Ethics in psychotherapy and counselling practice: the Indian scenario
Published online: February 2, 2018
Poornima Bhola and Ahalya Raguram, Editors, Ethical issues in counselling and psychotherapy practice: Walking the line. Singapore: Springer Science + Business Media; 2016. Rs 7860 (hardcover) Rs 7467 (Kindle). ISBN-10: 9811018065. Pp 247.
All counsellors and psychotherapists experience ethical concerns and challenges in their practice. This book comes at a time when there is a lacuna in the field with regard to discussion of cultural and local issues that present ethical challenges in the practice of psychotherapy and counselling in India.
The foreword by Dr Shyam Sundar sets the stage by linking psychotherapy practice in the modern day with human values and the ancient Indian tradition. He describes the sources and causes of ethical dilemmas in his inimitable style.
The editors, in the very first chapter, contextualise the foundations, determinants and basis of ethics in mental health. This chapter traces the philosophical positions in ethics and leads us toethical dilemmas in the therapy room. They review research from across the world and discuss codes of conduct and guidelines, briefly touching on the relationship of ethics and the law and on training issues in ethics and therapeutic practice.
The subsequent chapters cover a wide range of settings and clients – private practice, children seen in hospitals and schools, couples and family, intimate partner violence in sex work, survivors of sexual violence, LGBTQ clients, employee assistance programmes, and online therapy. The cultural universality and validity of ethics in therapeutic practice is discussed. Legal contexts and the interpretation of ethics are debated, too. The role of institutional ethical review boards in research in therapy and psychosocial interventions is also addressed. The exhaustive range of areas, settings, clients and situations covered is commendable. Some areas that could have been included are lay counselling, working with chronically/terminally ill individuals in medical settings; and supervision/regulatory mechanisms in the practice of counselling and psychotherapy.
Isaac traces challenges in the setting up and development of private practice from a practical viewpoint. She blends guidelines and recommendations with her experiences to suggest good practices for continued professional development. A practitioner’s perspective of ethics in child psychotherapy is provided by Bhaskaran and Seshadri who address basic principles like boundaries, autonomy and confidentiality. In addition, they address unique situations with children such as multiple therapists, communication with third parties, child custody disputes etc. Raman addresses working with children in the consultation liaison setting and highlights issues of documentation, physical setting, physician variables and end-of-life care in a hospital context. The perspective of counsellor ethics from the classroom is provided by David who traces the responsibilities of the counsellor to various stakeholders- students, school, parents and self. Sobhana, Saxena and Daimari highlight ethical concerns contextualised to the Indian couple and family therapy practice setting, with case illustrations.
Moving from the clinic and school setting, subsequent chapters look at ethical issues in other settings and populations. Iyengar examines challenges in working with women in sex work facing intimate partner violence (IPV). She traces the steps required to handle IPV and offers a multi sectoral model. Dilemmas in working with survivors of sexual violence faced by a feminist organisation are discussed by Kapoor and Baksi. They share, from an experiential perspective, strategies developed by the organisation and demonstrate resolution of conflicts, reconciliation of feminist principles and organisational ethics and handling complex legal, social and psychological considerations. Ranade and Chakravarty trace the ambivalence about homosexuality among mental health sciences historically in India. They discuss heteronormativity in counselling and the issues in working with clients who want to change their sexual orientation and the need for gay affirmative counselling practice.
In her chapter on employee assistance programmes (EAPs) and emergent ethical issues, Shinde uses case scenarios to highlight the balancing of individual client’s concerns vs organisational policy; contractual obligations vs needs of clients; and multiple aspects of the role of an EAP provider – conflicts of interest arising from dual or multiple relationships. Online client – therapist interactions and e-therapy are discussed by Gupta, Sinha and Bhola. They highlight the use of specific terminologies in the digital space, the fit between clients and e-therapy and factors influencing the fit. In addition to a personal account, the challenges of confidentiality and electronic security, professional boundaries are addressed with special emphasis on personal and institutional media policies with guidelines.
