International Journal of Culture and Mental Health

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‘Power positions are embedded in our minds’: focus

group discussions on psychotherapy ethics in India

Ananya Sinha, Poornima Bhola, Ahalya Raguram & Prabha S. Chandra

To cite this article: Ananya Sinha, Poornima Bhola, Ahalya Raguram & Prabha S. Chandra
(2017) ‘Power�positions�are�embedded�in�our�minds’: focus group discussions on psychotherapy
ethics in India, International Journal of Culture and Mental Health, 10:2, 217-227, DOI:
10.1080/17542863.2017.1294192

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INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH, 2017
VOL. 10, NO. 2, 217–227
http://dx.doi.org/10.1080/17542863.2017.1294192

‘Power positions are embedded in our minds’: focus group

discussions on psychotherapy ethics in India
Ananya Sinhaa, Poornima Bholaa, Ahalya Ragurama and Prabha S. Chandrab
a
Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bangalore, India;
b
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India

ABSTRACT ARTICLE HISTORY

Background: Ethical issues are ubiquitous during therapeutic work, Received 4 October 2016
despite the presence of professional ethics codes that guide ethical Accepted 8 February 2017
decision making. This exploratory research looks at how mental health
KEYWORDS
trainees and practitioners, across various mental health disciplines, Ethical dilemmas; focus
perceive and experience ethical dilemmas in the therapy space. group discussion; culture;
Method: The sample included 12 mental health practitioners from varied psychotherapy; values
mental health disciplines (clinical psychology, psychiatry and psychiatric
social work), and practising counsellors, from an urban city in India.
Three focus group discussions were conducted, where participants
expressed the ethical issues and challenges encountered during their
sessions with clients.
Results: Content analysis of the narratives of the focus group discussions
highlighted prominent ethical dilemmas in these domains: negotiation of
boundaries or frames of the interaction; involvement of family in
therapeutic decisions; negotiation of issues of gender and power in
therapy; value conflicts in working with sexuality issues; therapist
competence; and method of resolution of ethical dilemmas. Personal
and cultural values emerged as impacting the perceptions,
interpretations and experience of ethically challenging situations. The
findings have implications for the development of culturally sensitive
and value-based training methodologies.

Introduction
‘Two souls, alas, are housed within my breast, and each will wrestle for the mastery there’ (Goethe,
1808). This quote exemplifies the experience of an ethical dilemma. Traditional psychotherapy
takes place behind the closed doors of a therapy room. Despite the guidance from professional ethical
codes, therapy practitioners are inevitably confronted with conflicting choices in their work with cli-
ents, each potentially leading to some compromise with one or more ethical principles (Bersoff &
Koeppl, 1993). Mental health practitioners, from different contexts and at different stages of their
professional development experience ethical dilemmas (Gibson & Pope, 1993; Knapp & Vande-
Creek, 2006; Pope, Tabachnick, & Keith-Spiegel, 1987). Developmental models of professional devel-
opment (Rønnestad & Skovholt, 2003) suggest that trainee therapists experience anxieties and
uncertainties as they begin working with clients, feel a sense of heightened responsibility and demon-
strate external dependency. This could make them more vulnerable in the face of ethical dilemmas
that emerge in the therapy room. Training in ethics may be inconsistent or even inadequate across
various mental health training courses in India (Isaac, 2009). In addition to the clinical psychologists,
psychiatric social workers and psychiatrists who address mental health needs, the counselling

CONTACT Poornima Bhola poornimabhola@gmail.com

© 2017 Informa UK Limited, trading as Taylor & Francis Group
218 A. SINHA ET AL.

