The Ethics Blog

A blog from the Centre for Research Ethics & Bioethics (CRB)

Author: sylviamartin

Sylvia Martin is a researcher at CRB. She specialised in cognitive-emotional behavioural therapies after obtaining classical university training in philosophy and clinical psychology. She obtained the title of Doctor in Clinical Psychology in Psychopathology from the University of Aix Marseille, France, in 2019. Since 2016, she has been working as a psychotherapist, investing her clinical skills and knowledge in patient follow-up in institutions and private practice. Sylvia Martin was initially trained in cognitive behavioural therapy, but her practice intersects with the emotional-rational therapy approach of Albert Ellis, the cognitive work of Aaron Beck, and more recent therapeutic approaches such as acceptance and commitment therapy, dialectal behavioural therapy, mindfulness-based approaches and the radically open dialectal therapy founded by Lynch & Co.

As a researcher, Sylvia Martin specialised in the treatment of personality disorders, impulsivity, and consciousness. She is involved in developing innovative care practices to improve psychotherapy care in France and internationally. She is the founder of the ECCCLORE group that develops training in cognitive and behavioural skills related to the observation and regulation of emotions.

New insights into borderline personality disorder

Man in dark clothes walking alone on a hill beside the ocean. Photo: Polina Kuzovkova, from Unsplash.
1 April, 2025 / / 1 Comment

Individuals with borderline personality disorder (BPD) often suffer from strong emotions that change rapidly, from one extreme to another. They may fear abandonment and experience an inner emptiness. They may also behave impulsively and have suicidal thoughts or behaviors. BPD is often mis- or underdiagnosed and there is a tendency among clinicians to avoid the diagnosis.

Given the diagnostic complexity of BPD, it is important to establish a diagnosis. Recent therapeutic advances show that the disorder responds to treatment and that significant recovery is possible. Because mental health services prioritize major psychiatric disorders, such as psychotic disorders and mood disorders, individuals with BPD have significant unmet needs. The suicide rate for BPD is as high as 10%, mirroring that of schizophrenia, and the enduring impairments from the disorder are comparable to those of chronic mental illnesses.

Clinical decision-making regarding diagnosis can be challenging for healthcare professionals for several reasons and is surrounded by ethical challenges. Several studies have shown that stigmatization and negative attitudes regarding the diagnosis of BPD are still common. Healthcare professionals, including emergency room staff and multidisciplinary teams, have been surveyed. Results suggest that even specialized mental health professionals have more negative attitudes toward BPD patients than toward those with other diagnoses, such as depression. This is likely due to factors associated with the diagnosis itself, but it is also probably related to clinicians’ perceptions of BPD symptoms and their previous treatment experiences.

Stigmatization is also reinforced by research. Derogatory terms and attitudes regarding BPD are pervasive in academic work on the disorder. A particularly common example is the attribution of negative intentions to individuals with BPD, such as wearing provocative clothing to attract attention or seeking attention by choosing, for example, artistic careers. Yet, we are not aware of any empirical documentation suggesting that BPD is associated with clothing or with specific intentions regarding career choices.

Additionally, many healthcare professionals do not consider BPD to be a genuine diagnosis and believe it to be self-induced or self-diagnosed. Consequently, individuals with BPD are often not informed about their disorder or are told that they have another diagnosis, such as bipolar disorder, compromising the principle of transparent diagnosis and patient empowerment for informed and consensual care.

The diagnosis of personality disorder is sometimes used as a label for disliked individuals. This is hardly surprising, given that interpersonal relationship problems are the primary characteristic of these disorders. However, we cannot ignore the fact that personality issues are extremely common, and rejection based on perceived undesirability is not acceptable. We now have evidence from around the world that personality disorders occur in 6 to 12% of the population, with a much higher prevalence among psychiatric patients. Of course, these figures may prompt accusations of inappropriate medicalization of normal human variations, but this criticism must be questioned. Recent findings have shown that even relatively mild personality disorders are associated with greater psychopathology, higher use of health services, and higher costs compared to individuals without personality pathology, and this is an increasing trend.

