the therapeu-
tic modality or with the professional experience of the re-
spondents. e results are presented in Tab.5.
Justications for the solutions (question C of the question-
naire) preferred in situations 1–3 were correlated with the
therapeutic modalities and the level of professional experi-
ence of therapists. Comparing the total number of selected
justications, we noticed a signicant advantage of ethical
justications over ambiguous and non-ethical ones, regard-
less of the professional experience of the therapists. We also
observed a signicant dierence in favour of ethical jus-
tications versus non-ethical and ambiguous justications
among the representatives of the cognitive-behavioural ap-
proach (χ2(1)=7.00, p=0.0082), integrating (χ2(1)=10.00,
p=0.0016), and systemic (χ2(1)=4.00, p=0.0455), but
not among representatives of the psychoanalytical-psycho-
dynamic and psychodynamic-systemic approaches. e re-
sults are presented in Tab.6.
DISCUSSION
e ndings of the international research on the develop-
ment of psychotherapists indicate that inexperienced ther-
apists face more challenges than experienced practitioners
in the later stages of their professional development. ese
challenges include anxiety about moral or ethical issues
when interacting with clients (Bhola et al., 2015). Howev-
er, there are no broader prospective studies analysing eth-
ical issues specifically among psychotherapists. Murray
et al. (2007) conducted a cross-sectional study on a na-
tionally representative sample of American doctors.
It turned out that 75% of doctors preferred to share decisions
with their patients, 14% preferred paternalism, while 11%
preferred an autonomic approach (informed consent).
Senior doctors (50 years or older) saw themselves as practi-
tioners of paternalism. Complementing these observations,
our study, which lls the gap in the area of prospective re-
search on ethical issues in the group of psychotherapists,
suggests that there is no relationship between the profes-
sional experience of psychotherapists and their solutions to
ethical dilemmas regarding the conict of paternalism and
autonomy. Most psychotherapists opt for autonomous solu-
tions regardless of the level of their professional experience.
However, psychotherapists also accept paternalistic activi-
ties. Depending on the presented situations, the percent-
age of paternalistic decisions either did not correlate with
professional experience, or if it was dominant, it was not-
ed in the groups of beginners and experienced therapists,
but not experts.
e results indicate a relationship between the psychother-
apeutic approach and the type of solution to ethical dilem-
mas regarding the conict between paternalism and au-
tonomy. A signicant global (situations 1–3) advantage of
autonomic over paternalistic solutions was demonstrated in
all analysed therapeutic approaches (integrating, systemic,
psychoanalytical-psychodynamic, and psychodynamic-sys-
temic) but not in the cognitive-behavioural approach. is
nding is consistent with the conclusions reported by other
authors who attribute more paternalistic tendencies to the
cognitive-behavioural therapy, in which the main technique
of work involves explaining the impact of negative biases
and to teach strategies to ‘de-bias’ the judgments that are
coloured by them (Biegler, 2010). Alternatively, in situation
(1) concerning the provision of information by the psycho-
therapist to the patient’s mother (condentiality), the rep-
resentatives of the psychoanalytical-psychodynamic and in-
tegrating approaches signicantly more commonly chose
paternalistic solutions, i.e. they refused to provide the in-
formation to the mother. Perhaps this behaviour can be ex-
plained by referring to other studies showing that autono-
my requires an appropriate relationship between the patient
and therapist. erapists are faced with an inherent tension
between their desire to respect and support the patient’s au-
tonomy and their responsibility to act in the best interests
of the patient, which some authors call paternalism (Rodri-
guez-Osorio and Dominguez-Cherit, 2008). If the analysed
Intuitiveness
of choice Ethical reection p (χ2)
Case Number % Number %
1 71 37% 116 61% 0.0010
2 65 34% 123 64% <0.0001
3 59 31% 130 68% <0.0001
Tab. 5. Intuitive choice or ethical reection as the basis for choos-
ing a solution in the presented situations (Pearson’s χ2
correlations)
Ethical justications Non-ethical and ambiguous
justications p (χ2)
Modality n%n%
Cognitive-behavioural 26 100% 19 73% 0.0082
Psychoanalytic-psychodynamic 53 98% 50 93% 0.1797
Integrated 57 98% 47 82% 0.0016
Psychodynamic-systemic 38 97% 35 90% 0.1797
Systemic 11 100% 7 64% 0.0455
Other 4 100% 1 25% 1.0000