profession is also growing. The lack of uniform training standards in counsellor education pro-
grammes and the absence of a regulatory body has been pointed out and this has implications for
the provision of competent, ethical practice (Thomas & George, 2016). There has been little research
that looks at exploring ethical dilemmas experienced by mental health trainees and practitioners in
India (Bhola, Sinha, Sonkar, & Raguram, 2015; Kurpad, Machado, & Galgali, 2010).
Ethical dilemmas are universal, but their experiences and meanings may vary across culture and
contexts (Hall, 2001; Muller & Desmond, 1992). The concept of cultural pluralism implies that
diverse ways of representing and responding to moral and ethical questions in different cultures
and contexts are legitimate (Shweder & LeVine, 1984). More importantly, differences may exist
both across and within cultures. When a therapist and a client walk into the therapy room, they
carry their personal, cultural and social values into the therapeutic interaction. The intersection of
the therapist as a ‘person’, from a particular culture and context, and as a ‘professional’ and the resul-
tant impact on therapeutic interactions and decisions, is an important domain of enquiry (Behnke,
2008; Pipes, Holstein, & Aguirre, 2005).
Survey methodology, which has been largely used all across the world to elicit the frequency and
types of ethical dilemmas experienced by mental health practitioners (Haas, Malouf, & Mayerson,
1986; Lindsay & Clarkson, 1999; Pope & Vetter, 1992), has its limitations in tapping the nuances
of the ethical questions and contextual issues in the practice of therapy. Focus group discussions
(FGDs) offer the opportunity to interview several respondents systematically and simultaneously
(Babbie, 2010), and can be useful for in depth exploration of sensitive issues, like ethics in therapy.
This study uses a qualitative framework to addresses the research question: What are the types
and nature of ethical dilemmas experienced by mental health trainees and counsellors during
their practice of psychotherapy or counselling?

Method
Sample
The sample included 12 mental health trainees and counsellors. Nine trainees in postgraduate
courses were recruited from the departments of Clinical Psychology, Psychiatry and Psychiatric
Social Work of a tertiary care government hospital for mental health and neurosciences in India.
The three counsellors were engaged in private practice in an urban community; two had completed
a one-year full-time training course and one had completed a one-year postgraduate distance edu-
cation diploma in counselling. The M.Phil. trainees in Clinical Psychology and Psychiatric Social
Work and the MD and DPM trainees in Psychiatry had received two hours of structured training
in ethics in the form of lectures. The Ph.D. scholars had undergone a four-hour workshop on ethics
during their coursework. Information about structured ethics training among counsellors is unavail-
able. All participants reported that ethical issues were also discussed in supervisory discussions, as
well as through informal discussions with peers.
The majority of the participants were females (75%) and married (58.33%). Their ages ranged
from 27 years to 50 years (M = 32.92 years, SD = 7.46 years). The total years of experience in therapy
or counselling practice ranged from 1–15 years (M = 6.17 years, SD = 4.24). The number of hours per
week spent in practising psychotherapy or counselling ranged from three to 48 (M = 15.84 hours,
SD = 13.62), with a 40–90 minute reported duration of therapy sessions.

Procedure
A semi-structured focus group discussion (FGD) guide contained open-ended questions and associ-
ated probes related to the experience of ethical issues and challenges in the practice of counselling/
psychotherapy. The discussion revolved around the questions outlined in Table 1:
 INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH 219

Table 1. Focus group discussion guide.

1) Please share some situations where you have encountered ethical questions during your practice of psychotherapy/
counselling. These can be situations which you have experienced directly or those you have heard of, observed or discussed with
others. Please refrain from giving any identifying details of the client, setting, or supervisor (if any).
2) Could you describe some instances where ethical issues were less challenging and comparatively easier to deal with?
3) Could you describe some instances where ethical issues have been comparatively difficult to deal with?
4) Please share any situation/s where you struggled with deciding how to resolve an ethical dilemma, despite there being
professional ethical guidelines regarding such situation/s.

The study was approved by the institutional ethical review board. Three groups were finalised,
each consisting of five members who provided written informed consent, representing diverse men-
tal health disciplines. In each of the three groups, there was one dropout owing to emergency clinical
duty.
The FGDs were carried out in a quiet and convenient place and each took around two hours to
complete. As a moderator, the first author ensured a safe environment where all participants could
express their concerns, diverse opinions and related emotions and engage in discussions with fellow
participants. Detailed notes were recorded, maintaining anonymity of the participants, and the
researcher outlined personal reflections about the content and processes, after completion of each
FGD.

Analysis
The FGD notes were analysed through content analysis (Stewart & Shamdasani, 2014). The notes
were first scanned to identify sections relevant to the research questions, divided into thematic cat-
egories and colour coding was done to identify different themes. The coded materials included
words, phrases or long exchanges between participants. Independent coding was done by first
and second authors. Changes in the coding were made and the thematic units were finalised through
a process of discussion and consensus.

Results
The following themes related to ethical dilemmas emerged after content analysis of the focus group
discussion notes (Table 2).

