ethical issues in private practice 3
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ETHICAL ISSUES IN PRIVATE PRACTICE
Introduction
The Authors of the Canadian Code of Conduct for
Psychologists (2000), explain the need for an ethical
code in the following manner:
“Every discipline that has relatively autonomous control
over its entry requirements, training, development of
knowledge, standards, methods, and practices does so only
within the context of a contract with the society in
which it functions. This social contract is based on
attitudes of mutual respect and trust, with society
granting support for the autonomy of a discipline in
exchange for a commitment by the discipline to do
everything it can to assure that its members act
ethically in conducting the affairs of the discipline
within society; in particular, a commitment to try to
assure that each member will place the welfare of the
society and individual members of that society above the
welfare of the discipline and its own members. By virtue
of this social contract, psychologists have a higher duty
of care to members of society than the general duty of
care that all members of society have to each other
(p1).”
What this means is, that when one chooses to be a
psychologist, one commits to ethical behaviour and
practice. Being ethical is more than following a set of
guidelines and getting signatures where appropriate, it
is a question of one’s personal and professional
identity. To be an ethical psychologist, one needs to
consider and consolidate one’s professional identity. As
students, we often derive our identity and standards from
the institution we are a part of. For many of us, it is
only when we step into private practice that we start
thinking about our professional identities. This is when
we start thinking about what kind of a person and what
kind of a psychologist we wish to be. This paper will
focus on the challenges and issues faced by such a
practitioner.
Through the paper, the word ‘therapy’ will be used to
describe all counseling, therapeutic and consultative
activities of the psychologist. The word ‘psychologist’
will be used to describe all professionals with adequate
training who see clients for psychological (counselling,
assessment, therapy, consultation) purposes.
If one looks at the contract between psychologists and
society, it seems aspirational; almost a political
stance, a dream of what a decent society comprises.
Within this framework, we need to live, work, negotiate
with clients and make our living. Private practitioners
face certain challenges due to their position in the
health services system. Some of these include:
1. No institutional back up: As mentioned previously,
the private practitioner needs to create his or her
own system of service delivery and ethical
framework. This includes documentation and to some
extent, determining one’s own competence.
2. Referral and liaison are not so easy: This makes
multidisciplinary work more complicated. However,
multidisciplinary work tends to be the norm and not
the exception in private practice as well. Therefore
developing a network of allied professionals,
including but not restricted to psychiatrists,
psychiatric social workers, child and education
specialists, medical doctors, lawyers and of course
others psychologists is recommended. Developing
protocols for documentation, confidentiality and
addressing ethical issues will be important.
3. The private practitioner typically works alone.
Opportunities for peer interaction are fewer, the
chance for biases to creep in are greater. The best
practitioner can sometimes get suck in a rut or a
single perspective. Reading, discussion and
supervision are essential to combat these problems.
A good relationship with peers ensures help and
support when you need it.
4. Less access to research and opinions: similarly, a
greater effort is required to keep abreast of
scientific knowledge and best practice as viewed by
peers. Subscribing to a journal, becoming the member
of a society, attending conferences and workshops
are some of the things you can do to create such
access.
5. Less/no access to test material/assessment: The
temptation to use test material that is not
completely ‘kosher’ is greater. One may use tests
off the Internet or tests that the teaching
institution had permission to use, but you do not.
You will need to select a few of the tests that meet
criteria for reliability, validity and culture
sensitivity and purchase them for use. If you are
using tests that you have not purchased, you need
permission to do so from the authors.
6. Setting appointments, collecting fees, setting fees
etc., usually need to be done personally. Handling
the “business end” of the relationship without
compromising on the therapeutic relationship is a
good skill to learn. Transparency, openness and
consistency in practice are ethical.
7. Contact information is more likely to be available
to clients: Some practitioners also practice out of
their own homes. This poses a challenge to
maintaining boundaries, and issues surrounding
emergency phone calls or visits are possible. Again,
clarity, consistency and firmness are important. You
will need to take the time out to explain to your
clients what your boundaries are and why it is
important to maintain them.
Ethical principles
Major psychological associations have developed ethical
codes to help guide the individual psychologist as to
what is to be done. The author has referred to codes
developed by the American, British, Canadian, Australian
and Indian Associations to identify common factors.
Subsequently, any reference to ‘the code’ is a reference
to the principles and standards found in these five
codes. Aspects of the codes that are pertinent for those
in private practice have been highlighted.
The specific guidelines and standards of each code are
based on the following general principles:
Respect for client rights/autonomy/individuality: This is particularly
relevant for individuals in a vulnerable position. This
means that we invariably have a higher ethical obligation
to clients than to employers/general public. Each
individual has the moral right to privacy, self-
determination, personal liberty, and natural justice and
human dignity. This includes cheating spouses, drug
addicted mothers and pregnant teenagers. Procedures for
informed consent, confidentiality, fair treatment, and
due process support these rights. Due process includes
the willingness to explain the basis for your
professional and ethical decision-making.
Responsible caring/beneficience/competence: This refers to
providing the best possible care for the client, and
rests heavily on training and keeping abreast with
literature, research and the current standards of the
discipline as a whole. Interaction with peers,
participation in continuing education and discussion
forums, and frequent supervision are key components.
Reflection and awareness of own biases and showing moral
behaviour as described by Rest are essential components
of competence. Clinical choices are ideally based on
adequate training, theoretical and research knowledge,
supervision, self-reflection and consideration of short,
medium and long term consequences.
Integrity/openness: A psychologist must be trustworthy. This
is a profession where there is some potential for good,
but great potential for harm. Accurately representing
your self, your qualifications, the possibilities and
limits of therapy and assessment are central to gaining
this trust. Being transparent about procedures and plans
can work very well and is often appreciated by clients.
If any data about your self or others is misrepresented,
one must make an effort to correct this as soon as
possible.
Above all, do no harm: this is a concept taken from the
Hippocratic oath, and involves a recognition that even
with the best of intentions, a psychologist may cause
some harm. Given an existing problem, it may be better
not to do something, or even to do nothing, than to risk
causing more harm than good. Further, psychotherapy may
not be the answer for everyone and some therapies have
documented deterioration rates of higher than 15%, and
can be considered potentially harmful (Lillienfield,
2007). This principle supersedes all others, and is more
important than respect, beneficence or integrity.
Psychologists can inadvertently harm clients by such
actions as: continuing therapy despite evidence of
failure, blaming the client for failure, taking credit
for success, etc.
Acting ethically may seem like an impossible mountain to
climb, given all our practical limitations of time and
resources. Deciding what is the right thing to do, may
seem unattainable when there exists so much debate about
what the ‘right’ thing is. All codes recognize this and
the APA asks for ‘reasonably’ sound judgements. They
qualify that “the term reasonable means the prevailing
professional judgment of psychologists engaged in similar
activities in similar circumstances, given the knowledge
the psychologist had or should have had at the time.”
(p2). As our knowledge base evolves, so too does the
standard of what is ethical practice. Remember, the use
of aversion therapy to ‘treat’ homosexuality, would at
one point in time been considered highly ethical!
