Academic Seminar

ETHICAL AND LEGAL ISSUES, CODE

OF CONDUCT AND CURRENT
TRENDS INVOLVED IN CLINICAL
WORK
Presented by: Supervised by:
Turfa Ahmed Prof. (Dr.) Sanjukta Das
M.Phil. Trainee, 1st year Department of Psychology
CPCUC University of Calcutta
University of Calcutta
 General Overview

▪ Laws and Policies on Mental Health

▪ Ethical Principles
▪ Code of Conduct
▪ Current trends in the field of mental health
LAWS AND POLICIES ON MENTAL
HEALTH
MENTAL HEALTH POLICIES IN INDIA
Mental hospitals in India were entirely British
conception. Modern medicine and hospitals were
first brought to India by the Portuguese during
17th century in Goa. Mental Asylums, primarily, World Health Organization
were built to protect the community from the (WHO) defined mental
insane and not to treat them as normal health as:
individuals.
“A state of well-being in
The Indian Psychiatric Society (IPS) came into which every individual
existence in 1947. The IPS along with the Indian realized his or her own
potential, can cope with the
Association of Clinical Psychologists (IACP)
normal stresses of life, can
which came into being 1968, and the Indian work productively and
Association of Professional Psychiatric Social fruitfully, and is able to
Workers have played important role in influencing make a contribution to her
mental health policy. Superintendents of all mental or his community”
hospitals were invited to conference in 1960, in
which a draft of mental health bill was discussed.
INDIAN LAWS REGULATING TREATMENT OF
PERSONS WITH MENTAL DISORDERS
 OVERVIEW OF THE MENTAL HEALTH LAWS:
PAST AND PRESENT
The Acts of 1858 (Indian Lunatic Asylum Act, The Lunacy (District Courts) Act, The Lunacy
(Supreme Courts) Act)
• Gave guidelines for establishment of mental asylums and procedure to admit mental patients.
• The various Acts of 1858 naturally reflected the legalistic frame for the management of the mentally
ill and governed the lunacy legislations.
• Public awareness about the pitiable conditions of mental hospitals accentuated as a part of the growing
political awareness and nationalistic views spearheaded by the Indian intelligentsia.

Indian Lunacy Act, 1912

• The management of mental hospitals moved from the control of the Inspector General of Prisons and into
the hands of the central government.
• The role of specialists in the treatment of mental patients recognized and psychiatrists appointed as full
time officers in mental hospitals.
• Mentally ill people viewed as ‘lunatics’, with a large focus being on the protection of the public from
those considered dangerous to society.
 National Mental Health Programme, 1982
The National Mental Health Programme (NMHP) was started in 1982 with the following objectives
✔ to ensure availability and accessibility of minimum mental health care for all,
✔ to encourage mental health knowledge and skills
✔ to promote community participation in mental health service development and to stimulate self-
help in the community.

The strategies of National Mental Health Programme were -

1) integration of mental health with primary health care through the NMHP
2) provision of tertiary care institutions for treatment of mental disorders
3) to eradicating stigmatization of mentally ill patients
4) protecting their rights through regulatory institutions like the Central Mental Health Authority and
State Mental Health Authority.

Gradually the approach of mental health care services has shifted from hospital based care (institutional)
to community based mental healthcare, as majority of mental disorders do not require hospitalization
and can be managed at community level. The National Mental Health Programme Division conducts
nationwide mass media campaign through audio-video and print media.
 Mental Health Act, 1987
After the Second World War, Universal Declaration of Human Rights was adopted by the UN General
Assembly. Indian Psychiatric Society submitted a draft Mental Health Bill in 1950 to replace the outmoded
ILA -1912. Mental Health Act (MHA-1987) was enacted in 1987.

Provisions Challenges
• Progressive definition of mental illness. • Adopts an institution-based approach, ignoring

• Establishment of Central/State Mental Health community-based care.