Negotiating boundaries or frames of interaction

All participants expressed that dual relationships between the therapist and client should be avoided
but also described some difficulties in delineating the boundaries of the professional relationship.
They were unanimous in their censure of sexual relationships with clients, while revealing instances
of such boundary violations by colleagues. The lack of proper guidelines and regulatory bodies left
them with unanswered questions about whether and how to respond to a colleague’s boundary
violation.

Table 2. FGD themes of ethical dilemmas in therapy.

1. Negotiating boundaries or frames of interaction
2. Involvement of family in therapeutic decisions
2.1. Reinterpreting disclosure in the Indian context
2.2. Client autonomy in therapy
3. Negotiating issues of gender and power in therapy
4. Value conflicts in working with sexuality issues
5. Therapist competence
6. Resolution of ethical dilemma in therapy – simple or complex?
220 A. SINHA ET AL.

Their dilemmas centred on the appropriateness of providing therapy for a colleague’s daughter,
the appropriate degree of closeness with an adolescent client or the sharing of personal contact infor-
mation with a client. Although most felt that being accessible to clients at times of emergency was
perhaps an ethical obligation, narratives indicated that this was often driven more by a need to pro-
tect oneself as a professional rather than by client welfare.
A majority of the participants expressed uncertainties related to the inadvertent and seemingly
unavoidable blurring of professional and personal identities in the online space. One of the partici-
pants expressed his concerns, ‘The boundary gets blurred … one click and there you are … your
holiday pictures, the restaurant you visited, the food you ate … everything!’
One of the most prominent ethical dilemmas experienced by the participants was related to
responding to gifts offered by clients during the course of therapy or counselling. One of the partici-
pants remarked, ‘ … there can be no black and white rules for accepting or not accepting gifts’, and this
theme resonated through all the three focus group discussions.
Narratives indicated that a range of factors like age, gender, socio-economic status and intention
of the client as well as the monetary and emotional value and frequency of the gift can be helpful in
determining an appropriate and ethical response. The majority view was that less expensive gifts and
food items may be accepted, while gifts of higher value or any favours from clients should be refused.
However, this was challenged by few other participants who felt it was the inexpensive or personal
gifts that gave rise to greater uncertainty. Others recounted their difficulty in judging the value of the
gift relative to the client’s socio-economic status.
Participants also placed stress upon the meaning attached to gift giving in the cultural context and
possible negative implications of insulting the client by the refusal of the gift. In the words of one of
the participants, ‘Cultural aspect of gift giving is unique to India, unlike western countries. A gift may
be a bribe, a token of gratitude or in our culture “gurudakshina” (Indian tradition of showing respect
and repaying the teacher for guidance).’
Another participant echoed this sentiment, ‘We used to give gifts to our teachers as a form of show-
ing respect. Clients also look up to us as guides … how will they feel if you refuse to accept it?’
A client’s way of presenting the gift as a family elder, for instance, ‘you are like my son’, or as cus-
tomary on religious festivals often made refusal difficult. Some participants also admitted that it was
quite tempting to accept the ‘extra appreciation’ for their work.
Although the discussions indicated that the participants were aware of the various complex fac-
tors affecting the decision to respond to boundary issues, cultural factors appeared to overshadow
other considerations in a majority of situations.

Involvement of family in therapeutic decisions

The FGD highlighted the ethical uncertainties concerning the involvement of family members in the
treatment of clients. While some practitioners struggled to decide how much to disclose to family
members, others had difficulty delineating autonomy issues with minors.

Reinterpreting disclosure in the Indian context

The theme related to confidentiality and disclosures revealed consensus on the ethical imperative to
disclose a client’s revelations of clear suicidal intent to family members, ‘ … there are no second
thoughts’. They expressed uncertainty about their ethical obligation in the context of self-harming
behaviour or uncertain intent.
Their primary ethical dilemmas were concerning the client’s right to confidentiality vis a vis the
family members’ right to know. The types of information included a variety of client revelations:
pregnancy in an unmarried female client; adolescent sexual activity; and sexual orientation of a
homosexual client.
One of the participants argued that, ‘If the male client decides to marry a boy … the parents’ lives
will be impacted … they must know … do I still not disclose it to the family members?’ The
 INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH 221

participants had difficulties in deciding whether it was ethical to conceal or reveal sensitive infor-
mation (for instance about an extramarital relationship) shared in an individual session, with the
spouse in the joint session.
A few participants described difficulties in the face of pressures for disclosure from the adminis-
tration or management in the settings where they worked, most typically in educational or corporate
settings. Similar concerns were voiced in the context of balancing ethical and legal obligations in
response to court orders; in terms of concerns about documentation of therapy notes; how much
to disclose; need for client consent; and obligations to share information with the client’s lawyer.