We will now look at the process of therapy and consider
some of the specific issues that can come up:
Part I- Negotiating with the client
Setting up a Practice
There are many issues one needs to be clear on before
setting up a psychotherapy practice.
Qualifications- This is primarily a question of
competence. One needs to be aware of the kind of work one
is qualified to do. Given the varied nature of training,
with an overlap in the syllabus between an MA and an
MPhil (Misra and Rizvi, 2012); given the huge need for
therapy/counselling services and the dearth of trained
personnel (Murthy, 2011); the author recommends the
following:
consider the syllabus that has been covered during
training, in terms of diagnostic groups,
forms/schools of therapy, child or adult client
populations to determine what one ought to know.
consider areas of comfort or expertise created or
enhanced by of better supervision opportunities or
because of interest and better available reading
material
consider special areas of discomfort or poor
training. seek additional resources to address these
gaps if possible.
work together to organize continuing education
programmes to help address new issues (for e.g.,
road rage)/client groups (for e.g. children of
divorce )/diagnostic categories (for e.g. eating
disorders).
Affiliations- Being part of a professional body and
taking an active part in its activities, can offer both a
support system and a sounding board. A psychologist in
Bangalore could become a member of the Karnataka
Association of Clinical Psychologists, the Indian
Association of Clinical Psychologists, and the
Rehabilitation Council of India. Interdisciplinary
professional bodies (for e.g., Indian Association of
Social Psychiatry) allow for interaction with members of
allied professions as well.
Treatment set up- One needs to determine where one will
practice- from home, from a rented room, from a
polyclinic? The space needs to be secure and ensure
privacy both during the course of the session and after.
The décor needs to be kept as neutral as possible and not
reflect too much of the psychologist’s cultural
background and preferences. You never know what will
upset a client- it once took almost an entire session to
soothe an OCD client who was upset by religious markings
on the clinic door. If other staff is being employed,
either in secretarial or janitorial roles, their access
to records, sessions and clients needs to be clarified.
They would need to understand the necessity for
confidentiality and discretion.
Inadvertent self-disclosure- this refers to part of
themselves that the psychologist cannot help but reveal
to the client. It includes face, name, accent, body,
clothing, etc, which can reveal educational background
(how well do you speak English), socio-economic status,
community (quite often) and even attitudes or social
groups (Zur, 2011). This is even more obvious in a
private practice set up, because either the office in the
home (in which case clients even know about how many
children you have and whether you like dogs), or the
external office space, will talk about tastes, special
interests, finances etc.
Establish a procedure for contact and ensure that contact
information is easily available to clients. Having a
simple website that describes your qualifications, areas
of interest, fees, availability, address and contact
information is ideal. All information on the website or
in any form of advertising needs to be accurate and
updated when applicable. False advertising and tall
claims call the integrity of the professional and the
profession into question. Creating an unrealistically
high expectation on the part of clients can do them much
harm in the long run.
For those who do not have a website, a standard procedure
for contact is useful. If you are available on the phone,
you may wish specify timings when you will attend to
calls from new clients, or encourage a message as first
contact, to set up a phone call at an appropriate. It can
be very frustrating for clients to call repeatedly to try
and make contact with the psychologist. If this process
is drawn out, it enhances the power differential between
client and psychologist and will need to be addressed in
the intake session.
If the psychologist is unable to see a client, then they
need to help them access other psychological services,
through referral and liaison if required.
The intake
The first session is one of the most crucial sessions in
therapy. The therapeutic contract is created and rapport
is (usually) established in this session. The therapeutic
contract refers to an understanding between client and
psychologist as to what will occur in therapy, what will
be expected/desired from the client and what the
therapist can and cannot offer. The client needs to be
made aware of “what they are getting into”, in terms of
commitments of time and money, possibility of change and
potential harmful effects. Clients also need to be made
aware of alternate treatment options, both psychological
and non psychological. Their understanding of this
material forms the basis for informed consent.
It is difficult to decide what information needs to be
covered in this session. It is often only through
experience that we come to understand the kinds of issues
that can come up, which could have been prevented. The
following is a list comprises information that could be
covered. This list had evolved over ten years of practice
and derived from issues that have actually come up with
clients:
1. Education, qualifications and background: these need
to be conveyed in a manner that minimizes
possibilities of misinterpretation. For example, one
cannot cite membership of a professional body as a
qualification, or be vague about the nature of the
course(s) undertaken.
2. Duration of appointments. Especially if sessions may
occasionally extend further or end sooner than the
standard duration of one hour.
3. Frequency of sessions and rationale for increasing
or decreasing frequency. This is usually based on
client need and stage of therapy.
4. The process for scheduling appointments. A regular
slot, where the client can come at the same time and
same day every week is ideal. The client needs to be
clear about how to fix appointments and the amount
of flexibility in terms of time and days that may be
possible for the psychologist. If the psychologist
has a waitlist system, then this needs to be as
transparent and fair as possible.
5. The process of re-scheduling appointments. The
client needs to know what happens if they cannot
make it for an appointment. In some cases they may
need to wait for the next scheduled appointment and
in other they may be able to have a compensatory
session. They also need to know how to contact the
psychologist if they need to re-schedule.
6. If the psychologist is charging cancellation fees,
then clarify procedure for the same. This is usually
a fee that is charged for a last-minute (less than
24 hours) cancellation of a session. It may be the
full session amount or a percentage of the same. A
cancellation fee helps the client to take therapy
seriously and also protects the income of the
psychologist.
7. Availability on the phone and other forms of media
will also need to be clarified. Let the clients know
whether you will be able to take calls, at which
phone number and what times and for what purposes.
For example, you may clarify that clients can call
to re-schedule appointments, but not to discuss
treatment related issues. Be very clear in refusing
requests for ‘friendships’ on social or professional
networking sites and explain the rationale for the
same.
8. Duration of therapy: This is usually based on
experience and standard practice more than on manual
or RCT based recommendations (Goldfried and Wolfe,
1998). Each psychologist may also develop a style
of working and have a duration that is typical for
them. For example, the author typically finds that
ten to fifteen weekly sessions are usual, with a
small percentage of clients continuing on for long-
term therapy, and of course a small percentage
terminating earlier. Clients need to be informed
about the average or expected duration, as well as
systems of review of therapy to decide on future
directions.
9. Early termination or drop out: Clients need to be
informed that they can discontinue with therapy at
any time they wish to. It helps to discuss and
validate possible reasons for termination (health,
financial, move, therapy not helping). It is
important to give clients an understanding of what
they need to do if they wish to stop sessions, as
this reduces the likelihood of unexplained dropouts.
It is also necessary to let them know what to do if
they change their minds and wish to restart therapy.
Clarify specially about availability- will they need
to go back on the waitlist or will they be seen
immediately.
10. Description of therapy: clients may need to be
introduced to the idea of therapy. Describe their
role as active participants, whose motivation and
willingness to consider new ideas and try new things
is germane to the process of therapy. Describe the
psychologist’s role as that of being a guide and
facilitator, who has an expert knowledge of
psychology and therapy, and will use this knowledge
to help clients achieve their stated goals. Emphasis
on client’s versus therapist’s role and the
‘expertness’ of the therapist’s position will vary
between schools of therapy. You may need to explain
that you will only be able to clarify what you will
do to help the client after assessment is over, and
so leave that issue open in the intake session.
