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.