Client autonomy in therapy

Another prominent ethical concern was the parental involvement and control over decisions about
initiation and continuation of psychiatric treatment in adolescent clients; particularly since adoles-
cents, in India, rarely seek help on their own.
Dilemmas concerning client autonomy also emerged in the context of therapist responses to cli-
ent disclosures about abuse and evoked strong emotions. The participants were aware of the recent
legislation mandating the reporting of child sexual abuse in India. A few participants expressed
uncertainties about some aspects of the reporting procedures and wondered if they should seek
the minor client’s consent before initiating the process. They viewed client safety and well being
as their primary ethical obligation. Complex ethical situations arose when the abuser was a family
member, when families refused to take legal recourse or when a client discontinued therapy after
a disclosure of abuse. Speaking of the difficulty in deciding the limits of therapist involvement
and responsibility for decision making, one participant expressed, ‘So where does my role begin
and where does it end?’

Negotiating issues of gender and power in therapy

For some therapists, their beliefs, values or actions appeared aligned with the dominant cultural pos-
ition related to gender and power, while for others, they appeared to be divergent.
One of the participants brought up an ethical dilemma encountered during couple therapy which
mirrored the position of women in the Indian socio-cultural context, ‘The wife is not paying for the
session. So would confronting the husband (about a sensitive issue individually shared by the wife)
during a session mean they will stop coming for the session altogether?’ The majority of participants
agreed that often the power dynamics in society impacted therapists’ actions (or inaction) and the
relative position of women clients in sessions.
Another male participant recounted situations of intimate partner violence faced by women and
shrugged, stating that ‘it is culturally accepted’. This was followed by strong emotions of anger among
the other participants, who perceived this statement as minimising a serious issue and indicative of a
biased perspective. The emotionally charged discussion ended with a reflection on the influence of
deep-rooted values and beliefs on their perceptions and corresponding behaviour in therapy situ-
ations, even when not directly in awareness. As one participant remarked, ‘That is probably the
beauty of our culture … the power positions are embedded in our minds.’
Cultural norms concerning women and marriage, and their economic dependence, were seen as
factors contributing to the reluctance of women to report violence or abuse from spouses or in-laws.
Practitioners who held values that were not synchronous with these cultural norms described diffi-
cult emotions when clients refused to report familial violence. Often, this led to subtle pressure on
the woman to approach the police or judiciary.

Value conflicts in working with sexuality issues

Many participants expressed difficulties in working with clients of the sexual minority. They
struggled with their biases, sometimes experiencing ‘guilt’, but felt it was probably ethical to refer
222 A. SINHA ET AL.

the client to another professional. This gave rise to additional questions, as expressed by one partici-
pant, ‘ … if I refer him to a colleague, what explanation will I give him? Should I lie? Will it be good for
him to hear the truth that I am not seeing him because of his sexual orientation?’
Participants also recognised that their own biases interfered with the identification of therapy
goals. One of the participants recollects, ‘The family wants change of sexual orientation and the client
needs help in acceptance of his sexual orientation. Whose need should we prioritize? Ideally it should be
the clients’ need, but again we have our own biases and we often end up prioritizing the parents’ need.’
A question asked by one of the participants, ‘With the law, if I see a gay client, should I inform the
police?’ evoked very strong negative emotions in the group. Others saw this as both unprofessional
and unethical and one participant challenged this view by saying, ‘We are therapists, we should follow
what the Diagnostic and Statistical Manual (DSM) says … it is not a disorder, forget crime!’ The par-
ticipant who raised this issue continued to insist, ‘As a citizen, am I not bound to report?’ Other group
members were disturbed by this and vociferously disagreed with him.

Therapist competence
An additional question, which emerged in only one FGD, concerned whether it was ethical for trai-
nees, with probable inadequate competence, to be working with clients in therapy. This concern was
resolved with a discussion on how this was inevitable in the training process and that adequate
supervision could ensure competent care to clients. In addition, a segment of the participants
expressed the need for training in ethical and competent therapy practice with clients from the les-
bian, gay, bisexual, transgender (LGBT) community.

Resolution of ethical dilemma in therapy: simple or complex?