11. Documentation and confidentiality: Explain what
will be documented. Clarify that if the client
reveals information that they do not wish to have
documented, it is required for you to leave it out
of written records, unless it is central to the
understanding of the client and therapy-related
decisions. Even where it is that important, the
information will be retained in the most innocuous
form possible. For example, in recording client’s
history, they may talk about wrongdoing by a family
member that they do not wish recorded. If this
wrongdoing does not have a direct impact on the
issue (for example, my father was accused of bribery
and corruption by his employers, when I was ten
years old), it need not be recorded. If it does (…
and therefore he lost his job and we had to shift to
another city…), it can be recorded as- “Client moved
to B… when he was ten due to work difficulties faced
by his father.”
12. Multiple relationships: if it is discovered
during the course of the first session that the
client and psychologist know some people in common,
the psychologist needs to mention this and assure
them of confidentiality. At this point, the client
can choose to seek the help of another psychologist
if they so prefer. The psychologist can facilitate
this to minimize impact on the client.
13. Use of client data: if the psychologist intends
to use client data for teaching, supervision, or
other professional activities, they need to get
permission from the clients for this. If information
is going to be used in research or publication, it
may be better to get written permission for the
same. In this, the psychologist needs to be aware of
inherent power differentials between themselves and
the client and make every effort to ensure that the
client understands that this is completely their
choice and that refusing will not have an impact on
the therapeutic relationship.
Informed consent
Psychologists hold a tremendous amount of power and
influence over the clients who seek their help. They are
deified, respected, and sometimes obeyed without
question. This distance between mental health care
provider and recipient is reinforced by individual and
cultural factors.
Although the scenario in private practice is for more
equal relationships, with clients and psychologists often
coming from similar backgrounds, clients being better
informed and more aware of their rights, there is still a
great reluctance to challenge or question the
psychologist. This means that the psychologist will
usually have to be proactive in informing clients about
their rights and in encouraging them to exercise these
rights. The psychologist needs to be sensitive to a
client’s reluctance to ‘confront’ or ‘challenge’ their
authority and even interpret client’s non-verbal signals
of discomfort.
It is difficult to decide when information about fees,
likelihood of success, confidentiality etc should be
given. If provided right at the beginning of the session,
it may flood an unready client with too much information
and interfere with rapport creation. If left to the end
of the session, after the client has had a chance to
share their stories and emotions, the client may feel
less choice about accepting the terms and conditions of
therapy. They may also not be in a position to process
the information provided adequately. Thus, emotional
vulnerability coupled with respect or deference to
authority leave psychotherapy clients particularly
dependent.
One means of addressing this dilemma, is to have a
written informed consent form. A written form has the
advantages of clarity and completeness, and also gives
clients time to reflect on what they are agreeing to. The
act of signing a form may help them to see this as a
mutual contract and increase client sense of
responsibility and involvement in therapy. However, some
clients may find it inimical to the process of
establishing a relationship and may prefer an oral
contract. This choice also depends on what the
psychologist is comfortable with. If consent is taken
orally, then the psychologist has an ethical obligation
to document what was discussed and consented to.
The ethical obligation that one has in this context is to
make sure that clients are aware of treatment options and
their rationale and are able to make treatment choices
that are in accordance with their worldview and desires.
Bearhs and Gutheil (2001) recommend an oral discussion of
the relevant points and suggest that any written form
should comprise a checklist of the information provided,
that the client could go through and sign. This process
may take more than one session, and it is useful to cover
the basic material again in the second session.
Subsequently, such issues can be discussed as and when
they come up during the course of the treatment. They
also recommend that the informed consent form can include
commitments made by the clients during therapy. For
example, a commitment not to abuse substances or wives
during the course of treatment. Finally, they warn that
even with written forms, one must get verbal consent for
fresh issues as they come up. See appendix A for a sample
informed consent form, that follows this model.
If the psychologist is attempting a non-standard
treatment, if alternate and less expensive/shorter
duration treatments are available, if there is potential
for harm (documented in research and evaluated through
clinical experience), then there is an even greater
burden on the psychologist to inform about alternate
treatments, different approaches to therapy and the known
benefits and limitations of the same. In such situations,
it is useful to encourage clients to get further
information for themselves and even a second opinion
before they make their choice (Bearhs and Gutheil, 2001).
Therapists are also advised to share uncertainty at the
outset, which can be an important component of the
informed consent process. There are many questions the
psychologist may not be able to answer: “Will I get
better? Are you sure this will work? Should I risk
increasing conflict with my partner at home, in order to
bring him into therapy?” A psychologist who is willing
to share uncertainty and empathize with the needs behind
the clients questions, who is honest and open about the
limits of scientific knowledge and own limits, while
conveying strong support- can leave a client feeling
empowered and ready to “embark on a journey together”.
This wonderful opportunity can be ruined with a more
defensive response “of course therapy works, and I am
using the best school and the best techniques for you”
The psychologist needs to take extra care with fully
dependant or more vulnerable individuals and explain
their rights and safeguard them to the extent possible.
The psychologist is more responsible to the dependant
person than an independent one (all codes). Where the
client is not in a position to give consent, one can
consult with family members, the ethics code and the laws
to make decisions about care and take precautions against
causing harm.
Finally, please note that informed consent without
responsible caring is not adequately ethical behaviour
(the code). The informed consent process and form should
not be used to protect the psychologist or excuse their
negligent behaviour.
Setting fees
The code recommends setting fees that are “fair in light
of the time, energy, and knowledge of the psychologist
and any associates or employees, and in light of the
market value of the product or service.” The client needs
to be informed of fees and mode of collection of fees in
the first session itself. The psychologist should be
careful not to take advantage of the trust or dependency
of the client to force services on them (for example- in
recommending an assessment or further sessions of
therapy).
Further, if services will be limited, because finances
are limited, this also needs to be discussed with the
client. For clients who cannot afford therapy, the
psychologist can refer to another center that charges
less, offer client a sliding scale or even accept
services as barter! However, once a client has been taken
on, it is unethical to discontinue needed services
because of financial issues. In this situation, a
psychologist needs to do their best to hand over client
to a suitable service that they can afford.
Third party payments
The issue of ‘who is the client’ or ‘whose needs the
therapy should address’ is particularly relevant when
parents are paying for sessions for their (legally) adult
children. Parents or spouses may wish the psychologist to
“make him realize…” or “make her stop…” something. This
is not just a question of protecting the client from the
expectations of others, but ensuring that their best
interests remains paramount. Here are some things that
can be done:
1. Discuss the validity of the external expectation
with the client. Not all expectations are
harmful/negative. Perhaps the client also wants to
make similar changes in themselves.
2. If the client feels that the expectation is unfair,
but is disempowered to negotiate with their family
member, help them learn how they can do this. If
they need extra support, you can offer them session
time to facilitate this conversation.
3. Be empathetic with the family member and try to
understand why they wish for a particular change.