Tab. 6. Ethical and non-ethical justications as the basis for choosing a solution in various psychotherapeutic modalities (Pearson’s χ2 correlations)
Paternalism and autonomy: psychotherapists’ choices in dilemmas and their justifications as ethical aspects of the therapeutic relationship
9
© PSYCHIATR PSYCHOL KLIN 2023, 23 (1), 3–11 DOI: 10.15557/PiPK.2023.0001
responses of psychotherapists are seen as an expression of
recognised norms, it can be concluded that the principle of
respect for autonomy plays an important role in the profes-
sional ethics of psychotherapists, which supports the rejec-
tion of the paternalistic model of professional relations in
this eld. At this point, our results are in accord with the ob-
servations of Biegler (2010) and Pelto-Piri et al. (2013) who
conducted studies in seven psychiatric clinics for adults and
six psychiatric clinics for children and adolescents, where
participants had the opportunity to freely describe the eth-
ical considerations associated with their work by keeping
an “ethics diary” for a week. One hundred seventy-three re-
spondents were nally taken into account. Paternalism was
the primary perspective among the participants, but there
was also an awareness of their patients’ right to autonomy
(Pelto-Piri et al., 2013). is specic coincidence of pater-
nalism and autonomy, also observed in our study, can be ex-
plained by the concept of maternalism proposed by Laura
Specker Sullivan (2016). While paradigmatic paternalism
involves the father deciding what is in his children’s best in-
terests and supporting his decision ‘because he said so’, par-
adigmatic maternalism involves the mother selecting her
children’s activities based on her understanding of their
emerging interests (Specker Sullivan, 2016). To paraphrase,
the author argues that a well-trained and sensitive therapist,
whom the patient knows well, is able to know reliably what
his or her patient wants without the patient having to ex-
press those desires. Perhaps this understanding sheds better
light on the motivation of the moral choices of therapists,
including the evaluation of the presented results. In each
professional group, paternalistic solutions were predomi-
nantly selected in situation (2) – the scope of therapeutic
work, signicantly less in situation (1) – condentiality, and
most uncommonly in situation (3) – abortion. In terms of
autonomic decisions, similarly signicant dierences were
found in all groups. In situation (3), the greatest number of
autonomic decisions was selected, signicantly fewer in sit-
uation (2), and the fewest in situation (1). Situations relat-
ed to the provision of information (condentiality) are the
most widely described in the literature on psychotherapeu-
tic ethics. Green (1995) suggests that the eectiveness of
psychotherapy for the individual and society at large would
be greatly undermined by growing doubts about the priva-
cy of the therapeutic setting. Most clinicians acknowledge
that condentiality is neither an absolute nor an objective
norm in the daily practice of medicine but rather it exists as
a value-laden standard (Green, 1995). In situation (1) con-
cerning the provision of information by the psychothera-
pist to the patient’s mother, the representatives of the psy-
choanalytical-psychodynamic and integrating approaches
signicantly more commonly chose the paternalistic solu-
tions, i.e. they refused to release information to the mother.
Importantly, the presented situation is not a typical example of
a situation requiring disclosure, e.g. a threat to the patient’s
life or health. e premise for the disclosure of the informa-
tion is the patient’s preference. In the presented situation,
the autonomy of the psychotherapist is also important, as
he or she believes that disclosure of the information would
not be benecial and, therefore, works to the benet of the
patient. Perhaps in these approaches, Conly’s (2013) per-
spective applies, stating that even if autonomy is an impor-
tant value recognised in solving ethical dilemmas, it does
not mean that it is the primary value. Commenting on the
idea of paternalism, Conly says that it could have a bene-
cial eect on peoples’ lives by helping them achieve a life-
style they want to live (Conly, 2013).
Also, the basic problem in any psychotherapy process is the
question about the scope of therapeutic work and the di-
rection of changes that are to result from therapy (Bastian-
sen, 1974). In situation (2) presented in our study, concern-
ing the determination of the scope of psychotherapy, the
respondents representing the integrating approach signif-
icantly more frequently chose autonomous solutions, sim-
ilarly to the representatives of the systemic approach, ac-
cepting the scope of therapy that the patient would agree to.
