Research Article - Clinical Schizophrenia & Related Psychoses ( 2022) Volume 16, Issue 2
A Comparative Account on Ethical Considerations in Practice of Clinical PsychologyNamood-E-Sahar1, Shakir Hussain2, Ali Ibrahim Noshili3*, Sayed Shahbal4*, Amal Mohammad Hamdi5, Amna Khan4, Hussam Yahia Hakami6, Atif Mohammed Saad Alsaed7, Azah Alotaibi8, Ali Aali Alharbi9, Abdulraheem Mulfi Almutairy10, Majed Hamdan Albeshri11, Nariman Nouh6, Nadyah Farhan Alshakarah12 and Turki Ali Haloash13
2Department of Psychology and Human Development, Karakorum International University, Gilgit-Baltistan, Pakistan
3Department of Infection Prevention and Control, Alhurath General Hospital, Jazan, KSA
4Department of Psychology, International Islamic University, Islamabad, Pakistan
5Department of Nursing, Abha Maternity and Children Hospital (AMCH), Asir, KSA
6Ministry of Health, Taif, KSA
7Ministry of Higher Education, Umm Al-Qura University, Mecca, KSA
8Department of Nursing, Mental Health Nursing, King Saud University, Riyadh, KSA
9Jeddah Psychiatric Hospital, Jeddah, KSA
10Erada and Mental Health Complex, Mental Services, Jeddah, KSA
11Makkah Health Cluster, Makkah, KSA
12Department of Nursing, King Saud University Medical City, Riyadh, KSA
13Department of Nursing Education, Khamis Mushait General Hospital, Khamis Mushait, KSA
Ali Ibrahim Noshili, Department of Infection Prevention and Control, Alhurath General Hospital, Jazan, KSA, Email: firstname.lastname@example.org Sayed Shahbal, Department of Psychology, International Islamic University, Islamabad, Pakistan, Email: syedshahabal@gmail.Com
Received: 16-May-2022, Manuscript No. CSRP-22-63902; Editor assigned: 18-May-2022, Pre QC No. CSRP-22-63902 (PQ); Reviewed: 01-Jun-2022, QC No. CSRP-22-63902; Revised: 08-Jun-0222, Manuscript No. CSRP-22-63902 (R); Published: 17-Jun-2022, DOI: 10.3371/CSRP.SNSH.061722
Background: Practice in the clinical psychology is knitted closely to the trust and rapport building with the client. This trust is supported by the set of ethical considerations being proposed by the APA Ethical Code. It helps to build trust among the clients and to ensure the efficacy of the clinical treatment. In Pakistan there are no officially recognized ethical standards or the organization to ensure the adherence of ethics for clinical psychologists. However, in Saudi Arabia there is e Saudi Commission for Health Specialties (SCHS) for this task. But both of the Muslim countries lack Indigenous perspective in this regard which has brought many challenges and issues with application of ethical concerns during clinical psychology practices.
Methods and Findings: The purpose of the study was to explore issues in application of ethical standard in Pakistan from an Indigenous perspective and present a comparative account of it with the concerns regarding practice of ethics in Saudi Arabia. Objective is accomplished through in-depth semi-structured interviews with clinical psychologists (N=7). Findings highlighted the absence of licensing, lack of training, and proper monitoring for clinical psychology practicing. Also, the participants provide recommendations for addressing the challenges associated with ethical concerns during clinical psychology’s practice. Results were then discussed considering Saudi literature to make a comparative account.
Conclusion: The findings demonstrated significance of indigenously exploring ethical related concerns in practice of clinical psychology for both Pakistan and Saudi Arabia. It is apprehended to help in devising the ethical standards in clinical psychology practices for both Muslim countries.
