Elisa Liberati and colleagues argue that understanding the systemic and institutional forces behind lack of compassion in mental health services is key to solutions to this problem

Mindfulness exercises are presented as being compatible with almost any spiritual, religious or philosophical beliefs. In this paper, we argue that they in fact involve imagining and conceptualising rather striking and controversial claims about the self, and the self's relationship to thoughts and feelings. For this reason, practising mindfulness exercises is likely to be in tension with many people's core beliefs and values, a tension that should be treated as a downside of therapeutic interventions involving mindfulness exercises, not unlike a side effect. Clients ought to be informed of these metaphysical aspects of the exercises, and mental health providers ought to take them into account in assessing which course of treatment to recommend. Given these concerns, the casual way in which mindfulness exercises are presently distributed by mental health providers to the general public is inappropriate.

Psychiatry has a long history of being criticised for the pathologisation and medicalisation of ordinary experiences. One of the most prominent of these critiques is advanced by Allan Horwitz and Jerome Wakefield who argue that instances of ordinary sadness in response to events such as bereavement, heartbreak and misfortune, are being mistakenly diagnosed as depression due to an increasing lack of consideration for aetiology and contextual factors. Critiques concerning pathologisation and medicalisation have not been forthcoming for psychiatry’s close cousin, psychotherapy. Using Cognitive Behavioural Therapy, one of the most prominent schools of contemporary psychotherapy as a case study, I demonstrate that psychotherapy also contributes to medicalising and pathologising bereavement, heartbreak and misfortune.

This chapter identifies ethical challenges in Cognitive Behavioral Therapy (CBT). It focuses on cognitive and behavioral techniques separately. The first part examines cognitive techniques, where the authors show that evaluating cognitions in terms of validity and utility entails evaluating failures of epistemic and practical rationality. This reveals concerns for professional ethics. For instance, if evaluating cognition for utility involves evaluating practical rationality, then CBT’s evaluation of cognitions is more value laden than first supposed and consequently presents a richer set of challenges for the therapeutic alliance. The second part highlights ethical challenges in exposure-based therapy (EBT) for behavioral therapy. The initiation of EBT provides particular ethical concerns relating to the issues of harm and informed consent. The authors argue that under a will-oriented conception of harm, EBT involves harm. Therefore, clients encounter EBT with rational ambivalence. The possibility of using motivational interviewing (MI) to resolve this ambivalence is discussed.

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