Ethical Issues in Indian Mental Health Practice
Have you ever heard the saying in schools and colleges that “rules are meant to be broken”? As students, some of us took that idea seriously, but then life happened, and it felt like following the rules became the best option. But is that really the case? I haven't officially started my practice journey yet, but I have had the opportunity to observe and learn as an understudy.
In psychological terms, an understudy is "someone who learns the duties of another therapist so they can serve as a substitute." During therapy sessions, we sit in as observers primarily to notice the therapist's body language and to understand how these sessions work with different clients.
Among all “ethics” that are supposed to be followed in a therapeutic setting/relationship. I will list out a few important ones in order to lay down a base level understanding, on what kinds of dilemmas can occur with these. From the American Counseling Association here is a brief list:
The Counseling Relationship
Confidentiality, Privileged Communication, and Privacy Section
Professional Responsibility
Relationships with Other
Professionals
Evaluation, Assessment, and Interpretation
Supervision, Training, and Teaching
Research and Publication
What exactly are these dilemmas, you may ask? What constitutes right or wrong in the field of psychology and mental health? Many of us assume that strictly adhering to the rulebook is sufficient. However, there is undoubtedly some grey area that we need to navigate in order to learn and explore more effectively. For instance, let’s consider the dilemmas faced by current and aspiring mental health professionals
Privacy and Confidentiality
Trust is a fundamental aspect of psychotherapy, commonly referred to as a therapy session. However, there are certain situations where we must navigate the concept of trust without compromising its essence. For instance, during my sessions, it is important to maintain confidentiality while addressing the complexities of the therapeutic relationship.
A research study conducted in India examined issues related to privacy and confidentiality in hospital settings. The findings revealed that crowded environments raise significant concerns about patient confidentiality. When multiple individuals are seated in a small room, it can create discomfort for those trying to share personal issues during sessions. Additionally, it becomes challenging to prevent others from overhearing these discussions, which presents a considerable challenge for many trainee therapists.
This situation is particularly problematic in the Indian context, as the concept of "privacy" is often viewed as a Western notion. Upholding this concept can lead to confusion and dilemmas for therapists. For example, if a therapist learns that a client is considering self-harm, they may feel conflicted about disclosing this information to the client's parents without the client’s consent. However, if there is an imminent threat to the client’s safety, it raises the question of how the therapist should respond.
Client-Therapist Relationship
This is an ethical issue that I have always found confusing, especially in a context like India, where gift-giving is a common and cherished practice. This custom conflicts with the principle of maintaining a formal relationship with clients. How should we navigate this situation? The APA guidelines from 2010 instruct therapists to refrain from accepting gifts from clients. However, wouldn't this approach hurt the clients' feelings and values on a personal level? It is certainly something worth reconsidering.
Different individuals may have varying levels of familiarity with the therapy process. Regardless of their experience, many clients view their therapist as a primary support person at all times. This perception can complicate situations involving gift-giving. When clients give gifts, it can reinforce the idea that they can contact their therapist anytime, regardless of the context or urgency of their needs. In emergency situations, it is essential for therapists to communicate emergency contact information to their clients beforehand. This way, clients can access the urgent help they need. Accepting or declining gifts can lead to challenges in the therapeutic relationship, so therapists must navigate this issue carefully. What is the best approach for them in these circumstances?
Cultural Dilemmas
Despite the widespread awareness of the concept of therapy in this country, there remains a significant gap between the number of people who want to seek therapy and those who actually do. Many individuals hesitate to pursue therapy due to concerns about being “negatively labeled” or falling into a stigmatized category. Even when a client decides to seek therapy, therapists often face the challenge of how to communicate the stigma surrounding the client’s condition to their family, a common issue experienced by many therapists in India.
Family support can be crucial in these situations. Therefore, therapists—especially those practicing in India—should be mindful of various cultural values and norms, which can be quite complex. Rather than disclosing all of the client's issues to their family, therapists might consider engaging the family in "family counseling." This approach allows the therapist to have one-on-one conversations with family members, such as parents, and gradually introduce psychoeducation based on their understanding of family dynamics. While this method sounds feasible in theory, the practical implementation often raises questions about its effectiveness.
The two main challenges therapists face are not only addressing the social dilemmas surrounding therapy but also ensuring they maintain the client’s confidentiality and privacy.
In the end, I would like to conclude that I do agree that I do not have the plethora of knowledge in this subject, as I am starting as well. But if this post does reach someone who is in a much higher position than me, and did encounter similar challenging situations, would love to hear your view on this topic. So in the end, I will leave you with one question that kept running in my puzzled mind. Is it still not acceptable if we as future psychologists/therapists bend these ethics and rules according to the situation?
