Safeguarding Client and Counselor
Ethical dilemmas in psychotherapy in India
cornerstone of practice
Counseling and psychotherapy* are growing professions in India. Once confined to hospitals or private practice settings, counseling has made its way into several other spaces (educational institutions, communities, workplaces, NGOs), including communication media (telephone, online chat, email). While such expansion promises easier access, it also raises concerns.
By its very nature, counseling deals with narratives of distress and vulnerability. The entire edifice of the profession depends upon therapists’ ability to create an environment of safety, confidentiality and trust. In such a scenario, ethics and ethical guidelines play a central role. Meara et al. list six basic principles of ethical practice: autonomy (self-determination); nonmaleficence (avoiding doing harm); beneficence (doing good and promoting client well-being); justice (fair and just treatment); fidelity (making realistic commitments and keeping promises); and veracity (truthfulness and honesty). Ethical dilemmas may be understood as “problems for which no choice seems completely satisfactory, since there are good, but contradictory reasons to take conflicting and incompatible courses of action”. Here the counselor must choose between two values or principles.
*Despite the debated difference between the two, the terms counseling and psychotherapy have been used interchangeably in this article.
A major ethical dilemma, commonly faced by counsellors, may arise around confidentiality. Clients divulge information about their current and past situations, as well as their opinions and innermost feelings, to the counselor. The guarantee of complete confidentiality facilitates these articulations. However, therapists may be required to breach confidentiality in certain circumstances – as when they are learning under supervision, or working as part of a team comprising multiple professionals. Besides, all ethical codes mandate counselors to breach confidentiality when it seems clients might harm themselves and/or others (suicide, child sexual abuse, substance abuse, homicide). Counselors need to be aware of laws such as The Protection of Children from Sexual Offences (POCSO) Act that make the reporting of violations mandatory, and also of the debates around mandatory reporting in order to ascertain their own position.
In India, given the collectivist nature of families and communities, and the interdependence among members, therapists are often expected to divulge information shared by the client. Families in India tend to be hierarchically organized (on the basis of social locations such as age, gender, caste, class, etc), with certain members wielding power over others. Members who demand confidential information may control the client’s very access to therapy. The therapist may be resented, as a stranger whom the client is willing to trust with private and intimate information to which family members are not being made privy. Complications can also arise when the therapist has two or more members of a family as clients (as individuals, or in couple or family therapy). Issues of confidentiality may get further complicated when the client is a minor. Counselors must keep in mind that many Indian laws deny persons “of unsound mind” full legal capacity in several areas of life, including contracting, political life, holding a job, voting, etc. Sections of family law deny agency to individuals diagnosed with mental illness when it comes to marrying, staying married, adopting, inheriting, child-bearing or terminating a pregnancy, etc. In several reported cases, mental illness diagnoses or client records have been used by family members or significant others to deprive individuals of their rights (Aaina, 2004). Thus, the counselor needs to take all possible steps to ensure client confidentiality and rights.
Closely related to the issue of confidentiality is that of client autonomy, or the right to selfdetermination – making their own informed decisions. In the case of minors and even with older individuals, the family may insist on making the decisions, both about life choices and medical or therapeutic treatment. Counselors need to make efforts to maximize client autonomy, while remaining mindful of potential conflicts.
The second dilemma pertains to boundaries in therapeutic relationships. Considering both client vulnerabilities and the power hierarchy implicit in the counseling relationship, boundaries become necessary. Therapeutic boundary may be thought of as an invisible line that separates the therapeutic relationship from social, familial, sexual, business, and other relationships. A boundary violation occurs when a therapist misuses their power to exploit or harm a client.6 Therapists must obviously refrain from any action that involves emotional, financial, or sexual exploitation.