Authority • Concerned mainly with the legal procedure (Narayan,
• Admission in special circumstances Narayan & Shikha, 2011).
• Role of Police and Magistrate • It could never be implemented properly (Dutta, 2001).
• Protection of human rights of persons with mental • Human right activists have questioned the
illness (PMI).
constitutional validity of the MHA, 1987 (Dhandha,
• Guardianship and Management of properties of
PMI. 2010).
• Penalties in case of breach of provisions • Less weightage given to family and community
psychiatry.
 Rehabilation Council Of India Act (RCI Act), 1992
• The RCI Act came into force on 22nd June, 1993. It was amended in 2000 and then in 2017 and
proposed to be called The Rehabilitation Council of India for Persons with Disabilities
(Divyangjan) Act.
• Incorporated the definiton of disabilities according to RPwD Act, 2016.
• Ensure uniformity and minimum standards, quality, professional conduct, etiquette and a code
of ethics of education and training of professionals.
• To regulate the training policies and programmes.
• To recognise institutions/universities.
• To protect PMI against abuse from others.
• To maintain Central Rehabilitation Register of persons possessing the recognised Rehabilitation
qualification may order that the removal of names from the Register in case of professional misconduct.
• To encourage Continuing Rehabilitation Education (CRE) for professionals.
• To promote research in rehabilitation and special education.
• To recognise Vocational Rehabilitation Centres as human resource development centres.
Persons with disability (equal opportunities, protection of rights, full participation)
Act, 1995
Was enacted in 1995 to remove discriminations in the sharing of developmental benefits vis-a-vis non-disabled
persons and to prevent abuse and exploitations of persons with disability (PWD). It provided:
(a) barrier-free environment; (b) spelled out responsibilities for the government to plan strategies for
comprehensive development programmes for integration of PWD into the social mainstream; (c) mental retardation
and mental illness are categorized as conditions of disabilities.

Limitation:
• There was a provision of 3% reservation in government jobs, but it was not available to the PMI.

District Mental Health Program, 1996

The objectives of the District Mental Health Program (DMHP) are:
• to ensure availability and accessibility with ease, of mental health care for the needy,
• to integrate mental health care with general health services, and
• to promote community participation and to increase awareness.
• Goal is a decentralized, community-based approach to care.
• Expanded to 123 districts under XIIth FiveYear Plan. continued…….
Providing mental healthcare beyond the district level has been very difficult (Singh, 2018).
• It is difficult to train medical officers and other health professionals in diagnosing and treating mental
health disorders and the Mental Healthcare Act (MHCA), 2017 requires diagnosis by internationally
recognized classificatory systems like International Classification of Diseases-10 th Edition (ICD-10).
• Legal consequenses
• Limitation in treating drug abuse cases in primary care.

Mid-term evaluation was carried out in 23 districts by NIMHANS in 2003. The evaluation reported:
The positive impacts: The hurdles:
• enhancement of early detection • problems in fund accessibility
• reduction in distance travelled • unavailability of trained
• decrease in case-load • motivated mental health professionals
• lack of effective central support and monitoring.
Indian Council of Marketing Research in 2009 highlighted the issues pertaining to
• funds
• training
• availability of the drugs
• community clinic not being the most common setting
• lack of community involvement
 Current status of DMHP in West Bengal

Source: NMHS 2016: Mental Health Systems Assessment. Factsheet West Bengal, Annexure-13.
 United Nations Convention on Rights of Persons with Disabilities (UNCRPD), 2006
UNCRPD was adopted in December, 2006. It was ratified by the Parliament of India in October, 2007. Countries
that have signed and ratified the UNCRPD are required to bring their laws and policies in harmony with it.

• Shift in respect of disabilities from a social welfare concern to a human right issue.
• Presumption of legal capacity, equality and dignity.
• Article 2 of the convention, PWD will enjoy legal capacity on an equal basis for all aspects of life.
• Article 3 calls the state to take appropriate measures to provide access to support by Persons with Disabilities
(PWD) to exercise the legal capacity.
• Article 4 calls for safeguards to prevent abuses of the system of support required by PWD.
The Convention permits compulsory mental health care.