4. If the family member requires psychoeducation to
understand the limits and potential of the client,
it is the duty of the psychologist to try and
provide this information.
5. Do not negotiate on behalf of the client, but
empower them to negotiate for themselves.
6. Refer for family therapy if issues seem very
intractable.
Where the client is psychotic, this can further
complicate issues. Psychoeducation for family members
(which is an essential component of good practice) often
occurs without the clients’ knowledge, as the client may
not have developed insight into their condition. In a
situation like this, respect for client rights seriously
interferes with their getting the required treatment. In
such a situation, the psychologist will need to explain
and address consent as soon as the client is capable of
understanding the situation.
In situations where there may be more than one client, or
one primary client and significant other(s), it is better
to have all of them come in on the first session, or meet
the primary client first. Meeting an informant first can
often bias the agenda of therapy. For example, if the
psychologist spends an hour hearing about the concerns
and fears of a mother over her teenaged son’s at risk
behaviour, they may be more inclined to limit setting
rather than building autonomy, regardless of what the
client’s primary need is.
Dual/multiple relationships
Multiple relationships are defined as those where the
psychologist owes an allegiance to several different
stakeholders. Or, where the psychologist plays more than
one role in the client’s life. The British code also
warns that conflicts of interest and inequity of power
may continue even after the professional relationship is
terminated. So if the psychologist engages in such a
relationship, their professional responsibilities still
apply.
Broadly, all codes warn against such relationships, when
they are likely to interfere with the therapeutic
process. However, multiple relationships that would not
be reasonably expected to cause harm can be entered into.
While multiple relationships that are obvious at the
beginning of therapy can be addressed more easily, some
may arise mid-therapy. For example, the author once faced
a situation where during the course of couples therapy,
where one partner had had an affair, it emerged that the
affair partner was a previous client. The psychologist
needs to take what steps are required to bring these to
the notice of the client and address their concerns.
In private practice, one form of multiple relationships
was encountered several times, which it was not easy to
find literature on. This happens when former or current
clients refer friends or relatives to the same
psychologist. Keeping boundaries between the former
client and the current one can be hard. The psychologist
may hear about problems or issues to do with the former
client, about which they have ‘inside information’ as it
were. In such situations one needs to carefully examine
whether evaluations and decisions are being influenced by
this extra knowledge. It can happen that the former
client in question may need booster sessions or to
restart therapy themselves. Even more complicated
situations arise when the two clients are in conflict
with each other, as often happens in post divorce
counselling. In such situations one must clarify the
rules of confidentiality and clearly establish goals of
therapy. An open discussion with the clients about their
feelings and concerns towards the multiple relationships
can go a long way to having both clients feel respected.
Referrals from friends and family members, who wish to
‘stay informed’ about what is going on also require
careful handling. Clarifying rules of confidentiality at
the time of referral itself is essential.
Can you refuse a client?
It is unethical to refuse a client on an arbitrary or
discriminatory basis. Time constraints, inadequate
competence to deal with an issue and harmful multiple
relationships are valid reasons to refuse to see a
client. However, in this situation, a psychologist needs
to do his or her best to ensure that someone else sees
the client.
Sometimes, at the end of the initial session, a
psychologist may feel that therapy would be potentially
harmful at the time, with no balancing benefits. The pros
and cons of therapy can be discussed and alternate means
suggested if required. This is a question of clinical
judgement and I do not know of any criteria that will
help one make this choice. I have heard from client-
report that they found such a stance a huge relief and
even empowering, when it was accompanied by empathic
listening, a thorough understanding of the situation and
a supportive stance.
Confidentiality
As a matter of principle, clients need to be able to
access information about the therapy that they are
undergoing. While this usually does not include session
notes and tentative hypotheses; discussing theoretical
frameworks, therapeutic techniques, goals and plans is
usually empowering and therapeutic for clients. If you
wish to contact other members of their treating team or
family, the reasons for this need to be discussed with
the client, and their permission taken for the same.
Patil, Nayak, Bhogale and Chate (2011) list the following
situations where confidentiality can be breached:
a) To ensure the best treatment, therapist will at times
discuss the case with his/her colleagues or supervisor,
keeping the identity of the client confidential.
b) If the client communicates threat of bodily injury to
self or to another the information would be disclosed to
the family members and the legal authorities.
c) When there is reasonable suspicion of child abuse or
abuse to a dependent adult has occurred, or is likely to
occur.
d) If ordered by a court of law, the details of the
treatment will be revealed to that court.
e) In case of the couple and family therapy, the
therapist should mention “if you tell me a secret, you
are asking me to help you disclose it, which I will
assist you in doing”. “I maintain the right to disclose
confidential information to other participants in the
family or couple if I feel it is in the best interest of
the family or couple to do so. You have equal rights to
release information to outside parties but I will
withhold it unless it is in your best interest”.
f) Therapist will disclose the information to a third
person or agency, if patient gives in written to release
the information
g) If the patient files a case in the court against the
therapist then the patients loses his privilege of
confidentiality”
Some of the important situations where there are grey
zones include confidentiality issues in case of minors,
when the parents are having conflictual relationship or
are undergoing the divorce proceedings; confidentiality
in case the client is dead and confidentiality issues in
case of marital or family therapy. In such situations it
is always better to discuss such issues in the informed
consent procedure and should be incorporated into the
therapeutic contract. However, in more complex
situations, the code suggests that the therapist and the
client can seek opinion of the colleagues and lawyers
before finalizing the contract.
Termination
Sometimes clients may wish to discontinue therapy before
the psychologist feels that they are ready to do so.
Respect the right of persons to discontinue therapy at
any time, and be responsive to non-verbal indications of
a desire to discontinue if a person has difficulty with
verbally communicating such a desire (e.g., young
children, verbally disabled persons) or, due to culture,
is unlikely to communicate such a desire orally.
Psychologists are also advised to terminate professional
services when clients do not appear to be deriving
benefit and are unlikely to do so. If the psychologist
feels that they have made their best efforts with reading
and supervision and are unable to help the client. It is
best to refer to someone else or discuss termination.
When doing this, it is important not to convey to the
client that they are a ‘hopeless case’ or that the
psychologist has given up on them. Finally, never
terminate without a plan in place for further contact as
and when required.
Psychologist unavailability
The psychologist may sometimes become unavailable to the
client during the course of therapy. This could be due to
anticipated or unanticipated events in the psychologist’s
life. However, they retain responsibility for client
care. In such a situation the following are recommended:
If it can be anticipated (for instance, pregnancy,
moving to another city), the psychologist needs to
inform clients in advance so they can both plan how
to respond.
If the client is moving on to another psychologist,
one must do whatever possible to make the transition
smooth. Having a joint session with the new
psychologist can be very useful in this regard. The
psychologist needs to remain available to the client
until they are comfortable with their new
psychologist.
If the psychologist is experiencing burnout or other
psychological issues, they need to get appropriate
help for themselves.
The psychologist should practice self-care
activities that help avoid such situations from
arising.