APA ethical code • Challenges • Clinical psychology • Ethical consideration • Issues
Guiding principles serve as the foundation for ethical norms. Within the subject of psychology, these recommendations establish practical rules and directions for appropriate conduct in various circumstances majorly the clinical practices. These rules cover general principles that all professional psychologists must follow . Professional ethics must be applied in a variety of settings to ensure that clients receive high-quality psychological treatments . Although all professional ethics are the same, diverse cultural environments translate them differently . Professionalism and ethics are culturally defined concepts or a set of characteristics and actions. The application of ethical principles for clinical professional must account for cultural beliefs and customs [4,5]. There is a need to raise ethical consciousness in specific cultures which involves the ability to recognize and resolve ethical issues in a variety of scenarios and cultural settings. A culture thus may frame clinical ethics in terms of how they should be applied . However, western medical professional frameworks may not resonate with Pakistani [7,8] and Arab cultural norms  because of indigenously varying perspective. The present study thus attempted to explore the indigenous nature of ethical concerns in Pakistan and discuss them with literature from Saudi Arabia to make a comparative account.
Materials and Methods
The research design for present study was descriptive in nature. It is a systematic way of data collection and detailed description of the topic of researcher’s interest such that, information from one participant do not influence that from another one .
Sample comprised of seven clinical psychologists from various government and private clinical setups. The purposive sampling technique was used to approach the sample. The inclusion criterion for the sample was such that the psychologist has an experience in the field of clinical psychology.
The guideline for semi-structured interviews was devised with the help of literature review. Basic questions underlying the guideline were about the status of ethical concerns in the practice of clinical psychology at Pakistan, reasons underlying the challenges which prevail, and the recommendations for addressing those challenges. The clinical psychologists were approached and briefed about the objectives of the study. The interviews were conducted at the time appropriate for the clinical psychologists and the consent for recording of interview was also taken from them. They were ensured about the confidentiality and anonymity of the information provided by them. All the clinical psychologists were also thanked at the end of interview for their time. The information obtained was categorized into respective themes and categories through thematic analysis. The results were discussed in the light of literature from Saudi Arabia. The main aim was to make comparative account of ethical concerns related challenges faced by the clinical psychologists in Pakistan and Saudi Arabia.
The data obtained was broadly classified into two themes. The themes and respective categories are mentioned as follows (Table 1):
|Status of ethical concern at clinical psychology practice||Nonprofessional attitude of the referring authority|
|Lack of awareness about psychotherapy|
|Irrespective attitude towards client|
|Unnecessary long clinical sessions|
|Minimal training of clinical psychologists|
|Absence of proper licensing and governing body|
|Suggestions on improvement of ethical application||Establishment of licensing and governing body|
|Standardization of clinical practice and ethical application|
|Registration of mental health organizations|
|Improve privacy during the sessions|
|Proper monitoring of clinical practices|
|Conduct research and surveys|
Status of ethical concern at clinical practice
The status of ethical concerns during clinical practices has both a positive and negative side. The clinical psychologist mentioned that in some hospitals there is a system of assigning code to the clients instead of extensive files and documents. The same code is used whenever the case is required to be referred to another professional. Also, there are some clinics in which the clinical sessions are properly monitored and supervised by the supervisors and the psychologist is held accountable for any unethical practice. In the words of psychologist: “If something out of the professional boundaries happen, the authorities take notice of that.” Also, the clients’ complaints are effectively addressed. However, the negative side was also highlighted and is summarized below.
Nonprofessional attitude of the referring authority: The clients are usually referred to a psychologist by a psychiatrist. The majority of the cases are not appropriate to be addressed by psychologists for example clients with knee pain or with breathing issues are also referred for psychotherapy. This depicts a very nonprofessional attitude and the psychiatrist who is referring should carefully listen to the problems and issues mentioned by the clients before recommending the psychotherapy. The psychologist mentioned it as: “The authorities don’t even listen carefully to an individual’s problem before referring them to psychologist.”
Lack of awareness about psychotherapy: Also, there exists a lack of awareness about psychotherapy among the masses due to which its significance and application also is neglected by the clients. The clinical psychologist mentioned that a number of clients are not willing to understand and listen about psychotherapy. However, psychotherapy is of great significance in clinical practice and the decision for giving psychotherapy should be made by psychologist as per the requirement for specific client, as said: “Psychotherapy is not for everyone.”
