Ethical Concerns in Clinical Psychology: A Brief Account of Challenges in Pakistan

The present report provides a brief indigenous account of these challenges and issues. The purpose of the report was accomplished through semi-structured interviews conducted with two clinical psychologists who have an extensive experience in the ﬁeld of clinical psychology

necessary improvements to be made in Pakistan.To achieve this purpose, two clinical psychologists with an extensive experience in the clinical practice were interviewed.The points highlighted are discussed in the following sections.

Status of Ethical Concern at Clinical Practice in Pakistan
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 exist 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 counseling 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 don't 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 have only Bachelor 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."

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 in 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 carried out 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 very effective to conduct the one-to-one 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 carried out.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 carried out for researching the clinical practices and identifying the loop holes present.This could help ensure the provision of better mental health services with proper ethical considerations.