Raguram advances the position that ethical principles need to be viewed within the prism of sociocultural forces that shape and influence them rather than as universal concepts that are invariant. He discusses the principles of autonomy, beneficence and non-maleficence, justice in the context of social power dynamics and sociopolitical challenges. The need for therapy to take into account diversity of situations, discrimination and injustice and go beyond the individual’s psyche is strongly made. The legal perspective and its relationship with ethical issues are dealt with by Vinay, Lakshmi and Badamath with regard to the clinical practice of psychotherapy. Professional negligence, tests of liability, record keeping, patient access to records and boundaries are discussed. Srinath and Bhola bring our attention to the role of institutional ethical review boards in ethical research and psychosocial interventions. Informed consent, disclosure and deception, comparison groups, compensation for research participation, research with vulnerable subjects, therapist competence and treatment integrity, intellectual property, copyright and publication ethics are discussed in addition to international collaborative research and information technology and the internet.
All the authors are individuals with a great deal of experience in their areas which they bring to their writings. Across the chapters of the book, one observes that similar conflicts, challenges, issues and very particular concerns and dilemmas are brought up, addressed and illustrated by each author with their specific thought process and experience in each of their unique contexts. In addition, special circumstances and demands of every setting are highlighted.
The authors, across settings, chapters and perspectives, have walked the line of academic and theoretical foundations along with giving clinical and case examples and rich anecdotal details to help the reader understand experientially the ethical challenges faced with different clients. Kapoor and Baksi have described the case of the Mahato girls in which a mother of five girls presented seeking help in view of the husband’s sexual transgressions towards other women and the daughters. He was the only provider with no social support available. The authors discuss the case with details of assessment, attempts at management with safety plans, possible avenues for financial independence, and subsequent debate about institutionalisation of daughters for their safety. The ethical dilemmas of autonomy versus basic child rights to safety are deliberated. Raman illustrates her dilemma about maintaining confidentiality in the case of a 12-year-old boy who is not cooperative with a thrice weekly dialysis regimen in view of financial burden to the family resulting in basic needs going unmet. The child refused consent to disclose this information to parents or the treating team. She discusses the attempts in individual sessions to resolve the conflict by facilitating a family session.
Shinde illustrates the balancing act of staying true to one’s “counsellor ethics” when retained and paid by the Company as referrals to an employee assistance programme dramatically increase and all employees referred are found to have been openly critical of changes in the company. Gupta’s personal account of her discovery and use of technology in seeking supervision and providing psychotherapy allows the reader to experience, second hand, an area that many clients are demanding and counsellors and therapists are faced with and seeking to understand. Vinay et al bring to mind questions about legal obligations, negligence and liability that therapists have when they discuss X who is seen for psychotherapy, and difficulties with boundaries result in termination of therapy and the client’s subsequent suicide. Case vignettes have been used by almost all authors to illustrate challenges and ethical dilemmas experienced by them in practice. Most authors have also discussed how they resolved these challenges and dilemmas. The bookforces our thinking to go beyond the sometimes emotionally distant theoretical perspective of ethics that we learn and understand. It compels us to relate to, feel and empathise with the authors when they talk of situations and dilemmas that all practitioners of psychotherapy and counselling have experienced in some way.
The appendices included in the book list the various codes of ethics – professional, international and Indian, across specialties, with a summary of each code along with a citation for digital access. A sample informed consent form is included which serves as a template that practitioners can use. These are important resources that a reader can access as required.
This book provides a space for possible answers to ethical dilemmas, as most authors elucidate principles and factors that can help in critical thinking and decision making. In addition, it facilitates the crucial skill of reflecting, thinking and debating about these issues especially when there are no finite or clear-cut answers available. Ethical issues in counselling and psychotherapy practice: Walking the line is a must-read for all students and practitioners of mental healthcare.