Was I supposed to avoid it? How do I avoid questions related to personal life? One of the other prominent concerns of the trainees wasconfidentiality The dilemmas were related to the disclosure of certain information about clients to their family members or the legal authorities and the uncertainty regarding the limits of confidentiality. This was compounded by the possibly negative impact on the therapeutic alliance or possible legal requirements.
Download this article as a PDF. We note several reasons why there is a need to gather more information prior to determining the appropriate ethical response. Identify and resolve or eliminate factors that might interfere with identified solutions, including reimbursement issues and misconceptions that patients may hold about treatment Through regular self-assessment and by following a valid process, physicians may consistently and accurately evaluate dilemmas in medical ethics and make ethically sound decisions that lead to optimal outcomes for their patients. The participants were told that they would be participating in research on memory and learning, and they consented to take part based on that knowledge. National Center for Biotechnology Information , U. Bangladesh Journal of Bioethics [Internet].
The process of disclosure was fraught with uncertainty. A subset of trainees 8. While some felt that the workload and time pressure in the training course were impairing the quality of their work with clients, others mentioned barriers stemming from their personal values, beliefs, emotions or lack of knowledge or skill in working with specific client groups or problem areas, eg gender identity disorder, extramarital relationships or intimate partner violence.
Around 8. For example, one therapist had ethical misgivings about using a particular strategic therapy technique:. Can I keep the client unaware that I expect this escalation or even that the worsening is partly planned either before or after it has happened? The trainee therapists 5. The sixth category included two different ethical conundrums that emerged during the therapeutic process. I certainly did not wish to talk about it with my supervisor on the case for the fear that it would get my friend into trouble. I also wondered what I would have done in this situation had the therapist not been a friend.
The trainee therapists experienced a range of difficult emotions when confronted with ethical dilemmas, and reported feeling pressured by a sense of responsibility, discomfort, anxiety, fear, panic, shock and irritation. The feelings of doubt and uncertainty were experienced across a range of ethical dilemmas, but were most prominently associated with the issues of competence and the appropriateness of disclosing information about oneself. The trainees reported feeling shocked when faced with unexpected ethical issues, e. The results indicate that there was no fixed pattern of emotional response to situations; the trainees responded differently to similar ethical dilemmas.
This highlights the role of individual differences and the importance of the interpretation of events.
The small sample size makes it difficult to contextualise the diverse emotional experiences of the trainees. The analysis examined the frequency of the methods used by the trainees in their attempt to resolve their ethical dilemma, apart from the more private process of self-questioning and reflection Table 2. The availability, accessibility and support of the supervisor were considered useful by the majority of the trainees who attempted to resolve their ethical quandary by this method. She helped me to delineate my personal values from what is professionally possible in these circumstances.
There were mixed perceptions of the utility of professional codes in ethically disturbing situations. About one-third of the respondents A large proportion of respondents Many expanded on the lack of responsiveness of the guidelines to the uniqueness or contextual aspects of each therapeutic situation. A few felt that adherence to rigid professional codes was in conflict with the value of humaneness required for relating to and working with clients.
One trainee elaborated on the lack of specificity and clarity:. Ethical regulations given by foreign professional bodies are not culturally appropriate. Another method of resolution was to involve clients in the ethical debate.
A small proportion of trainees 8. A much less common approach 2.
Previous international research with practising therapists 15 , 24 found that confidentiality and the negotiation of the boundaries of the relationship with clients were the most problematic domains. The findings of the present study showed a similar trend. While the trainee therapists were aware of their obligation in this respect, uncertainty regarding disclosure arose when their clients confided about past behaviours which contravened the law, or which related to sexual or physical abuse.
The trainees also expressed a sense of conflict when it came to confidentiality in the treatment of minors, which is an area where there are no clear answers.
The perspectives of the law, clinical practice and ethics intersect, and need to be negotiated, discussed and revisited in the process of therapy Perhaps these cultural realities lead to uncertainty among trainees, even though the professional ethics codes are quite clear on the need to keep information about the client confidential. This study has identified a range of key areas for training in confidentiality.