In a new article, I challenge existing perspectives and discourses about the clinical reality of the disorder. I compared impulsivity, anxiety, hopelessness, suicidal tendencies and depression in BPD patients and the general population during the COVID-19 isolation in France. While all groups exhibited elevated levels of impulsivity and anxiety, statistically significant differences were found in the severity of hopelessness, suicidal ideation, anxiety, and depression. Specifically, individuals with BPD showed markedly higher levels of these symptoms compared to the general population sample. This suggests that BPD exhibits a distinct profile of chronic distress, exceeding the levels seen in general stress reactions or other disorders like depression or anxiety that are more recognized and accepted in society.

My own and similar studies suggest that there is a need for a critical reevaluation of the diagnostic methods for personality disorders such as BPD. There is growing concern that some healthcare professionals may underdiagnose personality disorders, possibly because such disorders are not perceived to be severe. This reluctance to diagnose, combined with inadequate training in diagnostic procedures, may contribute to a systemic failure to recognize and address the prevalence and impact of personality disorders. The healthcare system then risks perpetuating the misconception that diagnostic and communication challenges related to personality disorders are not significant.

Better diagnostic practices, coupled with more accurate case descriptions and better treatment planning, can ensure faster and more effective treatment. This would provide individuals with the opportunity for personal and clinical recovery. Furthermore, the process of communicating the diagnosis of BPD is fundamental to how people understand and interpret their diagnosis, which in turn can affect their hope for recovery and motivation to use healthcare services. In conclusion, there is room for significant improvement in how we approach personality disorders such as borderline personality disorder.

This post is written by…

Sylvia Martin

Sylvia Martin, Clinical Psychologist and Senior Researcher at the Centre for Research Ethics & Bioethics (CRB).

Sylvia Martin, Instability of the unstable, an observation of borderline personality disorder traits and impulsivity declaration during the pandemic, L’Encéphale, 2025, https://doi.org/10.1016/j.encep.2024.10.007

We challenge habits of thought

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Nurses’ experiences of dehumanization

Female nurse resting on a sofa with her face towards the ceiling, and her eyes shut. Photo: Cedric Fauntleroy, from Pexels.
11 March, 2025 / / 1 Comment

Many healthcare professionals who work in nursing report that they experience a sense of dehumanization in their work. Although this is an increasingly recognized problem, it is still unclear how it manifests itself in practice and should be addressed. Previous studies indicate that the experience of dehumanization is often linked to excessive workload, lack of institutional support, and growing bureaucratization of medical care. As healthcare becomes more standardized and protocol-driven, nurses find themselves constrained by rigid structures that limit their ability to provide personalized and compassionate care. Over time, these conditions contribute to professional exhaustion, a loss of meaning in work, and in some cases, institutional mistreatment that is not intentional but arises as a byproduct of a dysfunctional organization of work.

The ethical implications of this phenomenon are significant. Respecting the dignity of both healthcare professionals and patients is fundamental to medical ethics, but this principle is increasingly challenged by current working conditions. The erosion of humanity in nurse-patient interactions not only affects the emotional well-being of nurses but also impacts the quality of care itself. Studies have shown that depersonalization in healthcare settings is associated with higher rates of medical errors. Furthermore, institutions bear a collective responsibility to ensure ethical working conditions, providing nurses with the necessary resources and support to maintain both their professional integrity and personal well-being.

Dehumanization of care is one of the topics of Marie-Charlotte Mollet’s soon-to-be completed dissertation at Paris Nanterre University. In one of her most recent studies, 263 French nurses, working in a variety of healthcare settings (public, private, nursing homes), were surveyed regarding factors related to their working conditions. They answered questionnaires about their workload, emotional demands, and organizational dehumanization. They also answered questions about their mental states, psychological flexibility, psychological distress, stress, and burnout. They moreover provided sociodemographic data on age, seniority, and gender.

