Summary of the class held on 22nd Feb 2010:
In this class, we spoke about culture and its influence in clinical psychology. Culture definitely plays an important role in the field of clinical psychology. Likewise, culture remains an ingredient submerged in this field. We came about with many culture based aspects in the class, of which some where naming the disorder and their meaning (like normal and abnormal could be culture specific), assessment (culture fair and culture free), treatment resources (involvement of family in collectivistic cultures), clash between culture of the psychologist and the client, who is an expert? ( is culturally dependent), culture based syndromes, tackling situations when the client and the therapist are from different cultural backgrounds and also other factors related to culture in this field.
Further, we also discussed about the styles used by clinical psychologists and whether they are in par with the norms written in books. Few from the class accepted that the clinical psychologists they met where following the norms as they were in books, namely:
• Firstly, the clinical psychologists conduct their sessions with the time slab in their mind. They conduct sessions for about 50 minutes and if the client comes late by about 30 minutes, the clinical psychologists start the session but stop it exactly after the remaining 20 minutes, and also advise them to be on time for the next session.
• Secondly, they follow the norm of charging their clients the entire session’s fee, if they don’t inform the clinician prior to 48 hours of their appointment about the cancellation. In other words, cancellation has to done 48 hours prior to the appointment taken with the clinician.
• Thirdly, the clinician also follows the norm of providing his client with a free session during the next appointment, if the clinician is not available during the previous fixed appointment.
Further, there was an issue also raised about the differences between the culture of the client and the clinician. Hence, lot of effort lies on the clinician to know and understand the various cultures and also analyse their clients based on the cultures they are brought up in, instead of imbibing and diagnosing their client blindly based on their personal cultural ideas and mere personal experience.
The major challenges for a clinical psychologist are
• Cultural competence, cultural awareness.
• Knowledge about diversity of cultures so as to understand client’s cultures.
The major key towards efficacy in one’s practice and experience is, understanding the client and the culture they are brought up in and are imbibed with and eventually diagnose them effectively!
In this context, there was a book referred by Sir named, “Listening to Cultures” by Nanditha Chowdhury.
Summary of the class held on 23rd Feb 2010:
This class was on the ethical code of conduct and the ethical principles. . It was discussed that there is correlation between law and ethics. There is an increase in filling of many law suits and also increase in professionals all over, which left many loose ends untied! There was no idea that a need for so many revisions would take place, but due to the above advancements, revision was imposed. Ethics is not a legal document, but it consists of few principles, followed by a group of professionals with an idea to provide the best possible help and support to your client, however there is no necessary legal mandate that the clinician will be jailed. Hence, the licensing came up in some states in a sense that if one values law, then they have to get licensing done to practice.
The Universal Declaration of Human Rights was started in the year 1948. The ethical code of conduct and the 1st APA guideline was published in the year 1953, and within 5 to 6 years, it’s revised 9 times. This needs to be given a thought as to why these intense revisions were needed, or rather the reasons. Some points came up by the class were:
• Research interest
• Laws in other field: general activism, laws in other fields
• Client becoming consumers, which refers to many insurance facilities and many law suits started.
• Sudden popularity of the field itself that is increase in the number of mental health professional, also stigma reducing and Individualisation. Survey shows that in the year 1940, there were about 20000 clinical psychologists. In 1990, there were about one lakh clinical psychologists.
In this context, the statistics given by Diana Gross (in her guest lecture on ) was taken in o consideration. She said, “Clinical psychology course happens to be the fourth- fifth popular most subject opted by students.”
In this regard, there were a number of laws and acts discussed, namely:
• Consumer Protection Act in the year 1986.
• Mental Health Act of India replaced the Indian Lunacy Act in the year 1987.
• RCI act came up in the year 1952.
• ISAP considered the Ethical Code of Conduct in the year 1993.
• Policy statement of ethical consideration by Indian council of Medical Reserach in the year 1994.
• Persons of Disability Act in the year 1995.
The APA code of conduct mentions two parts as the general principles, namely: Aspirational part and Enforceable part.
Aspirational part: There is an internal aspiration to follow books but however there is no need to follow t 100% of the times. Further, the norms in the book are very general and broad as what to what had to be done.
Enforceable part: Ethics is important and as such, there will have a member committee in APA and meetings go on to analyse the intensity and the degree of violation. Later, this case is referred to local court to judge if the clinician can continue practice or not. But most cases licence is cancelled.
In this regards, there was a case study discussed: In the early 1970’s there was a case related to ethical violation in California. There was a Bengali guy, who was undergoing this doctorate program and was taking therapy under a clinical psychologist. In the course of the session, the clinician learnt that his client was sexually drawn towards a lady named Tara scoff, who refused it. As such, he wanted o revenge her to an extent that he was even ready to kill her. This aspect was noted by the clinician during the session and he immediately informed the local police about his client and cautioned them, thinking he was helping out his client from falling a trap to law. This was his first step towards breaking his ethical issue that is, he breached the client’s confidentiality. After few months, the client managed to harm the lady and this brought the lady’s parents to the court of law. They filled a case against all involved in this, including the clinical psychologist. This case went on for a few months – years. The court found out evidence that the clinician failed to inform Tara about the harm involving her, of rather refused to caution her family about the harm, so that they could take necessary precautions.
After this case, there were many cases which came up in this context. And since then, there are many laws in this area. The client fills a case in the court of law, when they feel dissatisfied with their clinician. And many a times, majority of these cases are false. In spite of tightening the loose ends, the number of ethical violations is increasing. Further, in order to upgrade one’s license and also to pass through a master’s degree, it’s important to educate oneself about the ethical code of conduct and advancements in this area.