There have been diverse perspectives on the sanctity and interpretation of boundaries in the therapeutic relationship. All boundary crossings, eg extending the duration of sessions and self-disclosures, may not be harmful but there is the danger of sliding down a slippery slope towards a clear boundary violation, such as sexual misconduct Are we to consider boundaries as borders or fences?
A recent commentary 27 discussed how boundaries may be viewed differently in the Indian culture.
For example, personal enquiries about the therapist might reflect typical patterns of social discourse. What then are the appropriate professional distance and emotional boundaries? De Sousa 27 outlines the need for novice therapists to be sensitive to these cultural variations and guard against too rigid or formal an approach.
It could also make clients vulnerable to exploitative relationships that transgress boundaries. While the approach of ethical relativism respects diversity, it cannot entirely circumvent or transform the ethical guidelines formulated for the profession. Self-awareness, monitoring and discussions with the supervisor could help trainees sort out the complex questions relating to culture and ethical practice. Issues such as accepting gifts and self-disclosure are not specifically addressed in most professional ethics codes for therapists and counsellors. These grey areas would be open to individual interpretation and trainee therapists would benefit from guided discussions and reading related professional literature 30 , The findings of this study have implications for training in the ethical decision-making process for psychotherapists and counsellors.
Tyron 33 proposed that ethical violations can be addressed by reviewing the training frameworks and evolving a range of experiential and participative methodologies. While Tyron 33 recommends that all trainees be given a copy of the professional ethical standards and sign to mark their commitment to ethical practice, this in itself would be incomplete.
The larger question is how trainees will learn to critically examine the codes, reflect on the ambiguities in certain areas and translate their knowledge into practice.
The integration of ethical issues across the curriculum, peer discussions in small groups and training in the ethical decision-making process 34 would strengthen training in this area. Select responses of the trainees in this study point to the need to discuss contextual variables that have an impact on the perceptions and interpretations of ethical codes.
Supervision is an important crucible for trainee therapists in the process of learning professional skills and developing their professional identity. The findings of this study confirmed the importance of guidance from an approachable supervisor when a trainee is confronted by ethical questions.
The supervisory space must prioritise and legitimise the discussion of ethical issues that inevitably arise during therapeutic work. The early phase of professional development is the opportune time to inculcate sensitivity to ethical issues; an ethical watchfulness 36 that anticipates and addresses emergent dilemmas. As for the reporting of ethical violations by a colleague, the revised code lacks specific directions and the mechanism of accountability is still not well defined in the Indian context. This method could be used to plan revisions of professional codes so that they cover the prominent dilemmas experienced by trainees and practitioners in India.
The findings of this study represent a preliminary exploration of the ethical dilemmas faced by emerging therapy practitioners. The small sample size, the purposive sampling method restricted to a single institution, and the fact that a single ethical dilemma was probed are some of the limitations of this research. There is no information on the characteristics that distinguish the group of responders from those who did not access or respond to the questionnaire.
This exploratory study gives us a few insights into the perspectives of clinical psychology trainees on the salient ethical dilemmas faced in the therapy room. The results may be considered signposts and could be used to identify the primary areas in which the strengthening of training in ethical paradigms and practice is required. Conflict of interest: The authors have no conflict of interest to declare. Toggle navigation Indian Journal of Medical Ethics.
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Email this article. Email the author. Post a Comment. The study had a cross-sectional research design and used qualitative methodology. Sample The potential sample included all 67 trainees enrolled in the MPhil or PhD programme in Clinical Psychology at a tertiary care government hospital for mental health and neurosciences in India. Measures A brief survey schedule was developed for the study. Figure 1: Survey questions.
Figure 2: Procedure of the study. Analysis Content analysis 22 of the responses was used to identify key themes or categories with respect to the main ethical dilemmas and methods of resolution. Results The ethical dilemmas encountered by the 35 trainees in the context of therapy were coded into six categories Table 1. Funding support: There was no funding support for the study. References Kidder, R.
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