A boundary crossing, on the other hand, is a deviation from the strictest professional role, and is harder to pin down. Given their limited awareness about the counseling process, clients might engage in boundary crossing – asking for friends or family members to be seen as clients, inviting counselors for social functions, or to the client’s home for a personal or professional visit, offering food and/ or gifts, sending friend requests on social media, etc. Considering the collectivist nature of Indian society, notions of the autonomous self and the boundaried relationship can seem alien, even offensive, making the maintaining of strict boundaries extremely challenging for therapists. While boundary crossing may often be initiated by clients, it could also be in exercises and conversations that help them to be aware of their own values and the sources of these values, and to be mindful of choosing when to engage clients in value discussions. ‘Socially aware psychology’, for which there is a growing demand, urges that psychologists and counselors be connected to values of non-violence, equality, diversity and social justice. ethical competence and awareness of client rights
The field of counseling and psychotherapy is expanding to new horizons. Today, the use of technology is posing new ethical challenges (confidentiality and electronic security; boundary management with respect to time, payments, and crisis handling) of which counsellors need to be aware. There is also need to increase awareness among counselors of the interface between ethics and laws such as POCSO, The Protection of Women from Domestic Violence (PWDVA) Act, marriage laws, the Mental Health Care Act, the Section 377 verdict which decriminalized same sex relationships between consenting adults. Despite its importance, the ethics training received by counselors in a matter of therapeutic intervention at the counselor’s discretion – using means such as self-disclosure, meeting the client in social situations (to end, for instance, isolation experienced due to marginalized and stigmatized identities based on sexuality or gender, or to participate in their growth process, or to appreciate their achievements), offering financial support to needy clients, engaging in non-sexual touch to convey empathy, etc. Dual/multiple relationships in which the counsellor assumes two or more roles at the same time or sequentially with a client, become unavoidable in many situations in a co-existing society like ours. Regardless of the therapeutic decision, therapists need to be motivated by clients’ needs and of the possible advantages and harms caused by this overlap or crossing.
“The entire edifice of the profession depends upon therapists’ ability to create an environment of safety, confidentiality, and trust.”
Counselors must practice within the bounds of their competence, and be forthcoming with clients about their limitations. Hence, the third ethical dilemma pertains to counselor competence – is of great concern in a country like India. Given regulatory and licensing confusions, the question of “who can practice as a counselor?” becomes pertinent. Answers require a clear laying down of required qualifications and competencies. In the absence of such clarity, there is a danger of clients approaching counselors who may lack the necessary training, skills, and experience. At the same time, in a resource-poor country like India which experiences a vast treatment gap, it is important to acknowledge the need for different cadres of mental health professionals and the roles each can play, and to define the competencies each requires. This would highlight the plurality needed in the mental health service sector, while setting minimum standards for quality practice.
The fourth ethical dilemma revolves around the role of values— beliefs and attitudes that provide direction to everyday living , in counseling process. Counseling is often portrayed as a value-neutral process. There is, however, enough research to show that counseling is not value-neutral. It is now generally recognized that all therapists, to some degree, communicate their own values to their clients. At times, these values could clash with those of the client, or with existing norms. The counselors’ self is the primary instrument of healing in the counseling relationship. This makes it imperative for counselors to engage in exercises and conversations that help them to be aware of their own values and the sources of these values, and to be mindful of choosing when to engage clients in value discussions. ‘Socially aware psychology’, for which there is a growing demand, urges that psychologists and counselors be connected to values of non-violence, equality, diversity and social justice.
ethical competence and awareness of client rights
The field of counseling and psychotherapy is expanding to new horizons. Today, the use of technology is posing new ethical challenges (confidentiality and electronic security; boundary management with respect to time, payments, and crisis handling) of which counsellors need to be aware. There is also need to increase awareness among counselors of the interface between ethics and laws such as POCSO, The Protection of Women from Domestic Violence (PWDVA) Act, marriage laws, the Mental Health Care Act, the Section 377 verdict which decriminalized same sex relationships between consenting adults. Despite its importance, the ethics training received by counselors in India is often patchy, even absent in some cases. Coupled with clients’ poor awareness about the counseling process and of their own rights, this may lead to rights violations or exploitation. Ethical awareness is a continuous process. Psychology and counseling curricula not only need to acquaint counselors with various ethical codes, dilemmas and their resolution, but also help counselors translate some of the ethical principles that have originated mainly in Western contexts into their clients’ sociocultural contexts. Client (or user-survivor) voices are conspicuous by their absence within the larger field of mental health in India. Client voices should be encouraged, and must inform counseling education and practice. Concerted efforts are needed to increase awareness among clients about the counseling process, and about their own rights. An important step towards protecting client rights is to seek informed consent. Clients should be encouraged to ask questions about different aspects of the process. The counselor ought also to seek regular feedback from the client, to gauge whether the therapeutic process matches client goals and expectations. This would help in holding counselors accountable in their practice, and also in improving the quality of practice. Feminists remind us of the need to share power with clients to create more equal relationships. Counselors must find ways of sharing dilemmas with their clients and involving them in the decisionmaking process whenever deemed appropriate. This would create greater transparency within the counseling relationship, and help empower the client. ¤