The rights enjoyed by the PWDs are:

(1) Respect for inherent dignity, individual autonomy (6) Equality of opportunity
(2) Accessibility (7) Equality between men and women
(3) Non-discrimination (8) Respect for the evolving capacities of children with
(4) Full and effective participation and inclusion disabilities
(5) Respect for difference and acceptance of PWDs
 Protection Of Children from Sexual Offences Act (POCSO Act), 2012

The POCSO Act, 2012 is a

comprehensive law to provide for
SALIENT FEATURES
the protection of children from the
❑ The Act is gender neutral and regards the best interests and welfare of the child
offences of sexual assault, sexual as a matter of paramount importance at every stage so as to ensure the healthy
harassment and pornography, while physical, emotional, intellectual and social development of the child.
safeguarding the interests of the
❑ The Act defines a child as any person below eighteen years of age.
child.
❑ It defines different forms of sexual abuse, including penetrative and non-
penetrative assault, as well as sexual harassment and pornography, and deems
a sexual assault to be “aggravated” under certain circumstances, such as when
the abused child is mentally ill or when the abuse is committed by a person in a
position of trust or authority vis-à-vis the child, like a family member, police
officer, teacher, or doctor.

❑ People who traffic children for sexual purposes are also punishable under the
provisions relating to abetment in the Act. The Act prescribes stringent
punishment graded as per the gravity of the offence, with a maximum term of
rigorous imprisonment for life, and fine.

❑ Procedures for reporting cases, recording child's statement and power of special
courts.
The Act was amended in 2019 (THE PROTECTION OF
CHILDREN FROM SEXUAL OFFENCES
(AMENDMENT) ACT, 2019), to make provisions for The District Child Protection Society under the
enhancement of punishments for various offences so as to deter Integrated Child Protection Scheme (ICPS) and the
the perpetrators and ensure safety, security and dignified District Child Protection Units (DCPUs) under the
childhood for a child. The following are a few changes: Juvenile Justice Act, 2015 envisages a detailed role and
responsibility for protection of rights of children.
They provide provisions to maintain a database of
❑ The Act defined "child pornography" means any visual experts who have experience of working with children.
depiction of sexually explicit conduct involving a child
which include photograph, video, digital or computer
generated image indistinguishable from an actual child, and Legal Involvement of Psychologists:
image created, adapted, or modified, but appear to depict a
child. • Co-ordinated response of all the key players that
provide social services to the children.
❑ Included the clause that whoever persuades, induces, entices • To understand the child's physical and emotional
or coerces a child to get administered or administers or state
direct anyone to administer, help in getting administered • To resolve trauma and foster healing and growth
any drug or hormone or any chemical substance, to a child • To hear the child's version of the circumstances
with the intent that such child attains early sexual maturity. leading to the concern
• To respond appropriately to the child when in crisis
❑ Punishment terms revised for aggravated penetrative sexual • To provide counselling, support, and group-based
assault, using child for pornographic purposes and storage programs to children referred to them
of pornographic material involving child. • To improve and enhance the child's overall personal
and social development, health and wellbeing
• To facilitate the reintegration of the child
 Juvenile Justice (Care and Protection of Children) Act 2015
The Juvenile Justice (Care and Protection of Children) Act 2015 came into force on January 15, 2016. It
replaced the Juvenile Justice Act, 2000.
The aims to consolidate the laws relating to children alleged and found to be in
conflict with law and children in need of care and protection by catering and
A “child” means a person who has not completed
eighteen years of age. The Act classifies the term
considering their basic needs through proper care & protection,
“Child” into two categories: – development, treatment, social- integration, by adopting a child friendly
❑ “Child in conflict with law” (who has committed approach in the adjudication and disposal of matters in the best interest of
an offence and he or she is under the age of 18 years children. The act also focuses on rehabilitation of juvenile offenders through
on the date of commission of the offence) various child care houses and institutions.
❑ “Child in need of care and protection” (found
without any home or settled place of residence or In normal course, a juvenile is entitled to bail, notwithstanding gravity of the
found as child labours) crime. His bail can be refused only when there are reasonable grounds for
Not tried as an adult and is believing that his release is likely to bring into association with any known
sent to Child Care Centre. criminal or expose his moral, physical or psychological danger or that his release
Minor implies young and would defeat the ends of justice.
teen persons
Constitution of a Child Welfare Committee for exercising the powers and to
Juvenile is a person between the age group of discharge the duties conferred on such Committees in relation to children in need
sixteen and eighteen years. A young person who is
of care and protection under this Act and ensure that induction training and
been accused of crime is a juvenile offender and is
tried as adult in court proceedings. A juvenile either sensitization of all members of the committee is provided within two months from
indicates immature person or young offenders. the date of notification.
Several rehabilitation and social reintegration measures have been Some Shortcomings
provided : □ This law becomes contentious because of the
✔ Under the institutional care, children are provided with rising phenomenon of teenagers eloping and
various services including education, health, nutrition, de- consensual sex among teenagers. The boys can
now face trials for rape. Under the Protection of
addiction, treatment of diseases, vocational training, skill Children from Sexual Offences Act (POCSO), a
development, life skill education, counselling, etc to help them child cannot consent to a sexual act until the age of
assume a constructive role in the society. 18, so any act of sex, even consensual, is
✔ The variety of non-institutional options include: sponsorship considered to be rape.
□ It reverses commitments to the UN Convention on
and foster care including group foster care for placing the Rights of the Child, flowing from several
children in a family environment which is other than child’s conventions and guidelines to which India is a
biological family, which is to be selected qualified, approved signatory, which specifically desire India to
and supervised for providing care to children. “ensure that persons under 18 are not tried as
adults, in accordance with the principle of non-
✔ Section 48 of the Act enables the State Government to establish discrimination contained in the Convention.
safety homes in every district for rehabilitation who are found □ As per the new Juvenile Justice Act there is a
to have committed an offence and who are placed there by an provision of availing experts to provide their
inputs to the JJBs. Based on their analysis it is to
order of the Juvenile Justice Board.
be decided whether or not a child committing a
✔ The Act prohibits the disclosure of identity of children with crime is in a ‘child-like’ frame of mind or not. It
respect to their name, address, school or any other particular in places too much liability on the Juvenile Justice
newspapers or any other media. Board which may end up succumbing to the public
✔ Provisions with respect to eligibility of adoptive parents and
outcry and consequently would lead to the children
being transferred to the adult criminal justice
the procedure for adoption. system.
Source: Ahuja, S. (2018). Salient features of juvenile justice act 2015: Comparative study with UK. International Journal of Law, 4(6), 108-117.
 National Mental Health Policy, 2014
It has been called progressive for its:
• Recognition of the interdisciplinary nature of mental health.
• Recognition of vulnerable groups such as children and the homeless.
• Focus on caregivers.
• Focus on prevention and early childhood care.
• Attempt to decriminalize suicide.

