Ethics Update: Culturally Competent Psychotherapy Informed by Ethical Principles

Culturally Competent Psychotherapy Informed By Ethical Principles

Komal Dutt, PhD Ethics Committee Member

Empathy, the essence of psychotherapy, is the most important tool psychologists have for understanding and reflecting patients’ feelings, thoughts, and behaviors. Empathy provides patients with validation that in turn motivates them to make desired changes or accept what they cannot change. In order for empathy to be based on a genuine understanding of a patient’s struggles, emotions, and behaviors, psychologists must have a keen understanding of their patients’ cultural world-view. It is not only critical for psychotherapists to understand their patients’ cultural beliefs but to provide help that is consistent with those beliefs (Choudhuri, Santiago-Rivera, & Garrett, 2012; Hays & Erford, 2010). For example, some researchers have indicated that to ensure culturally competent treatment, family based interventions are more effective for South Asian Americans (e.g., Almeida & Dolan-Delvecchio, 1999; Inman & Tewari, 2003).

In addition to providing empathy from a place of cultural understanding, a psychologist is also obliged to adhere to ethical principles established by the American Psychological Association (APA). Occasionally, psychologists may face a dilemma between respecting their patient’s cultural worldview and upholding the ethical principles of their profession. This article will illustrate such situations and propose possible solutions, respecting the need for ethical principles to take precedence in all circumstances.

In particular, this article will focus on ethical principles regarding limits of confidentiality (i.e., duty to protect), and boundaries of competence listed under the preamble of the APA Ethics Code. Using case examples from Indian culture, this article will illustrate potential dilemmas and present possible resolutions.

Ethical Standard 4.05 - Discussing limits of confidentiality:

The essence of this principle is that “psychologists may disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose, such as to protect the client/patient, psychologist, or others from harm.” The psychologist’s underlying responsibility is in this case is their “duty to protect.”

It is important that the limits of confidentiality be discussed prior to starting therapy. In addition to providing this information to patients verbally, it should be clearly stated in the psychologist’s informed consent.

Case example:

A private psychologist of Indian origin receives a call from an Indian man requesting therapy for his 15-year-old daughter. The caller mentions that his daughter has been feeling depressed, is often irritable, and is struggling socially at school due to a recent falling out with her friends. He elaborates that when he and his wife try to confront her, she often “threatens to harm herself.” The caller goes on to deny that his daughter has ever actually harmed herself.

The caller adds that his daughter has tried therapy with a few Caucasian psychologists, and has not found it helpful. He then mentions that these psychologists have recommended hospitalization for his daughter when she has threatened to harm herself in the past, and that he and his wife have not appreciated this. The caller shares that he and his wife believe that their daughter threatens to harm herself as a means of seeking attention and managing her mood and struggles at school. He adds that he is specifically contacting an Indian psychologist in the hope that “she would not try to hospitalize her daughter whenever she threatens harm.”

Before accepting the case, the psychologist’s responsibility is two-fold. First, she must communicate that she has a duty to protect, and explain clearly the circumstances in which this duty will apply. The second responsibility is more clinical in nature. The psychologist must demonstrate her understanding of the parents’ frustration while explaining that understanding and helping patients manage symptoms is more effective than dismissing them. In other words, the clinician must convey to the parent that although she understands the cultural viewpoint (perhaps there is a cultural shame in being hospitalized for mental health reasons, or a culturally influenced tendency to deny or dismiss mental health symptoms), the duty to protect will take precedence.

Ethical standard 2.01 - Boundaries of competence:

This principle states that “Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.”

Although a growing number of psychologists in the United States come from different cultural backgrounds, there is still a shortage of psychologists from Indian cultures. Many Indian couples prefer to see a psychologist from their own culture, believing that he or she will be more equipped to understand their conflicts. However, in order to work effectively with couples, a psychologist needs to be trained in couples therapy, and may need advanced training or supervision to work with high conflict couples/families. Simply knowing a patient’s culture is not sufficient to address complex problems.

Case example:

An Indian therapist gets a call from a 45-year-old Indian woman, married for 18 years.

She expresses that she is feeling stressed by conflicts in her marriage. She states that she would like to bring her husband for sessions, but he is reluctant (a common problem amongst Indians). The therapist agrees to see the patient.

Therapy ensues and the patient reveals that she suspects her husband is having an affair. This would not be the first time; early in the marriage, the husband had a brief affair followed by many years of trying to work through this issue.

After a few therapy meetings alone with the wife, the husband joins the therapy session.

In these sessions their conflict is particularly intense, occasionally escalating to the point of being unmanageable. The therapist struggles and eventually seeks supervision, recognizing that she is missing needed skills to de-escalate conflicts in session and help the couple more effectively. Clearly, while familiarity with a patient’s cultural background is necessary, it is not sufficient.

Ethical standard 2.06 Personal Problems and Conflicts:

This principle states that “Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner. Additionally, when psychologists become aware of personal problems that may interfere with their performing workrelated duties adequately, they take appropriate measures.”

This principle can be applied to cases in which a therapist’s world-view becomes an interfering factor in therapy. Couples often seek treatment (individual therapy or couples) either to resolve their conflicts or to make a decision to end their marriage. The therapist’s world-view about divorce can interfere in the therapy process. As such, it is important for therapists to be mindful of their own therapy-interfering behaviors and attitudes. For example, a therapist’s accepting view of divorce may create a barrier to those whose culture stigmatizes divorce.

Case example:

A 55-year-old Indian woman, requests therapy from an Indian therapist. She states that she recently terminated couples therapy. In the first session, she reveals that she and her husband have struggled with long-standing conflicts (although she denies abuse) in their marriage.

After their children left home for college, the couple decided to end the marriage, but first sought therapy to facilitate a smooth transition for their children and themselves. After a few sessions, the couple changed their mind and decided against divorcing despite the “loveless” nature of their marriage. On hearing this, their couples therapist, strongly recommend that they reconsider their decision as their differences seemed irreconcilable. Although the couple agreed that their differences may be irreconcilable, they felt that their therapist did not understand their dilemma. In response, the couple decided to terminate therapy with this therapist and look for someone more likely to understand their decision in the context of their culture.

In light of this, the new therapist and the patient collaboratively established the goal of helping the patient to develop skills to manage her well-being while staying in the marriage. The previous couple’s therapist made the mistake of failing to educate himself on the influence of social pressure and religious beliefs on the decision to divorce. As such, he did not incorporate this relevant factor into his understanding of the case.

In sum, psychologists should make every effort to both provide culturally informed psychotherapy and carefully uphold ethical principles listed by the APA. ❖

Postgraduate Training in Psychodynamic Clinical Practice at CPPNJ Your antidote to disjointed CE events and educational gaps that leave you wanting:

• a series of four courses that integrate theory with practical, clinical applications • a chance to develop a cohesive, meaningful framework – a way of being in your clinical relationships – that is both foundational and career building

To learn more, visit www.cppnj.org or call 973-912-4432 to speak directly with a CPPNJ faculty member

Sign up now for this fall, 2020 Discover a community of a lifetime!