Many surveys were conducted in this regard. In the year 1987, a survey was conducted on 460 practising clinical psychologists, who efficiently responded to the survey. There were 83 separate behaviours given to them, through the case details and asked what they would do and not do in these situations. Only few clinicians had a very clear idea about answering ‘yes’ and ‘no’ to the questions, but majority answered that it was based on the context and depended on the situation they were in. Thus, there was a major dilemma in their responses on what to do and not to do. (Page 87 of Pomerantz)
If we replicate the same survey today, we can see many cases in grey area and the ethical dilemma still persistent in them. This may be because of unclear ethical codes presented by APA and however, the revisions made are not that that clear to solve the dilemma in the clinician’s mind.
There was an OHP put up on the revised version of the ethical code of conduct, the APA guidelines.
ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT (2002):
CONTENTS:
• Introduction and applicability
• Preamble
• General principles
• A beneficence and non-mal beneficence
• Fidelity and responsibility
• Integrity
• Justice
• Respect for people’s rights and dignity
• ETHICAL STANDARDS
1. Resolving ethical issues. Some sub-categories are Misuse of psychologists work, improper complaints, informal resolution of ethical violations, cooperating with ethics committees, conflicts between ethics and organizational demands, conflicts between ethics and law/regulations/other, improper complaints.
2. Competence. Some sub-categories are boundaries of competence, bases for scientific and professional judgements, maintaining competence, personal problems and conflicts, delegation of work to others, providing service in emergency.
3. Human relations. Some sub-categories are avoiding harm, unfair discriminations, sexual harassment, other harassment, conflict of interest, informed consent, interruption of psychological services, conflict of interest, third party requests for services, exploitative relationships, co-operation with other professionals.
4. Privacy and confidentiality. Some sub-categories are maintaining confidentiality, recording, disclosure, consultants, use of confidential information for didactic of other purpose, discuss the limits of confidentiality.
5. Advertising and other public statements. Some examples are fees and financial arrangements, referrals and fees, barter with clients, withholding records for payments.
6. Education and training. Some sub-categories are assessing student and supervisor performance, accuracy in teaching, student disclosure of personal information, mandatory individual or group therapy.
8. Research and publication. Some sub-categories are institutional approval, debriefing, plagiarism, reviewers.
9. Assessments. Some sub-categories are bases for assessments, release of test data, use of assessments, test construction, interpreting assessment results, maintaining test security, obsolete tests and outdated test results, assessment by unqualified persons, test scoring and interpretation services.
10. Therapy. Some sub-categories are group therapy, informed consent to therapy, terminating therapy, therapy involving couples or families, interruption of therapy.
The latter half of the class was spent by studying and analysing a few case studies, which were on the violation lines. The class was divided into groups and different case studies were given and the groups had to identify whether there was violation taking place, by referring to the ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT (2002) and also come out with different solutions to the said violation in each case.
Summary of the class held on 16th Feb 2010:
There was a debate held in this class on the topic, “whether prescribing rights should be given to clinical psychologists or not”. The class was divided in to groups to discus on the above said topic. This topic initially began by referring to two states in the United States namely New Mexico and Louisuana, where the clinical psychologists are given the prescription rights and initially this license is supervised by professionals for two years.
The arguments for the prescribing rights were:
• Shortage of psychiatrists (which is not very true in India)
• Non- physician professionals (dentists, ayurvedic doctors who have prescribing rights)
• Convenience for clients
• Professional autonomy
• Professional identification
• Substantial increase of Revenue for psychologists
• Enable clinical psychologists to provide a wide variety of treatments and conduct tests on wider spectrum.
• Potential increase in efficacy and cost effectiveness, which is in the benefit of the client, who are in need of both psychotherapy and medication- psychopharmacology.
• Prescribing rights will give the clinical psychologist a competitive advancement in health care market place.
• Less confusion for clients as to whom they have to approach, as the clinical psychologist can give the whole picture.
• Natural progression in clinical psychology quests towards becoming a ‘fully fledged’ health care professional.
• Clinical psychologist would know when to use medication and when to use psychotherapy, rather than one sided approach.
Arguments against prescribing rights for clinical psychologists:
• Effect of drug on multiple bodily systems can never be estimated without long term medical training/inclination.
• Focus on psychotherapy eventually will get diluted (this point was argued saying that the clinical psychologist has an internal inclination of practising psychotherapy)
• Identity confusion – exact roles of psychologist and psychiatrist are befuddled.
• Decrease in the potential influence of pharmaceutical industry.
• May lead to de- emphasis of psychological form of treatment because medications are often faster acting and potentially more profitable than psychotherapy.
• A conceptual shift may occur, with biological explanation taking precedents over the psychological ones.
• May damage the clinician’s relation with psychiatry and general medicine which my lead to financially excessive law suits and general feelings of animosity.
• The students who are pursuing their masters do not have a background of biology in their graduate programs, which eventually emphasis on the aspect that, the clinical psychologists lack the ability to identify which drug plays on which part of the body and further, any side effect caused to the client can be trusted on the drug itself.
• If prescribing rights are given, this would result in very little difference between psychiatrist and psychologist.
Implications on training:
If we gain prescribing rights, basic pharmacology training will be required and mastery in the medication strategies used for treatment as well as the knowledge of the substance abuse are very important for the clinician to know. Probably, one semester course on psychopharmacology is recommended. Collaborative practice must also be given importance in psychopharmacology, diagnostic assessment, physical assessment, drug interaction. A strong background in biology classes, 2 years graded training in psychopharmacology and post doctoral psychopharmacology residency is recommended.
The reference given in class was Pomerantz and Wikipedia.
There were many other possibilities and assumptions discussed in class. The debate was concluded with a very thought provoking and a probably considerable idea, that is:
“Can there be an integration of training programs for all mental health professionals in future? “
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