Assessments
There are several issues to consider when conducting
psychological assessments. Some of the primary ones are:
1. When to conduct the assessment- The assessment
should add to treatment planning or benefit the
client in a clearly definable way. The simplest way
to put it is to that you only conduct and assessment
if you are able to frame to yourself and the client
that what the benefit will be:
For example- “Doing this IQ test will help me to
understand that potential range and limits of your
capabilities. This will help us to narrow down the
career possibilities in front of you” or “Doing this
personality assessment will help me crystallize the
areas that may require further intervention. We can
discuss the results and decide if you wish to take
on any of these areas as goals for yourself.”
2. Which tests to use- make sure that the norms are
relevant and the test is up to date. The test should
be proven to have good reliability and validity. It
should be in the language that the client is
comfortable with. It should be contextually and
culturally relevant. Please note this does not mean
that any tool with an Indian author is automatically
more relevant than a tool of foreign origin. Where
certainty of results on the test are open to
question (because of reliability, validity or
unavailability of relevant norms), this needs to be
documented in the report.
3. Use only tests that you have purchased and have the
rights to use or tests available in the public
domain. Use tests where one has access to the manual
to help with scoring and interpretation.
4. As a psychologist, it is not enough for you to know
how to administer the test, but one also needs to be
thorough on know theoretical background of the test,
how it was developed and how reliable and valid it
is. Therefore, it is important to use only tests
that one has been trained to use.
5. Particularly with testing, the psychologist needs to
evaluate if the additional information will harm or
help a client- do you really need to know that your
IQ is 81?
6. Personality tests and projective techniques need to
be used with adequate discussion and acknowledgment
of results as hypotheses rather than conclusions.
The psychologist needs to develop the ability to use
information from such tests to provide a clear plan
of action. There is no point in informing the client
that they probably have issues in their relationship
with their father if there is no plan to address it
in therapy.
7. A written report should only include that
information that the psychologist can be sure about,
based on accepted/reasonable interpretation of test
data. It is crucial to differentiate fact from
opinion and speculation.
8. Informed consent on assessment includes an
explanation of the nature and purpose of the
assessment, fees, involvement of third parties and
limits of confidentiality and sufficient opportunity
for the client/patient to ask questions and receive
answers.
9. Raw data from tests can be released on client
request (unless the psychologist feels that release
of data will cause harm); or as required by law.
10. One cannot get an unqualified junior to
administer the test. Unless psychological assessment
was part of the qualifying course and the particular
test to be used has been covered under that course-
one is not qualified to conduct that assessment.
While juniors/interns can help with scoring, the
final interpretation and report has to be written by
the psychologist.
The ethical psychologist ought to use the above standards
to determine which tests one can validly use. However,
many tests that are considered obsolete in the west are
still used here and are a part of standard practice
(Misra and Rizvi, 2012). This raises serious questions
about the ethics of psychological assessment as typically
conducted in India (Isaac, 2009).
Part II- Negotiating with the self
Boundaries
The boundary in question is the boundary between the
personal and the professional- how does one keep this
intensely personal relationship professional? The
distinction between gratification derived from being a
good therapist and personal gratification, is a useful
one in creating this boundary. Personal gratification can
include: ego boosting/soothing/distraction from your
worries/meeting intimacy needs. Clients are often willing
to meet these needs- either as part of their
personalities or as part of negotiating the therapeutic
relationship. Cocooned within the perfect and completely
private world of you therapy room, it is hard to remember
these seemingly obvious things. I often get asked “how
are you, how are the kids/you look tired/are you getting
enough sleep etc- and it is extremely tempting to share
my trials and tribulations with someone who will care…I
need to keep reminding myself that I am the one
collecting fees and not the client!
Touch- is a ethical grey area and more likely to be
influenced by theoretical orientation than an ethics
code. Humanistic and relationship therapies recognize
that not all boundary violations are counter-therapeutic
or harmful to the client. Joshi et al (2010), found that
most therapists are comfortable with touch, and it is
rated as therapeutic particularly by female therapists.
While touching a member of the opposite gender may still
cross cultural boundaries, using minimal touch with same
gender clients seems a part of good practice in India.
They also found that younger therapists use touch more
indiscriminately, suggesting that experience teaches us
when and how much touch is effective.
Sometimes situations may arise that offer the chance to
do something ‘extra’ for a client. While stepping out of
one’s comfort zone can be very rewarding, it is not
always so. The author found that a daily sms reminder or
wake up call, helped a client who was living alone to
establish her daily routine, and contributed to her
recovery from depression. A sms saying happy birthday to
a client who felt alone, while leading to positive
immediate effects on her mood…may not have addressed her
low self esteem and wariness about social contact! The
author suggests that if one is planning to do something
extra, think about which treatment goals it will help
achieve and not about what may feel good for the
psychologist or the client.
Stepping out of physical boundaries can be something as
small as opening a door for a client with a baby, or
offering a tissue to a crying client. In general, while
brief/small violations for the benefit of the client are
now seen as acceptable, progressively larger violations
are an issue. Describing the slippery slope towards a
serious boundary violation, Simon (1992) lists several
warning signs to watch out for; of which two will be
described:
Relative therapist neutrality to outcomes- The
psychologist should not express personal views (for
example: there is nothing as wonderful as having
children) and should not make choices for clients, but
does need to advise/monitor on the process of decision
making (for example, while one does not directly tell a
client that they should or should not separate from their
spouses, one can recommend that big decisions are not
made under extreme emotion).
Foster psychological separateness- It is important to
actively encourage the client to explore means of
managing without therapy, and keep a strict eye on goals
of therapy and progress towards said goals. Such
monitoring will help retain a therapeutic focus. This is
particularly important with long term clients, where both
therapist and client can settle into an easy familiarity
that neither questions.
Self Disclosure:
Zur (2011) decribes four types of self disclosure:
Deliberate- This may be through things the therapist
says, or specific objects like family photographs. These
can be self-revealing (telling about self) or self-
involving (discussing own reactions to client and session
occurrences). Self-involving processes are more likely to
be useful that self revealing processes.
Unavoidable- This had been partially described under
therapy setting. At a more subtle level, one can also
reveal oneself by the kind of questions asked or the
aspect of the problem that is emphasised.
Accidental- unplanned meeting outside the office, or
unplanned revelation of reactions. This is also self-
disclosure that is hard to avoid. It is important to
discuss such incidents with the client and not try to
brush one’s awkwardness under the carpet.
Clients actions- Clients may feel the need to know about
the therapist. They may google, explore through social
media or ask a direct question. According to Roberts
(2012), clients consistently rate self disclosure
positively/as useful and
may feel put off by refusal to answer any questions.
Therapists’ stories can help clients feel that they are
not all alone or not all bad and form a very supportive
and personal connection.
However, self-disclosure can very easily become self-
gratifying. Roberts (2012) lists situations where it is
more likely to be harmful:
When the client feels that they need to care for the
therapist
When the therapist has not fully resolved their own
emotions about what they are revealing, it can be
difficult to stay in emotional control and keep the
focus on the client.
When an expectation of how the client should react
(laughter, sympathy, agreement) is also
communicated.
When it derails the conversation, rather than
deepening it.