Rights of Persons with Disabilities Act (RPWD Act), 2016

RPWD Act, 2016, received the assent of the President on December 27, 2016. CATEGORIES:
• to uphold the dignity of every PwD I. locomotor disability including cerebral palsy,
• to prevent any form of discrimination leprosy cured, dwarfism, acid attack victims and
• full acceptance of people with disability muscular dystrophy;
• ensures full participation and inclusion II. blindness and low-vision;
III. deaf and hard of hearing and speech and
It defines PwD as any person with long-term physical, mental, language disability;
intellectual, or sensory impairments which on interacting with barriers hinder IV. intellectual disability and specific learning
effective and equal growth in the society. It also defines “Person with Bench- disabilities;
mark Disability” as a person with not <40% of specified disability. V. mental illness;
VI. chronic neurological conditions;
5% of seats are reserved in the higher educational institutions for persons with VII. haemophilia, thalassemia and sickle cell
benchmark disability disease; and
(contd..) VIII. multiple disabilities.
 Challenges
• The gazette notification issued
• Duration of 'long term’ intellectual or sensory impairment not spelled out.
on January 4, 2018 regarding
• Special needs of PMI and their families have not been properly addressed. the assessment of SLD had
severe lacunae (John et al.,
• Reservation of only 1% of the total number of vacancies for persons with benchmark
2018):
disabilities arising of autism, intellectual disability, SLD, and mental illnesses a) NIMHANS battery for SLD
assessment is not
(Section 34).
comprehensive for all ages
• Assessment of autism is yet to be notified under the RPWD Act, 2016. and languages. NIMHANS
battery is standardized for 7th
• Act does not spell out measures that need to be taken to ensure the realization of the
grade only (approximately
rights for PMI. till 12 years of age).
b) SLD is the only disability
• In case of intellectual disability, the disability calculation will be done based on
without a scale to quantify in
VSMS score alone and categorization of intellectual disability for IQ range of 70-85 percentage.
c) Lack of well-established
has been left out; ignoring the role of clinical assessment. Disability calculation is
norms for all tests, and these
based only on VSMS score chart ignoring the age of the person with disability norms are based on a very
small sample which makes
• Use of specific percentage of disability instead of mentioning a range when using
generalization difficult.
IDEAS.
 Mental Healthcare Act, 2017
Admission of persons
Rights of persons with with mental illness The Decriminalizing suicide and
mental illness Every act also outlines the procedure prohibiting electroconvulsive
person will have the right and process for admission, therapy It imposes on the
to access affordable and treatment, and subsequent government a duty to rehabilitate such
person who take suicide attempts. A
accessible mental discharge of mentally ill
person with mental illness shall not be
healthcare services. persons. subjected to electroconvulsive therapy
(ECT) therapy without the use of muscle
relaxants and anaesthesia. ECT therapy
will not be performed for minors.
Responsibility of certain
other agencies A police officer in
charge of a police station shall report to
the Magistrate if he has reason to believe
that a mentally ill person is being
ill‑treated or neglected.
Financial punishment
Violating of provisions will
❑ Advance Directive: This empowers invite imprisonment up to 6
a mentally ill person to have the ❑ Mental Health
months or Rs. 10,000 or both.
right to make an advance directive Establishments:
Repeat offenders can face up to 2
toward the way she/he wants to be Central Mental years in jail or a fine of Rs.
treated for the requisite illness and Health Authority 50,000–5 lakhs or both.
who her/his nominated and State Mental
representative shall be. Health Authority.
 `Challen
1) REGULATION OF INFORMAL
ges 5) NO SAFEGUARDS IN THE
(Kumar, 2018)
ADMISSIONS IS DISCRIMINATION 3) SHIFTING RESPONSIBILITY TO