Privacy violation: The clinical psychologist highlighted that in foreign countries the case histories and data of clients is not in hard copies or documents, it is stored through different software and the information is accessible only to the relevant professional. In our country, however, there exists a great privacy violation. A number of clients are observed by the psychologist to be listened to in a same room by different psychologists and everyone is able to listen to everyone’s story. The psychologist also mentioned that there also is a high violation of privacy during family counselling and no consideration for the client’s confidentiality is observed. Also, in case of female clients it happens that she is accompanied by some family member during the therapy whereas the therapeutic session is to be between client and therapist only. The psychologist also highlighted that in Pakistan we do not have proper professional translators and a family member is used in place of a translator to translate whatever client is reporting for the psychologist which also damage the privacy of client. This scenario also violates privacy. There exist certain protocols for case presentation whereas, unfortunately none such protocol is followed here, and every irrelevant person is made allowed to attend it. Also, in educational institutions the anonymity of cases is not appropriately maintained. In words of psychologist: “Anonymity concerns were not taken care of as per ethical code of conduct.”
Irrespective attitude towards client: The attitude of some psychologists toward client is very irrespective. Psychologist mentioned that the selfrespect of the patient is not cared of during sessions and unfortunately in our society the ethics are defined by the status of the other person. And due to this inconsiderate behavior of psychologist the client drops out of the therapeutic session, as mentioned: “The client doesn’t show up for the next sessions.” Inappropriate remarks passing was also observed by the psychologist in clinical practice which damage the already low self-esteem of client. The clinical psychologist also highlighted that some psychologists use a very unethical way of communicating with the client for example a client with suicidal ideations was observed to be inquired about the issue in a very harsh tone as: “Did you tried to kill yourself? Don’t you know it is like murdering your own self?” Also, some psychologists are found to deal very inappropriately with children as: “Yes, what is your problem?” which unfortunately is a very inappropriate tone to speak with especially to a child.
Unnecessary long clinical sessions: Some clinical psychologists take unnecessarily long sessions and assessments just for money making which impose a financial burden on the client. In most of the cases the testing is not required for the client but is carried out through different professionals just to prolong the session. It is mentioned as: “Some psychologists took unnecessarily long sessions just for money which is so unethical.” It is because of no accountability and absence of any standardized rules.
Minimal training of clinical psychologists: The clinical psychologists are practicing without a substantial training and experience. These untrained psychologists are also providing training sessions to interns which would lead to nonprofessional psychologists in the future. It was mentioned by psychologist as: “The professionals who are training the intern psychologists are not trained themselves so how could they provide an effective training.”
Absence of proper licensing and governing body: Another major concern highlighted by the psychologist is the absence of licensing bodies that could issue proper license to the psychotherapists for practicing in the field. Due to which every Tom, Dick, and Harry has opened their clinic without enough experience, expertise, and training. The psychologist mentioned that there are therapists over here that only degree and have started working which is so unethical. Thus, the proper licensing is very essential. The psychologist also mention that a license makes the person accountable before the governing body for all the ethics and rules just like a driving license make us accountable for traffic rules. At present there is no accountability which results in a high ratio of ethical violations. In the words of psychologist: “What licensing does basically is that it makes you accountable.”
Suggestions on improvement of ethical application
Establishment of licensing and governing body: The psychologist mentioned that all the doctors and even psychiatrists are issued with licenses so we psychologists should also have proper license, as said: “Medical students and psychiatrists are also issued with licenses so psychologists too should have license.” There should be a local governing body of psychologists like there is for medical doctors i.e., Pakistan Medical and Dental Council (PMDC). This body should issue proper certification for the psychologists after examination in which ethics should also be assessed. The certificate should be made compulsory for practicing as a psychologist. The local governing body should also define proper criteria for clinical practice including definite educational capability, ethical considerations, and appropriate clinical settings.