When it involves a very strongly expressed opinion
(Roberts, 2012).
Prejudice
Our prejudices are a part of us. Once we have moved on
from the beginner therapist stage, it is tempting to feel
that we are above such obvious errors. Sometimes, new
views and prejudices can creep in based on new life
experiences and as such, require constant monitoring. The
ethical therapist should identify their personal biases
(gender, community, caste, region, religion) and both
acknowledge them and work on them. They should also
differentiate between fact and opinion, as well as
identify the source of information- research/accepted
opinion/clinical experience.
Openness
The values of openness and straightforwardness exist
within the context of Respect for the Dignity of Persons
and Responsible Caring. As such, there will be
circumstances in which openness and straightforwardness
will need to be tempered. Full disclosure might not be
needed or desired by clients and in some circumstances,
might be a risk to their dignity or well-being, or
considered culturally inappropriate. In such
circumstances, however, psychologists have a
responsibility to ensure that their decision not to be
fully open or straightforward is justified by higher-
order values and does not invalidate any informed consent
procedures.
Competence
All the codes emphasise that one should not do anything
one not trained for/not qualified for. That a
psychologist can only use only those forms of treatment
they have received training in, for clients they are
qualified to see. The psychologist must use adequate
safeguards if it’s a new area of work (for eg- more
frequent supervision sessions, and try not to use methods
that are non standard, unless there is compelling
evidence for their effectiveness. This seems pretty
straightforward, but it is also a fairly tall order for
the typical Indian private practitioner. In a survey of
250 psychologists across the country, lack of competence
was listed as the single biggest limitation, experienced
by 41% of the sample (Bhola, Kumaria and Orlinsky, 2012).
The issue here, is that it is hard to decide what exactly
one is qualified to do. The training system in India
typically offers some insights into all the major schools
of therapy, without a very in-depth training in any one
school. We don’t usually have access to treatment
manuals- can one say they are doing DBT when they have
not done Linnehan’s course? What if one does not even
have the manual? Should one then refuse to see client who
require DBT?
And if one does refuse to see such clients, who will? The
APA code says that if there is no qualified person to see
a client, the next best or closest in qualification may
do so, as long as they commit to training themselves as
much as possible. But what does that actually translate
into here?
Another issue is that there is often debate within the
scientific community as well about how to choose a
treatment and what type of data represents the “Truth”
(Castelnuovo, 2010) as exemplified by the debate between
effectiveness and efficacy research. This raises the
question: is a common factors, effectiveness,
relationship based flexible model of psychotherapy
research more relevant or is it only an RCT that is
scientifically valid? While research tends to examine
pure therapies, in practice, cross modality therapy is
the norm (with as many as 95% of psychologists in Bhola’s
study reporting this). Even where therapists felt
confident of their competence, they rarely mentioned the
use of modality specific techniques. The kind of
treatments that each psychologist will choose or see as
ethical will likely depend on their worldview as well. So
how does one determine what is the best treatment choice
or what is true competence?
Finally- the reality is that treatment choice is not
something we do in isolation, but something done in
discussion with the client, taking into account their
beliefs, needs, psychological readiness and response to
interventions. CBT may be the most scientifically valid
treatment for depression, but the author has had clients
specifically requesting not to do that. Most private
practitioners use an integrated model (Goldfried and
Wolfe, 1998) each psychologist is likely to have their
unique method of doing this integration and no two
therapies are alike. In this situation, one must be very
sensitive to client responses and feedback to make
choices between schools of therapy and techniques.
The author recommends the following simple ways of
addressing competence issues:
1. Try to do case based reading- from classic textbooks
as well as currently available online information
(google scholar, pubmed, pbs).
2. Always have a supervisor/someone you respect who you
can discuss cases with (this can be a formal
arrangement where you pay for supervision or an
informal arrangement, where a group of psychologists
meet).
3. Always have a therapy plan and frequently review
4. Examine yourself for problems, prejudices etc.
5. Keep session notes and keep time for reflection on
them.
6. Listen to feedback from your client
7. Be willing to accept when you are out of your depth-
examine whether your desire to refer is a competence
issue or a transference issue.
8. Refer to other disciplines where necessary-for
instance do not start sex therapy without a review
by a medical doctor.
9. Become a member of a society, attend conferences and
CMEs, talk to colleagues and find out what standard
practice is. Be willing to share about your
practice.
Part III- Negotiating with the profession
What to do when you hear something bad about another
psychologist?
This is a tricky situation, where the needs of the
profession and ones personal relationships and power
struggles need to be balanced. The following are
recommended actions:
To bring concerns about possible unethical actions
by a psychologist directly to the psychologist when
the action appears to be primarily a lack of
sensitivity, knowledge, or experience, and attempt
to reach an agreement on the issue and, if needed,
on the appropriate action to be taken.
To bring concerns about possible unethical actions
of a more serious nature (e.g., actions that have
caused or could cause serious harm, or actions that
are considered misconduct in the jurisdiction) to
the person(s) or body(ies) best suited to
investigating the situation and to stopping or
offsetting the harm. This could be the KACP, IACP or
RCI.
To consider seriously others’ concerns about one’s
own possibly unethical actions and attempt to reach
an agreement on the issue and, if needed, take
appropriate action.
In bringing or in responding to concerns about
possible unethical actions, not to be vexatious or
malicious, and not reveal information that is not
conclusive evidence.
Personal behaviour becomes a concern of the
discipline only if it is of such a nature that it
undermines public trust in the discipline as a whole
or if it raises questions about the psychologist’s
ability to carry out appropriately his/her
responsibilities as a psychologist. (Canadian code)
Be careful not to relay information about other
professionals except as required or justified by
law.
Don’t act on impulse, and think about getting a body
of evidence before confronting the colleague.
All codes emphasise a responsibility to safeguard to
profession by being concerned about the ethical
conduct of colleagues, but it is very important to
examine your own motives before you comment on a
colleague, and do it with sensitivity and focus on
the ethical issue, rather than the person involved.
There should be no condemnation of colleagues who
have been through an ethical enquiry, but then
exonerated. One should not spread rumours based on
hearsay- even with qualifiers.
When Principles Conflict
All four principles are to be taken into account and
balanced in ethical decision making. However, there are
circumstances in which ethical principles will conflict
and it will not be possible to give each principle equal
weight. The complexity of ethical conflicts precludes a
firm ordering of the principles. However, the four
principles have been ordered according to the weight each
generally should be given when they conflict, namely:
Above all, do no harm
Principle I: Respect for the Dignity of Persons. This
principle, with its emphasis on moral rights, generally
should be given the highest weight, except in
circumstances in which there is a clear and imminent
danger to the physical safety of any person. Please note
that harm is defined as physical harm and not
psychological harm- ie the assumption is that a person
must be free to choose psychological harm for themselves.
For instance, if a client wishes to confront the person
who abused them the psychologist needs to support them,
even with misgivings about the possible psychological
impact of the same. Such misgivings of course, do need to
be aired in the session.
Principle II: Responsible Caring. This principle
generally should be given the second highest weight.
Responsible caring requires competence and should be
carried out only in ways that respect the dignity of
persons.