In the analysis of the data, gender was found to be a relevant factor, raising new questions about dehumanization. For example, a significant difference between men and women was observed regarding dehumanization of patients: male nurses dehumanize patients more than female nurses do. This difference was measured by having study participants answer questions about “depersonalization” in a psychological assessment instrument for burnout (Maslach Burnout Inventory). Marie-Charlotte Mollet’s work thus suggests that dehumanization in healthcare needs to be examined through a gendered lens. For example, several studies have demonstrated that female nurses often face different expectations than their male counterparts, especially when it comes to emotional labor. Female nurses are more often expected to show empathy and provide emotional support, which places an additional burden on them and increases their vulnerability to burnout.

Addressing challenges related to dehumanization requires serious rethinking of the ethical and institutional frameworks of healthcare. Systemic reforms are necessary to uphold humanistic values and ethical standards in medical practice and to ensure that nurses are not merely treated as functional units within an overburdened system. Empirically informed reflection on equity, recognition, and gender in nursing is crucial to fostering a more sustainable and just profession; one where both patients and nurses are treated with the dignity they deserve. It is in the context of this need for well-founded reflection on the working conditions of nursing that this study and similar research efforts should be understood and considered: for the nurses’ own sake but also for the well-being of the patients and the quality of the care they receive.

This post is written by…

Sylvia Martin

Sylvia Martin, Clinical Psychologist and Senior Researcher at the Centre for Research Ethics & Bioethics (CRB).

Marie-Charlotte Mollet, PhD student at Paris Nanterre University.

Ethics needs empirical input

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Psychological distress: an overlooked issue in immigrants

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29 October, 2024 / / 1 Comment

Psychological distress that ethnic minorities experience is an often overlooked problem. In France, the mental well-being of ethnic minorities, particularly those with North African immigrant backgrounds is an important issue to study. Both first- and second-generation immigrants face unique challenges that may make them more vulnerable to more general mental health issues, and psychological disorders. A fresh report from the European Fundamental Rights Association on being a Muslim in the EU (published on October 24, 2024) sheds some light on issues related to health and racial harassment and violence. The report did not study psychological issues specifically, but it is worth noting that race-related violence has psychological impact for 55 percent of the respondents (p. 21).

Vulnerability is frequently linked to ethnic minority status, leading to recurring experiences of discrimination and difficulties in reconciling cultural identity with a society that often prioritizes assimilation. In this context, assimilation tends to erase or disregard the original cultural heritage in favor of integration into the dominant culture. Such dynamics can lead to feelings of isolation, invalidation, and psychological distress among affected individuals.

Research on the mental health of French populations of North African descent remains largely neglected. In other regions, for example North America, mental health and immigration is much better studied. While the topic of discrimination has been explored in some areas, few studies have focused on the psychological effects of these experiences and the coping strategies adopted by these populations in France. Some research does indicate a rise in discrimination, but lack of comprehensive studies on this issue creates both a scientific and social void, keeping these topics largely invisible.

In other southern European countries such as Italy and Spain, the mental health problems of ethnic minorities are recognized, but do not yet receive the same attention as in North America. In Italy, studies on the mental health of minorities are mainly focused on recent migrants and refugees, not least because of the importance of migratory flows in the Mediterranean. Researchers are mainly interested in the traumas associated with exile and the precarious conditions of migrants, but issues of discrimination or systemic racism are less well explored.

In Spain, there is also research on the mental health of migrants, particularly from Latin America and North Africa. However, the framework remains focused on social integration and economic issues, and less on the dynamics of discrimination and ethnicity. Both countries are beginning to recognize the importance of these issues, but in-depth studies on the impact of racial discrimination on the mental health of ethnic minorities, as in all parts of Europe, are still limited.