Standardization of clinical practice and ethical application: There is a requirement to standardize facilities and procedures for the clinical practice. There should be appropriate pay scales for the psychologists from government as per their respective educational capabilities and expertise which would also contribute to standardizing the fee of psychologist. The psychologist mentioned it as: “Psychologist should be assigned proper pay scales by government.”
Registration of mental health organizations: It was highlighted by the clinical psychologist that the mental health organizations should be properly registered on the basis of some strictly identified criteria of evaluation for the appropriateness of setting, capabilities and qualities of staff, and transparency of the therapeutic sessions conducted there. A major proportion of unqualified psychologists have opened up their mental health centers just so that they could easily practice there. It was mentioned as: “Some psychologists open up their own mental health organization or clinics only so they could practice there.”
Improve privacy during the sessions: The assigning of code or case number to the clients could help secure the privacy. The use of transparent rooms or camera could also be highly effective to conduct the one-toone sessions especially with the female clients. This would also help the supervisors to monitor the sessions carefully and maintain a check and balance for ethical considerations.
Proper monitoring of clinical practices: Clinical supervisors are to properly monitor the junior psychologists so as to keep track of how the session is conducted. And if anything is observed to be out of the professional boundaries then the psychologist must be held accountable for it.
Conduct research and surveys: The participant or nonparticipant (i.e., disguised) observation was suggested by the psychologist to conducted for researching the clinical practices and identifying the loopholes present. This could help ensure the provision of better mental health services with proper ethical considerations.
The findings of the study suggested that the major ethical concerns highlighted by clinical psychologists were about nonprofessional attitude of authority who refers the clients, lack of awareness about psychotherapy, privacy violation, irrespective attitude towards client, unnecessary long clinical sessions, minimal training of clinical psychologists, and absence of proper licensing and governing body. The literature from Saudi Arabia  also suggested that clinical psychologists should respect rights of privacy, confidentiality, self-expression, and autonomy despite of their age, identity, gender, ethnic background, religion, socioeconomic status, or disability. Also, they have responsibility to complete recognized education and evidence-based knowledge according to international standards, the requirements of the Saudi Minister of Higher Education, and psychologists’ professional requirements by Saudi Commission for Health Specialties (SCHS). Psychologists should refrain from deception when describing their skills. But unfortunately, there is no such requirement in Pakistan through which the competence of psychologists could be ensured.
In reference to the privacy of female clients, the clinical psychologists of Pakistan who were interviewed under present study highlighted the issue of their privacy or pardah as per Islamic Sharia. It was also highlighted by Saudi literature that the application of psychological Western norms to Islamic services is fairly limited . One common example is the question of whether a male psychologist or a female psychologist may treat the same client. The specific question here concerns khalwa (i.e., privacy) . Privacy between a girl and a male who is not mahram (i.e., not her father, brother, uncle, husband, or son) is forbidden under Islamic Sharia law. As a result, even in a professional situation, a female cannot be alone with a male with a closed door . Unlike other medical health specialties, psychological intervention requires the presence of the psychologist and the client alone in a room. The privacy established by this khalwa is critical to the therapy's success . Even if it is for a professional reason, the man may not allow his wife or daughter being with a male psychologist who is a foreigner behind closed doors . The possible solution could be the presence of female nurse inside the clinic during the session .
Certain suggestions for improvement were also mentioned by the clinical psychologists interviewed in the present study. The major suggestion included establishment of licensing and governing body, standardization of clinical practice and ethical application, registration of mental health organizations, improvement of privacy during the sessions, proper monitoring of clinical practices, and conducting research and surveys on this topic for better identification of key areas that need to be addressed.
The Saudi literature also highlighted those certain valid international assessments contain items that are unaccepted culturally . Psychologists must use assessment instruments whose validity and reliability have been established for use in Saudi Arabia and/or with the Arabian population. This point, however, was not mentioned by the clinical psychologists of Pakistan who were interviewed. But in Pakistan there is also need of establishing the psychometrics of international assessments used in clinical trials for better applicability.