Principle III: Integrity in Relationships. This principle
generally should be given the third highest weight.
Psychologists are expected to demonstrate the highest
integrity in all of their relationships. However, in rare
circumstances, values such as openness and
straightforwardness might need to be subordinated to the
values contained in the Principles of Respect for the
Dignity of Persons and Responsible Caring.
Principle IV: Responsibility to Society. This principle
generally should be given the lowest weight of the four
principles when it conflicts with one or more of them.
Although it is necessary and important to consider
responsibility to society in every ethical decision,
adherence to this principle must be subject to and guided
by Respect for the Dignity of Persons, Responsible
Caring, and Integrity in Relationships. When a person’s
welfare appears to conflict with benefits to society, it
is often possible to find ways of working for the benefit
of society that do not violate respect and responsible
caring for the person. However, if this is not possible,
the dignity and well-being of a person should not be
sacrificed to a vision of the greater good of society,
and greater weight must be given to respect and
responsible caring for the person.
If the psychologist can demonstrate that every reasonable
effort was made to apply the ethical principles of the
Code and resolution of the conflict has had to depend on
the personal conscience of the psychologist, such a
psychologist would be deemed to have followed the Code.
Ethical dilemmas and decision-making
The process of ethical decision-making will be
demonstrated, using a case vignette. This represents a
fairly simple issue, which one hopes all psychologists
will be able to relate to.
The couple first came for sessions after they had decided
to separate. The wife was looking for reconciliation
while the husband was looking for closure. When it became
clear that there was no chance of reconciliation, the
psychologist introduced concept and goals of divorce
therapy. They decided to continue with individual
sessions, and come back to separation related issues when
they felt ready.
After a month of individual sessions, they both stopped
therapy for the next four months or so, while they
explored and worked on their current life tasks. The wife
went abroad. When she came back, she wanted to come for a
series of joint sessions with the husband to negotiate
finances and custody. Husband was less keen on the joint
sessions, as he felt he had lost trust in the wife. He
then restarted individual sessions to decide what to do,
and the psychologist was promoting the notion of conjoint
sessions with both of them.
Husband then contacted psychologist and referred his
sister who had been abroad till now, but had got divorced
and had come back to the parental home. The psychologist
agreed without considering the implications.
The sister came in for an intake session. She talked
freely and related the story of her marriage and divorce.
She also said she wasn’t sure if she needed therapy or
not, and so no therapeutic contract was established.
Further contact was left open-ended at her discretion.
A few days later the wife contacted the psychologist –
saying she heard I was seeing the sister. She felt that
this would represent a serious boundary issue, as many of
the discussions between husband and wife on visitation,
now included the impact of the sister and her family on
their child and therefore visitation. She wished the
psychologist to terminate contact with the sister, until
their negotiations were over!
The following describes the steps of ethical decision
making:
a. Who were the stakeholders and what did the
psychologist owe each of them? How would the
decision impact them in the short and long term?
Client 1: The wife
1. What was client 1’s motivation in making this
request? Was it a genuine concern or an attempt to
control sessions?
2. Would seeing the sister-in-law have an impact on
neutrality as to visitation. After some reflection,
the psychologist was reluctantly forced to agree
that it would. Therefore, the effectiveness of the
divorce therapy would be reduced by also seeing the
sister at the same time.
3. However, her refusal to accept sister in law,
increased husbands feelings of frustration with her
and may make it more difficult for them to
negotiate.
Client 2: The husband
4. It could damage his relationship with his family, if
the offer to start therapy (his agenda for his
sister) was suddenly withdrawn.
5. However, it could hamper his chances of getting the
visitation he desperately wanted, if the wife now
saw him as unsupportive to her needs, and insisting
on sister continuing with therapy.
6. The psychologist felt morally obligated to him, as
she had agreed to see his sister when he made the
request. her!
The child
In divorce therapy, the therapist has an obligation
to protect the rights and interests of any children
involved.
How would the child be served by my decisions?
Client 3: the sister
7. It was unclear what she was owed by the
psychologist, as she had had an intake session, but
had not agreed to be a client.
b. Consulting the code:
one needs to consider those aspects of the code that may
be relevant, and explore actions in terms of implications
on each of the relevant principles.
Above all do no harm
Consider who stood to be harmed?
Would declining to have further sessions with client 3
mean that she doesn’t get the therapy that she really
needed?
Would agreeing to wife’s demands break rapport/neutrality
with the husband and therefore cause harm to the couple
as well as the child in question?
Would refusing wife’s request damage my
rapport/neutrality with her and therefore cause harm to
the couple as well as the child in question?
Beneficence
What would help achieve the goals of divorce therapy- ie
the smooth transition to a single state?
What did I owe client 3?
This was clearly a situation where there were multiple
relationships that were potentially harmful.
I needed to terminate one of the contacts for sure. The
question was- which one(s)? Who was most likely to be
harmed and who was least likely to be harmed?
c. Identify clients’ rights?
Concepts of openness and integrity indicate that whatever
the outcome, the situation needs to be explained to the
clients involved. Respect for client’s autonomy indicates
that they be involved also in the decision making
process.
d. Consider personal factors that may have contributed?
The psychologist’s instant response to the wife’s need
suggests the possibility that psychologist was taking too
much personal responsibility for her welfare. The
psychologist reflected and recognized a sense of pressure
to “come through for her”. There was also a need to be
liked by both of them, and perhaps the psychologist was
over-compensating for the fact that it was easier to work
with the husband.
The psychologist then explored more objectively whether
her stance also had some reasonable backing from ideas of
effective and ethical therapy. Going through the codes
helped identify that multiple relationships were the
issue. Also, the most vulnerable individual in this
context, was the child, and so the first responsibility
was to protect the child.
e. Consider alternate courses of action and their
consequences:
Do nothing and hope it goes away- this could work, except
if client 3 did choose to come back for therapy, and
the psychologist had to make the choice at that
point, it would likely damage her and greatly damage
couple’s chance of a meaningful resolution; thereby
also negatively affecting the child.
Stick to the original decision of seeing the sister as well- this would
mean dealing with the multiple relationship. It may
reduce client 1’s trust in therapy, and potentially
lead to a breakdown. The psychologist did not feel
it was worth sacrificing an ongoing therapy that had
already come a long way, for the sake of a new
client. Even if she wished to continue with therapy,
she would find it easier to establish a relationship
with someone else. This would not serve the needs of
client 1. Client 2 or their child, towards whom was
the primary responsibility.
Agree to terminate contact/withdraw potential contact from client 3-
this could harm client 3 as discussed. Responding to
Client 1’s request would empower her and help her
negotiate from a position of strength rather than
fear. It was more uncertain what the impact would be
on Client 2. The psychologist evaluated that his
long term goal was to resolve impasse with wife, and
that this was a more important agenda for him than
helping his sister.
f. Consider evidence from research /literature or peer
viewpoints
These were not actively elicited, primarily due to lack
of time and resources.
g. Make a choice and take responsibility for it
The psychologist decided to withdraw from contact with client 3, and make
special efforts to address needs and feelings of client 2.
h. Implement the choice:
1. The psychologist communicated to client 1 that her
concerns were valid and acknowledged. The potential
negative consequences of agreeing to her request were
discussed, particularly in terms of damage to chance of
negotiation. Having ensured that she understood risks
involved and was genuinely concerned about losing
therapist neutrality, the psychologist was able to
respect her choice and the risk that she wished to take.