The majority of the participants were not able to clearly articulate the process of resolution of ethical
dilemmas. Some expressed that they were thinking about ethical decision-making for the first time.
While most agreed that prescribed guidelines could be helpful, others argued that ‘ethics should be
partly internal and partly structured’, and training could help develop an ‘internal sense of ethics’.
Participants spoke of the complex intersections and mismatches between cultural, personal and pro-
fessional values and the role of self-reflection in the ethical decision-making process.

Discussion
The findings revealed an array of ethical dilemmas experienced by mental health trainees and coun-
sellors at different stages of their professional development. The dominant concerns related to draw-
ing boundaries around the interaction with clients and negotiating confidentiality requirements are
perhaps universal experiences for many in the helping profession (Bhola et al., 2015; Haas et al.,
1986; Lindsay & Clarkson, 1999; Pope & Vetter, 1992). While there was consensus about ethical
choices in certain situations – for instance, breaking of confidentiality when a client expresses
suicidal intent or the need to avoid dual relationships – uncertainty and varied perspectives were
evident in other situations.
Professional ethical frameworks may not always address the complexity of the resolution of ‘real-
life’ ethical dilemmas in the therapy room and in different cultures or practice contexts, e.g. contem-
porary issues of online therapist-client interaction. The findings suggest that many emergent ethical
questions reflect the often asynchronous influences of cultural values, the values upheld by the pro-
fession, therapists’ own personal value positions and their understanding of legal frameworks that
influence ethical decisions. The difficulties in ‘reconciling rules with context’ (James & Foster,
2006) were most prominent in decisions involving boundaries and confidentiality.
Cultural constructions of relationships may be reflected in expectations about the therapist–client
relationship and impact the management of boundaries. In the Indian context, therapists may often
 INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH 223

be idolised by clients (Neki, 1973) and this power differential increases the risk of boundary trans-
gressions and exploitation (Gottlieb, 1993).This implies that practitioners should be aware of clients’
culturally mediated expectations about the relationship, discuss these with clients when required and
guard against potential ethical violations.
The understanding and negotiation of dual relationships may vary across cultures. Recent surveys
of counsellors and psychotherapists in China revealed that between one-third to half provided
therapy for friends, students, supervisees or employees and did not necessarily see this as an ethical
transgression (Zhao, Cheng, & Fu, 2009; Zhao et al., 2011). The explanation included the difficulty in
refusing known people and the dearth of trained therapists in the Chinese context (Deng et al., 2016).
Similarities in the underlying cultural ethos of Eastern countries, like India and China, have been
described (Nakamura, 1964), and Indian therapists in this study expressed certain difficulties in
defining and delineating dual relationships. Of course, it is not possible, and sometimes not advisa-
ble, to completely avoid dual relationships (Adleman & Barrett, 1990), for instance when working in
small rural communities (Schank & Skovholt, 1997). However, the onus is always on the therapist to
ensure that there is no exploitation or harm to the client.
Gift giving is a cultural expression of respect and gratitude in many cultures (Sue, Arredondo, &
McDavis, 1992). In India, the therapeutic relationship may be viewed within a ‘Guru (teacher) –
Chela (disciple)’ framework (Neki, 1973), often with gifts considered as a form of ‘Gurudakshina’
or offering to the Guru. However, the acceptance of gifts within a professional fiduciary relationship
is often considered a potential boundary transgression (Hundert, 1998). To complicate the picture,
most professional ethical codes do not specifically address the issue of gifts (Knox, 2008). While the
American Counseling Association Code of Ethics (American Counseling Association, 2014) urges
practitioners to be culturally sensitive in their response to client gifts, the Indian Psychiatric Society
code (Ahuja, 2006) emphatically states that ‘gifts and gratifications’ should not be accepted during
the treatment process. No doubt, the latter firm stance protects clients’ rights but its cultural congru-
ence is in question. More recently in the Indian context, Kurpad et al. (2010) suggested that a box of
sweets, on an occasion, from a client who can afford it, may be acceptable. Safeguarding against poss-
ible boundary violations is essential and ‘the curtain of culture’ (Khan, 2010) cannot be used as a
carte blanche to accept gifts. In all contexts, a comprehensive ethical decision making process
must incorporate the meaning associated with the gift, the cultural background of the client and
the implications of accepting or refusing the gift (Bhola et al., 2015). The training and supervision
space needs to equip trainees with the skills of gentle but assertive refusal, when required, as part
of a culturally sensitive decision-making process.
The participants experienced ethical dilemmas negotiating the role of family in the context of
decision-making and disclosures in therapy. The hierarchical collectivist Indian society ‘promotes
interdependence and co-operation, with the family forming the focal point of this social structure’
(Chadda & Deb, 2013, p. 299). Western cultures tend to emphasise individual autonomy (Chadda
& Deb, 2013) while the relational autonomy perspective in Eastern cultures (Mackenzie & Stoljar,
2000) views selfhood in the context of social relationships, where personal autonomy, space and priv-
acy may take a back seat (Markus & Kitayama, 1991). The definition of the ‘client’ tends to be
broader: one that often incorporates the family and the involvement of the family in the treatment
process is viewed as an asset in many cultures like India (Chadda & Deb, 2013). Age cannot be the
sole deciding factor vis-à-vis autonomy of child or adolescent clients, and aspects such as maturity,
legal and parental prerogatives all come into play (Strom-Gottfried, 2008). In working with minor
clients in India, de Sousa (2010) recommended that a culturally responsive approach could involve
parents along with the child in the process of assent to therapy and treatment. With family involve-
ment often a sine qua non in the process of help-seeking for mental health concerns in India, the
practitioner needs to ensure that individual autonomy and rights are also protected.
The negotiation of issues concerning gender, power and sexuality evoked the strongest emotions
and indicated sharply divergent viewpoints during the FGDs. The discrepancy between practitioners’
personal values and the dominant patriarchal cultural position reflecting gender-power inequalities
224 A. SINHA ET AL.