NOMINATED REPRESENTATIVES
AGAINST MENTAL ILLNESS FAMILIES
• Families already struggling SYSTEM
• A mentally unwell adult with free will and
with an unfortunate illness are • A patient who lacks capacity cannot
full capacity to make decisions about his
now burdened with the remove an existing NR even if the
or her care cannot easily access an
inpatient bed unless the medical officer responsibility of all important NR is not acting in the best interest.
(MO) is satisfied with the need for decisions such as compulsory • A procedure to remove the NR (like
admission admission, many of which may DRB review) could have been
• Admission and treatment only after not be accepted by the patient. included in the act to deal with
diagnosis This makes families the direct instances where the MO desires to
target of the patient’s anger and do so in the best interests of the
resentment.
patient.
2) THE STATE AVOIDING STATUTORY 4) DISCRIMINATION AGAINST • The DRB can revoke a minor’s NR
RESPONSIBILITY SINGLE INDIVIDUALS LIVING and a board-appoint a NR.
• The act does not specify how the state is WITHOUT FAMILY
going to fulfill its moral and ethical • Without an NR, mental health
6) ADVANCE DIRECTIVE THAT
responsibility of bearing the cost of such establishment (MHE) would not be
CAN BACKFIRE
treatments and the aftercare, as is able to admit them. The only option
available is for the MO to request • Even if the individual has no
prevalent in many modern societies.
the district review board (DRB) to capacity currently, his AD has to be
appoint an NR. respected.
7) CAPACITY CONUNDRUM AND 9) REJECTING THE LIFESAVING 11) PERSISTING
TREATMENT REFUSAL WHILE EFFECT OF PATERNALISTIC VIEWS
UNDER 89 ELECTROCONVULSIVE • Admission of minors to MHE
• treatment refusal in instances where the THERAPY is another example of
• In situations, when the patient lacks discrimination against
patient cannot either decide for themselves
capacity, psychiatrists should have mentally ill.
or shouldn’t be allowed to decide for • The minor, if a female, cannot
been allowed to administer ECT
themselves. (subject to additional safeguards) as have a male carer, including
• the Act does not give the MO the power to a lifesaving measure. her father.
appropriately treat the admitted patient if
the treatment contravenes the patient’s 10) UNREALISTIC
previous wishes (AD), the patient refuses EXPECTATIONS 12) FORGOTTEN SETTINGS
the treatment (while having capacity to do • Mental health professionals (MHP) AND UNSEEN GAPS
so), or the NR (for a person with no make an independent judgement of • The act confines itself to
capacity) refuses the proposed treatment. the individuals’ mental health and MHE.
determine whether they meet the • The act conveniently avoids
admission criteria. This is an the reality that many patients
8) NEGLECT OF THE NEED FOR
extremely complex task and would receiving treatment in
COMPREHENSIVE CAPACITY
require these professionals to have physical health facilities could
CLAUSES
extensive training. The new act does also have serious mental
• If a medical practitioner attempts to treat a
not specify any mandatory health issues that may need
person without valid consent, he or she
requirements or accreditation immediate treatment,
will be liable under both tort and criminal
process for the professionals sometimes against their
law.
involved in such complex wishes.
• Section 120 of the new act states that the
provisions of the act shall. procedures.
Mental Healthcare (Rights of Persons with Mental Illness) Rules, 2018
The Central Government or the State Government, as the case may be, shall establish such number of half-way homes, sheltered
accommodations and supported accommodations, at such places, as it deems fit, for providing services required by persons with
mental illness, having regard to the following, namely:-
(a) the expected or actual workload of the facility to be established;
(b) the number of mental health establishments existing in the State;
(c) the number of persons with mental illness in the State;
(d) the geographical and climatic conditions of the place where such facility is to be established .