2. The psychologist then spoke with client 2 and took
complete responsibility for the situation and explained
what one ought to have done. The psychologist emphasized
that wife was not being obstructive for the sake of it
and that multiple relations could indeed create problems.
He was reassured of the psychologists’ support and offer
was made to find an alternative psychologist for the
sister and communicate with the new therapist about what
had happened; to minimize negative impact.
While he was not very pleased, he was also more focused
on negotiations with wife.
3. Client 3 was sent an email to see if she wished to
continue with therapy. While it is not standard procedure
to contact clients who have come in just for one session
and follow up on their plans, the psychologist deemed
that it was important to be open with her, and not leave
it to be sorted out within the family.
She has not responded to date.
i. Documentation of the dilemma and resolution
The psychologist created this document and added to the
session notes
j. Follow up and evaluation of outcome
The couple did come in for sessions and have been fairly
successful in coming to a mutual agreement.
k. Preventive steps
Firstly, the psychologist reconsidered her boundaries and
the balance between the personal and the professional. As
a therapist who identified better with
humanistic/feminist models of therapy and who believes
that the relationship is more core to the therapeutic
process than technique per se; there is a greater
responsibility to consider boundary issues and not take
responsibility for things that should rightly be the
client’s responsibility (eg- how much responsibility does
the psychologist have towards husband’s relationship with
his family?) and to ensure that that one acts to meet the
client’s needs and not one’s own.
Secondly, whenever a new client is referred, particularly
by an older client…the psychologist spends time
considering whether a similar situation could arise. The
specifics about multiple relationships and refusing
clients that were presented earlier arose largely out of
this experience.
Finally, there was a renewed commitment to using session
notes more actively for reflection and not just for
recording.
Larger level issues this raised:
What exactly do we owe a client who has come in for one
session of therapy, but not decided on whether they
should continue?
For how long after such contact does our ethical
obligation to them continue?
Was the psychologist making a big deal out of nothing?
Would that have been less damaging to just leave the
issue alone?
What do different forms of contact imply, and when is it
appropriate to use which? When is a phone call better
than an email, and when should one use an sms?
References:
American Psychological Association. Ethical principles of
psychologists and code of conduct. American Psychologist.
2002; 57: 1060-73.
Anderson, SK and Handelsman MM (2010) Ethics for
Psychotherapists and Counselors: A Proactive Approach.
John Wiley & Sons, New York.
apa code www.apa.org › Ethics Office
Avasthi, A. (2011). Indianizing psychiatry - Is there a
case enough? Indian Journal of Psychiatry, 53, 111-120.
Beahrs, JO and Gutheil, TG (2001) Informed Consent in
Psychotherapy. American Journal of Psychiatry, 158:4-10.
Bhola, P; Kumaria S and Orlinsky DE. (2012): Looking
within: Self-perceived professional strengths and
limitations of psychotherapists in India, Asia Pacific
Castelnuovo G. (2010) Empirically Supported Treatments in
Psychotherapy: Towards an Evidence-Based or Evidence-
Biased Psychology in Clinical Settings? Frontiers in
Psychology. 1: 27.
code of ethics and conduct. guidance published by the
ethics committee of the British psychological society.
2009, Leicester.
www.bps.org.uk/system/files/.../code_of_ethics_and_conduc
t.pdf
De Sousa (2010) Ethical issues in child and adolescent
psychotherapy: A clinical review. Indian Journal of
Medical Ethics Vol VII No 3.
Goldfried, M.R. and Wolfe, B.E. (1998). Toward a more
clinically valid approach to therapy
Gupta SC. (1993) Code of Conduct. (Adopted by IACP,
circulated to its members). Lucknow: IACP Secretariat.
Isaac, R. (2009) Ethics in the practice of clinical
psychology. Indian Journal of Medical Ethics, Vol VI, 69-
74.
Janine Roberts (2012). Think before you get personal.
Psychotherapy networker. retrieved on 3/11/13 from
www.psychotherapynetworker.org/magazine/currentissue/item
/1741-therapist-self-disclosure
Journal of Counselling and Psychotherapy,
DOI:10.1080/21507686.2012.703957
Lilienfeld S.O. (2007) Psychological Treatments That
Cause Harm. Perspectives on Psychological Science. Vol. 2
no. 1: 53-70.
Murthy RS. (2011) Mental health initiatives in India
(1947–2010) National Medical Journal India, 24:98–107.
Nanasaheb M. Patil, Raghavendra B. Nayak, Govind S.
Bhogale, and Sameeran S. Chate (2011) Dilemmas in Private
Psychiatric Practice Indian Journal of Psychological
Medicine, 33(2), 149–152.
Rajendra K. Misra and Sabeen H. Rizvi (2012) Clinical
Psychology in India: A Meta-analytic Review.
International Journal of Psychological Studies; Vol. 4,
No. 4; 2012
research. Journal of Consulting and Clinical Psychology,
66, 143-150.
Simon, RI (1992). Treatment Boundary Violations:
Clinical, Ethical, and Legal Considerations. Journal of
the American Academy of Psychiatry Law 20:3:269-288
Widiger TA and Rorer LG.(1984) The responsible
psychotherapist. American Psychologist. 39: 503-15.
Zur, O. (2011). Gifts in Psychotherapy. Retrieved 3/11/13
from http://www.zurinstitute.com/giftsintherapy.html.
Zur, O. (2011). Self-disclosure and transparency in
psychotherapy and counselling: To disclose or not to
disclose, this is the question. Retrieved 20/11/13 from
http://www.zurinstitute.com/selfdisclosure1.html
Appendix
Informed consent form
The following topics have been discussed adequately with
me:
The nature and process of therapy/counselling,
including potential risks and benefits and estimated
duration of contact.
My role and what I can expect from my
therapist/counsellor.
The goals we could work towards.
Treatment options that are available to me and their
pros and cons.
Details about fees, scheduling and cancelling
appointments, and Dr/Mr/Ms…….’s availability and
contact procedure.
The confidentiality I can expect (with verbal
information and psychologist’s records) and limits
to the same.
My right to terminate treatment if I wish to, and my
right to withdraw consent.
I agree to the terms discussed and further, commit to the
following during the course of therapy/counselling:
1. ………………………………………………………………………………………………………
2. ………………………………………………………………………………………………………...
…………………………………………
Name and Signature
This form was developed by the author, based on the various codes of
conduct as well as scientific literature. It is ideal for adult individual
psychotherapy. Please note that child/adolescent therapy and couples
therapy will require additional areas to be addressed. Any informed consent
form will need to be printed on the letterhead of the psychologist. The form
can to be modified to add items if you find that certain issues come up
frequently in your setting, and therefore feel a need to be more explicit about
them. However, I would not recommend deletion of any of the items.