(Markus & Kitayama, 1998; Patel, 2016) was evident in therapeutic scenarios that involved women
clients. The range of issues included negotiating the position of a woman in a couple/family therapy
when the husband is paying for the session and reporting of incidents of intra-familial violence.
Working with sexual minority clients represented the most prominent ethical dilemma for
many participants. Overall the professional stance – diagnostic frameworks (American Psychiatric
Association, 2013), professional ethical guidelines (e.g. British Association of Counselling and
Psychotherapy) and statements from professional organisations in India (Chandra, 2009;
Hemchand, 2016) – has moved away from considering homosexuality as a disorder and advocates
an affirmative approach towards sexual minority clients. This is at odds with the deeply held, and
often private, personal beliefs and values of select mental health trainees and practitioners in this
study. Such biases against LGBT clients contravene the ethical principles of justice and autonomy
and interfere with the provision of a neutral therapeutic stance. These beliefs must be understood
in the backdrop of inconsistencies in diagnostic manuals (World Health Organisation, 2010), the
silence of many professional mental health organisations, prevalent societal homophobic attitudes
(Narrain, 2016; Ranade & Chakravarty, 2013), and Section 377 in India which criminalises homo-
sexual acts. Even when trainees and practitioners have an affirmative attitude towards sexual
minority clients, there is a lack of adequate training in this domain. The findings highlight unseen
variations in the beliefs and values held by members of the professional community, and this may
impinge upon the perceptions, interpretations and experience of ethically challenging situations.
The interface between ethics and the law introduced additional questions. Most participants in
the study were trainees in the initial phase of their professional journey. While they were broadly
aware of laws relevant to mental health practice, they lacked clarity about the intricacies of recent
legislation, e.g. The Protection of Children from Sexual Offences Act (Ministry of Law and Justice,
2012). On many occasions, clients may disclose sensitive personal information in therapy that con-
travenes the law, and there could be uncertainty about therapists’ legal obligations. This is exempli-
fied by the question about legal reporting of client’s sexual orientation that emerged in the present
study. While the 1996 Jaffee v Redmond US Supreme Court decision (Mosher & Swire, 2002) pro-
tects against compulsory disclosures by therapists under psychotherapist-patient privilege, this issue
is not clearly addressed in Indian law. Together, the findings suggest the need for training about rel-
evant laws in the country as well as reflection or debate about their impact on therapy practice, par-
ticularly when laws and professional positions appear to be contradictory.
The study was not without limitations and these impact on the generalisability of the findings.
Most prominently, these related to the small sample size, of which a majority were trainees. It is
possible that seasoned mental health professionals might have had different experiences, and
more effective ways to address such ethical dilemmas. In addition, the absence of a co-moderator
or audio-recording and transcription of the focus group discussions could have introduced an
element of bias or omissions in the note-taking process. Inter-rater reliability estimates were not
calculated for the qualitative content analysis. Future research should address these lacunae and
include a larger sample comprising of trainees and mental health practitioners having different levels
of clinical experience.
Despite these limitations, the study design facilitated the sharing of sensitive information about
ethical dilemmas from diverse perspectives. The findings have implications for comprehensive train-
ing in ethics for therapists and counsellors – one that reflects the complexity of the potential conflicts
among personal values, professional values or ethics codes, cultural values and laws of the country.
The findings do not imply that ethics guidelines or training must be ethnocentric, but they do point
towards the need for ethics frameworks and decision-making processes to be culturally responsive
and contextually relevant. Adopting the rigid position that ethics must always be culturally congru-
ent has its own dangers; non-dominant voices in the culture (e.g. minority groups) may be margin-
alised (Zechenter, 1997). This may pressure practitioners to align with culturally sanctioned
violations of individual rights and constrain them from questioning culturally imposed positions
in the process of ethical decision-making. Philosophical positions like the social constructivist
 INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH 225