The Central Government or the State Government, as the case may be, shall establish such number of hospital and community based
rehabilitation establishments.
Reimbursement of the intermediary costs of treatment at mental health establishment till such time as the services are made
available in a health establishment established or funded by the State Government, in the district where a persons with mental,
illness resides, such person may apply to a Chief Medical Officer of such District for reimbursement of costs of treatment at such
mental health establishment.
Right to access basic medical records
Any individual resident who is in the custody of the person in charge of custodial institution run by Government is not permitted to
leave without the consent of such person, shall display signage board in a prominent place in English, Hindi and local language, for
the information of such individual or any person with mental illness residing in such institution or his nominated representative
informing that such person is entitled to free legal services under the. Legal Services Authorities Act, 1987 or other relevant laws or
under any order of the court if so ordered and shall also provide the contact details of the availability of services.
ETHICAL PRINCIPLES
 BACKGROUND
Human understanding of the source of mental illness has evolved over the centuries.

The idea of demonic possession

• Ideas of witchcraft and exorcism in medieval Europe. Attribution of mental illness to demons and treatment by magic and
occult practices was noted in the Indus valley period (around 1500 BCE).

Development of the concept of “psyche” and psychological treatment

• Emphasising the importance of looking within to understand mental disturbance and talking through to deal with it. Bhagavad
Gita is considered to be the simplified and condensed form of the Vedas and Upanishads which provided one of the earliest
written descriptions of anxiety and depression.

Renaissance
• Scientific scrutiny and emphasis on individual differences along with placing mental illnesses in the realm of medicine did much
to demystify mental disorders at that time.
Humanistic stance of Pinel, Luke and Dix
• The treatment of the mentally ill and asked for more ethical and humanitarian treatment (Butcher et al., 2014; Day, 1990).
Concepts of ethics and morality appeared in many cultures throughout
recorded history. The oldest and most common source for moral Following the arrival of the British
guidance usually comes from a culture’s religious scripts. A review of
Christian, Eastern, and Muslim cultures reveals that the fundamental empire in India the contribution has
rule of conduct Jesus, Buddha, Mohammad, and others teach is that
people should treat each other as they would like to be treated
mostly been about institutions and
themselves. The old saying “Love thy neighbor as thyself” is a message increasing their accommodation.
that repeatedly emerges in various scriptures as the most basic
religious/spiritual/moral commandment, calling us
to behave ethically. Psychologists’ striving for
ethical behaviour led to the development
of a code of conduct that governs and
“Always treat others as you would like them to treat you: ensures the rights of client and clinician.
that is the law and the prophets.” (Christian; from “The
Sermon on the Mount,” The Book of Matthew) The atrocities committed by Nazi doctors
brought the whole question of medical
ethics to the forefront (Pettifor, 1996). In
“Hurt not others in ways that you yourself would find
hurtful.” (Buddhist; Udana-Varga 5:18) the US, an ethics committee was formed
in 1947 and its recommended code of
ethics was circulated as early as 1953.
“No one of you is a believer until he desires for his
brother that which he desires for himself.” (Islamic; from
Muhammad’s last sermon, Sunnah)
 WHAT ARE ETHICS?
concerns distinction
It all starts with morals, which are rules to guide our behavior based on socially agreed principles. between right and
wrong