One psychological phenomenon that is still underexplored in this context is “racial battle fatigue.” Introduced in the early 2000s by William A. Smith, this concept refers to the emotional and psychological stress accumulated by individuals who repeatedly face racism. It represents the emotional burden that ethnic minorities carry as a result of racial discrimination and societal expectations. This burden can drive individuals to minimize or suppress their own suffering to avoid being perceived as “weak” or “complaining.” These coping mechanisms can exacerbate psychological issues, creating a vicious cycle of untreated distress.

In academic and professional settings, there is often reluctance to openly discuss these challenges. Some individuals may regard these topics as taboo or controversial, limiting the opportunities for open dialogue and scientific advancement. This reflects a broader trend in the mental health field, where the specific needs of ethnic minorities, particularly in terms of tailored psychological care, are not adequately addressed.

If we are going to be able to provide concrete answers to these questions, we need to study this phenomenon and shed some light on the mechanisms underlying the psychological suffering of ethnic minorities. Research on the psychological distress experienced by ethnic minorities could also help develop therapeutic interventions better suited to these populations. A recent French pilot study can lead the way: in Rania Driouach’s sample of people with North African descent, 226 out of a total of 387 participants indicated heightened psychological distress on a transgenerational level. Her study is the first step towards a scientific framework that acknowledges the specific needs of these groups while promoting an inclusive and rigorous therapeutic approach. Perhaps such a framework can help pave the way for a better understanding of the effects of migration on psychological distress across generations, and provide better tools for the (mental) health care providers that provide both first and second line care.

This post is written by Rania Driouach (Paris Nanterre University) and:

Sylvia Martin

Sylvia Martin, Clinical Psychologist and Senior Researcher at the Centre for Research Ethics & Bioethics (CRB).

We transcend disciplinary borders

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The branding of psychotherapy and responsible practice

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7 February, 2023 / / 2 Comments

Clinical psychologists receive degrees from universities, training them to effectively apply psychotherapy programs in psychiatry settings. But after graduation, whose responsibility is it to train, or perhaps re-train, clinical psychologists to practice “proper” therapy? Is it the responsibility of the owner of a three-letter branded protocol, such as DBT (Dialectical Behavior Therapy), SFT (Schema Focused Therapy) or MBSR (Metacognition Based Stress Reduction)? Or is it the responsibility of the health care systems that provide treatment? Perhaps they should ensure that a psychologist’s training is regularly updated, as in most other clinical professions?

As a clinical psychologist myself, with experience from practice in France, I want to address some challenges that I have experienced and reflected upon as I have tried to develop my own way of practicing therapy.

Medical training updates are widely encouraged for psychiatrists via the counting of credits for attending certified courses or international conferences (Continuing Medical Education Points). However, when it comes to clinical psychologists, the psychiatrists’ side-kicks offering psychotherapy treatment, there is no such unified system. Psychotherapy is in essence social work, and the success depends on the relationship between the therapist and the patient. But in many countries, particularly in the English speaking world, there is a tendency to brand specific therapeutic programs, such as the commonly known cognitive behavioral therapy, CBT, or versions of it such as dialectic behavioral therapy, DBT. Being “branded” as a psychotherapist comes with the advantage of being recurrently involved in seminars, training and follow-ups on our practice. But as a therapist, you are offering more than a program, you are offering years of experience and training. It is neither practical nor possible to “label” every little piece of training that made your practice look the way it does now. Yet psychotherapists face an entire branding system, with names such as DBT (Dialectical Behavioral Therapy), TFT (Transference Focused Therapy), SFT (Schema Focused Therapy) and MIT (Metacognition and Insight Therapy). All these names give structure, labels to refer to, which help both patients and colleagues to identify what happens in the therapy. But at the same time we might be confusing everyone involved with a jargon of acronyms. Depending on the cultural context, even using the word “client” instead of “patient” can be seen as subversive. The very idea that psychotherapy could be branded may appear strange and unusual. Are we considering the values at stake? Might not branding shift focus, from values of care towards economic considerations (such as selling your brand)? On the surface, it looks reasonable and as an approach that supports a fair distribution of care.