(Liu & Matthews, 2005) or feminist (Hill, Glaser, & Harden, 1998) perspectives which incorporate
cultural and contextual factors may be help in tapping the complexity of ethical decision making.
The therapist’s personal values, which are an amalgamation of personal experiences and cultural
values (Matsumoto, 1989), cannot be completely separated from the ethical decision-making pro-
cess. Should we then strive for ‘cultural matching’ between therapist and client, to reduce ethical
issues arising from discrepant value positions? This approach is accompanied by its own challenges
in a multicultural Indian society, with diverse crosscutting characteristics like gender, religion, ethnic
group, language, and values and beliefs. Moreover, according to the ethical principle of justice, thera-
pists should be pluralistic and inclusive, regardless of the cultural worldview of the client. While ethi-
cal guidelines provide some structure to ethical decision making, the process of ethical auditing must
also incorporate the practitioner’s values, ideological biases, political positions and organisational
dynamics (Reamer, 2001). It is through continued reflection, dialogue, training and supervision in
ethics that the impact of personal values on the perceptions and negotiation of ethical issues can
be understood and addressed. Methodologies that incorporate self-reflection would help trainees
become more aware of their personal values, biases and stigmas and should also include different
methods to resolve therapist–client value conflicts (Farnsworth & Callahan, 2013).
Future research could incorporate both qualitative and quantitative methodologies and use a cul-
tural lens to understand ethical beliefs and practices among mental health practitioners across differ-
ent contexts. Studies could also explore the intersections between therapist personal values and their
ethical decision-making.

Acknowledgements
The authors thank participants of the focus group discussions for their involvement and Ms D. Padmavathy, Ms Anu
Antose and other staff of the NIMHANS Centre for Well Being for their support.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by the University Grants Commission-Senior Research Fellowship under Grant 429/ (NET-
JUNE 2010), as a part of doctoral research by the first author.

Notes on contributors
Ananya Sinha is a PhD research scholar and a Senior Research Fellow at the Department of Clinical Psychology. Her
doctoral work delves into the ethical aspects of psychotherapy and counselling. Her areas of interest include ethics,
trauma, social skills training, sexual minorities and borderline personality disorder.
Poornima Bhola is an Additional Professor at the Department of Clinical Psychology. Her keen interest in ethical
questions is reflected in her involvement in teaching, training and research concerning the ethics of practice. She is
a member of ethics committees and has co-edited a book on ethics. Her areas of interest include psychotherapy pro-
cesses and training, psychiatric rehabilitation and youth mental health.
Ahalya Raguram is Professor and former Head of the Department of Clinical Psychology, with over 25 years of experi-
ence. She is the coordinator of the psychotherapy training programme in the department and has been a member of the
Institutional Ethical Review Board at NIMHANS. Her clinical, teaching and research interests reflect an abiding inter-
est in families and interpersonal relationships as well as individual, family and couple therapies.
Prabha S Chandra is Head & Professor of Psychiatry and has been working in the field of perinatal psychiatry since
1994. She has worked at Mother Baby Psychiatry units in the UK and has special interest in the areas of pre-pregnancy
and pre- conception counselling in mothers with mental health problems; interventions for mother–infant bonding
disorders and medication use in pregnancy and postpartum.
226 A. SINHA ET AL.

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