In situation 3 (abortion), the psychotherapists participat-
ing in the study, representing all approaches except the sys-
temic one, chose the most autonomous decisions, limiting
themselves to analysing the situation and leaving decisions
to the patients. is nding conrms the observations of
other authors that in the ethical practice in obstetrics, non-
directive counselling means discussing dierent alternatives
to pregnancy outcomes and not recommending any of them
in particular (Coverdale et al., 1997). e comparison of the
dierences found in the responses given in each described
situation also shows that when assessing the admissibility
of paternalistic actions, the specicity of the situations they
concern is an important factor. Comparing the choices of
solutions depending on the therapeutic modality and clin-
ical situation, it can be inferred that in more emotional-
ly involving situations (e.g. abortion), psychotherapists are
more likely to choose solutions that respect the patient’s au-
tonomy. Bhola et al. (2015) also emphasise that the ethi-
cal dilemmas most frequently reported by psychotherapists
during professional training include condentiality issues
related to the provision of certain information about clients
to family members. Ambiguity prevailed as to who should
be privy to information on the client’s disclosures or the
diagnosis of mental illness or intellectual disability (Bhola
et al., 2015). In such circumstances, the share of non-profes-
sional morality in decisions made is greater than in others.
Precisely such situations have serious consequences for the
patient’s life and are emotionally engaging for the therapist.
is observation is consistent with similar studies showing
that therapists react dierently to similar ethical dilemmas
(Bhola et al., 2015). is nding underlines the role of in-
dividual differences and the importance of interpreting
events. In this aspect, our results are consistent with the re-
ports by other authors. Our respondents signicantly more
commonly declared a tendency to engage in ethical con-
siderations when making decisions in ethically signicant
situations. Assessing the eectiveness of psychotherapy or
Anna Bogatyńska-Kucharska, Jarosław Kucharski, Marcin J. Jabłoński
10
© PSYCHIATR PSYCHOL KLIN 2023, 23 (1), 3–11DOI: 10.15557/PiPK.2023.00001
understanding the patient’s psychopathology was not equal-
ly important for making ethical choices. is relationship
was revealed only in the group of therapists working in the
psychoanalytical-psychodynamic and psychodynamic-sys-
temic modalities. In these groups, it was more important to
refer to the understanding of psychopathology and the ef-
fectiveness of psychotherapy. is nding agrees with the
claims made by Baier (1985), who, among other things,
opposes rationality as the sole basis of ethical theory and
argues that human psychology and moral emotions play
a major role in making ethical choices. ese results sug-
gest, in line with other studies, that supervision/consul-
tation with peers and professional colleagues as well as
guidance derived from ethical codes are the most useful
strategies for resolving ethical problems (Bhola et al., 2015).
erapists should understand the range of preferences in
society and oer the opportunity to participate in treat-
ment by sharing decision-making responsibilities (Rodri-
guez-Osorio and Dominguez-Cherit, 2008). We hope that
the ndings of our study will also be taken into account
by professional therapists considering the need for ethical
education, training, and supervision.
CONCLUSIONS
1. Regardless of the level of their professional experience,
psychotherapists, while allowing paternalistic solutions,
tend to choose autonomous solutions to ethical dilemmas.
2. e principle of respect for autonomy plays an important
role in the professional ethics of psychotherapists.
3. e preference for ethical considerations and justica-
tions when choosing solutions to practical ethical dilem-
mas points towards a potential benet of incorporating
ethics into the professional training of therapists.
4. With respect to the preferred solutions to ethical dilem-
mas, what matters is not so much the therapeutic modal-
ity as the type of situation in which a decision must be
made. In evaluating key aspects of the situation, psycho-
therapists vary depending on the approach they represent.
5. e dierences revealed in the study, consisting in the lack
of a signicant advantage of autonomic over paternalis-
tic decisions in the cognitive-behavioural approach, and
the lack of a signicant advantage of ethical justication
of choices made in the psychoanalytical-psychodynamic
and psychodynamic-systemic modalities, require further
research in representative groups of respondents.
LIMITATIONS OF THE STUDY
It was a cross-sectional qualitative study conducted in the
form of a questionnaire completed aer a short written in-
struction, without any additional help from the interviewer.
Moreover, the size of the groups being studied does not
meet the criterion of representativeness, so the conclusions
do not apply to the general population. e questionnaire
used in the study is innovative, it has not been veried with
statistical methods, and its results can be qualitatively as-
sessed only based on a comparison with the opinions of
competent judges. In view of the lack of empirical research
based on a similar method, the discussion of the results is
based solely on similar studies.
Supplementary Material
Refer to the web version on www.psychiatria.com.pl for supplementa-
ry material.
Ethics approval
e institutional ethics review committee of the Jesuit University Ignati-
anum in Kraków approved the study on 23 May 2018.
Availability of data and materials
e datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Funding/Support and role of the sponsor
Jesuit University Ignatianum in Kraków (DS/2017/WF/026, DS/2018/
WF/15/A, MDS/2019/WF/25, DS/2018/WF/27, DS/2019/WF/15/D,
DS/2020/WF/16/A, DS/2020/WF/16/B).
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