As an author of a CBT protocol myself, using a much longer acronym, ECCCLORE, I have been forced to question the underlying dynamic of naming or branding a particular kind of psychotherapy.  Like most of the CBT protocols, the effectiveness is in the structure of the protocol. Although I wanted to protect that structure, I did not want to rule out potential changes or improvements, but to make the protocol open to practitioners’ own experiences of using it with their patients. Therefore, I always encourage my students and colleagues to integrate the protocol with their own experiences, strengths and discoveries along the way.

Why? Well, because in using a protocol to engage with people in the intimate setting that psychotherapy is, we must also examine our values as caregivers, always considering the ethical principles of non-malevolence, respect and justice. And just as you must find your way to practice any branded therapy, you must find your way to observe these ethical principles in your work.

I was not harming my patients with the ECCCLORE protocol, but I created something that requires training to apply. Otherwise, like any mechanically applied protocol, it could potentially harm patients. Can that risk be overcome by adding another branded sub-protocol? There are already names all over the place in the CBT world. We all use “branded skills” such as Beck’s Columns and Padesky’s Polygram, and they are free to use, but they are just names for very commonly used tools, which we must again learn to use in practice.

When you dive into the specificity of “certified programs,” things start to become even more complicated. If I did not brand my project, anyone could use (or abuse) the ECCCLORE brand. For example, in France one needs to declare intellectual property in order to protect the project or research results from being stolen (as the research outcome is not considered the intellectual property of the researcher, as it is in Sweden). This means that anyone can use the name, even if it is unrelated to the CBT framework. But by acknowledging the creator’s intellectual property, it is possible for me to brand my own research protocol and evidence-based program, preventing misuse of the methods. But is it helping the replication and dissemination of the protocol? And if my ultimate goal is to offer the protocol to help as many patients as possible, is branding it the best solution?

I sensed an affinity between my own reflections and recent research that questioned the ethical guidelines for social justice work in psychology and outlined the need for social justice ethics. When I thought about branded CBT programs, I recognized ethical risks everywhere. If you pay a lot of money to be trained in Program A, you expect to be recognized as a Program A practitioner, and you expect to benefit from the specific expertise that you earned. Is it fair then to offer such services at premium prices? Or to refuse to have Program A training delivered to most of the clinical psychologists? Does it make the program more affordable and accessible to the patients in need of it? Is a society fair where most of the latest advances are not available to everyone, but only in private practice? Well, there are of course economic considerations, but on the clinical level it is not easy to sort out the pros and cons of these “acronymized” psychotherapies.

As a treatment developer, I do recognize that having a name to identify the program really helps. The social component of psychotherapy is known to be an important effectiveness factor. This was the case also for me. Avoiding any stigmatizing name of my therapeutic group, such as “Borderline Group,” was a move toward justice, respect and non-malevolence. I decided to create the acronym together with the first patient group, which helped create motivation and reflected the collaborative process. Because in therapy, it is the patients who have the most at stake. Along the way, I also had a chance to be trained in a manual-based psychotherapy, and I saw the advantages, as a clinician, to have a tribe supporting me as I entered their group. Branded evidence-based psychotherapies are organizing trainings and conferences, which offer many resources for their practitioners. They build up more and more specific results around subgroups of patients, and take responsibility for the full functioning of their practitioners.

Branded psychotherapies are probably here to stay, but I wanted to highlight some practical and ethical challenges that I have experienced and reflected upon as a treatment developer. Let me conclude with one final consideration about the future. In recent research on the effectiveness of personality disorder psychotherapy, the main factors were found to be the therapeutic attitude (active and collaborative) and the clarity of the protocol (the underlying theories). Future research may further investigate whether the branding of psychotherapies, which can be confusing, may also contribute to these factors.

Sylvia Martin

Sylvia Martin, Clinical Psychologist and Senior Researcher at the Centre for Research Ethics & Bioethics (CRB).

Sylvia Martin. (2022) Le programme ECCCLORE: Une nouvelle approche du trouble borderline. Deboeck Supérior.

In dialogue with patients

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