Pakistan and Saudi Arabia both are Muslim countries. The study has highlighted the ethical concerns faced by the clinical psychologists from both countries. It also has demonstrated the need of indigenous ethical considerations and guidelines. The ethical guiding principles could be thus extracted from Islamic Sharia which could be more relevant in context of a Muslim country as per our religious and cultural foundations.
The major limitation of the study is that the comparative account was made only based on literature review from research conducted in Saudi Arabia. Indigenous information from the clinical psychologists of Saudi Arabia through interviews could have helped to better generalize the findings. Also, the study was purely qualitative in nature the mixed method design could have helped in better understanding of the ethical concerns during practice of clinical psychology.
Suggestions and Recommendations
It is suggested that the future researchers collect data directly from clinical psychologists of Saudi Arabia too so as to develop better and extensive comparative account of ethical concerns faced by both Muslim countries. The study of variables like professional competency, personality factors, and demographic variables that are related to the application of ethical considerations during clinical psychology’s practice is also recommended.
- Pope, K. S. and M. J. Vasquez. Ethics in Psychotherapy and Counseling: A Practical Guide. New Jersey: Wiley, USA, (1992).
- Linden E, Radestrom J. Ethical Dilemmas among Psychologists in Sweden and South Africa. Linköping: Linkoping University, Sweden, (2008).
- Sadat-Ali, Mir. "Professionalism: Are we Doing Enough?" Saudi Med J 25 (2004): 676-7.
- American Psychological Association. Ethical Principles of Psychologists and Code of Conduct. New York: American Psychological Association, USA, (1992).
- Dickens, Bernard M. "The Challenges and Opportunities of Ethics." AJPH 95 (2005): 1094.
- Tangwa, Godfrey B. "Between Universalism and Relativism: A Conceptual Exploration of Problems in Formulating and Applying International Biomedical Ethical Guidelines." J Med Ethics 30 (2004): 63-67.
- Ashraf, Marriam. Lived Experiences of Pakistani American Women Who Sought Mental Health Treatment. Minneapolis: Walden University, USA, (2021).
- Naeem, Farooq, Muhammad Ayub, Mary Gobbi and David Kingdon. "Development of Southampton Adaptation Framework for CBT (SAF-CBT): A Framework for Adaptation of CBT in Non-Western Culture." JPPS 6 (2009): 79-84.
- Al-Eraky, Mohamed M., Madawa Chandratilake, Gohar Wajid and Jeroen Donkers, et al. "Medical Professionalism: Development and Validation of the Arabian LAMPS." Med Teach 35 (2013): S56-S62.
- Shuttleworth, Martyn. "Descriptive Research Design." Explorable, September 26, (2008).
- Alqahtani, Mohammed MJ and Nadia Altamimi. "Code of ethics and professionalism in light of cultural competency: A guideline for Saudi psychologists, supervisors, and Trainees." Psychol Stud 61 (2016): 103-12.
- Pridmore, Saxby and Mohamed Iqbal Pasha. "Psychiatry and Islam." Australas Psychiatry 12 (2004): 380-5.
- Rispler-Chaim V. Islamic Medical Ethics in the Twentieth Century. Leiden: Brill Publishers, Netherlands (1993).
- Inhorn, Marcia C. and Gamal I. Serour. "Islam, Medicine, and Arab-Muslim Refugee Health in America after 9/11." Lancet 378 (2011): 935-43.
- Atighetchi, Dariusch. Islamic Bioethics: Problems and Perspectives. Dordrecht: Springer, Netherlands (2007).
- Fakhr El-Islam, M. "Arab Culture and Mental Health Care." Transcult Psychiatry 45 (2008): 671-82.
- Kaslow, Nadine J. "Competencies in Professional Psychology." Am Psychol 59 (2004): 774-81.
Citation: Sahar, Namood E., Shakir Hussain, Ali Ibrahim Noshili and Sayed Shahbal, et al. “Comparative Account on Ethical Considerations in Practice of Clinical Psychology.” Clin Schizophr Relat Psychoses 16 (2022). Doi: 10.3371/CSRP.SNSH.061722.
Copyright: © 2022 Sahar NE, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.