Ethics are a moral framework that is applied in evaluation of human actions.

This term has two meanings:

• one is ‘a social, religious, or civil code of behavior considered correct.
• the other is ‘the philosophical study of the moral value of human conduct and of the rules and
principles that ought to govern it.
It thus seems that the term ethics relates to principles of
appropriate, correct, and just behavior among members of the
human family.

Thus, for psychologists, ethics are absolute standards or principles that form the basis for ethical
judgements. From these principles one might develop some guidelines for behavior or code of conduct.

The various organizations that develop codes of ethics use the terms in different ways.
 WHY ARE ETHICAL GUIDELINES REQUIRED?

Development of professional competence. This is a complex, multidimensional construct (Epstein & Hundert,
2002).

The development of psychological fitness. Pope and Brown termed emotional competence for therapy (Pope &
Brown, 1996; Pope & Vasquez, 2010). Emotional competence is in part an active awareness of the emotional
aspects of providing clinical services and the limits of our emotional competence.

Self-proclaimed and unqualified practitioners and traditional faith healers are adversely affecting the standard of
mental health services in India.

In India, although practicing therapists need to be registered with the Rehabilitation Council of India (RCI), no
accreditation or proof of adequate supervision is needed to offer psychological services.
 GENERAL ETHICAL PRINCIPLES BY AMERICAN
PSYCHOLOGICAL ASSOCIATION (APA), 2002

Beneficence and Fidelity and

Nonmaleficence: Responsibility: Integrity:
Psychologists seek to safeguard the Psychologists establish relationships Psychologists seek to promote
welfare and rights of those with of trust and cooperation with those accuracy, honesty, and
whom they interact professionally with whom they work to the extent
and other affected persons, and the needed to serve the best interests and truthfulness in the science,
welfare of animal subjects of seek to manage conflicts of interest teaching, and practice of
research and avoid or minimize that could lead to exploitation or
harm. psychology.
harm.

Justice: Respect for People’s

Fairness and justice entitle all Rights and Dignity:
persons to access and benefit from
services and to equal quality in the Psychologists respect the dignity and
processes, procedures and services. worth of all people, and the rights of
Ensure potential biases, boundaries individuals to privacy,
of competence and the limitations of
psychologists' expertise do not lead confidentiality, and self-
to or condone unjust practices. determination.
ETHICAL STANDARDS AS DEFINED IN APA ETHICS CODE
1. Resolving ethical issues Take reasonable steps to correct or minimize the misuse or misrepresentation of their work and
take steps to resolve conflicts.
2. Competence Guide professional practice based on the limitations of their education, training and
professional experience.
3. Human relations Avoid unfair discrimination or forms of harassment, conflicts of interest and multiple
relationships and resolve personal problems and conflicts.
4. Privacy and Psychologists have a primary obligation and take reasonable precautions to protect
confidential information obtained through or stored in any medium, recognizing that the
confidentiality extent and limits of confidentiality may be regulated by law or established by institutional
rules or professional or scientific relationship.
5. Advertising and other Psychologists are required to avoid false and deceptive statements both directly and by others
whom they have engaged to represent them.
public statements
6. Record keeping and fees Maintain satisfactory documentation of their professional activities and the confidentiality of
records. Reach payment and billing arrangements as soon as it is feasible. Fees are paid with
money and not barter of services. Therapy is not to be terminated due to non-payment of fees.

7. Education and training Course content must meet ethical standards for professionalism and scientific merit. Unethical
demands are not to be made on students.

continued.......
8. Research and When institutional approval is required, psychologists provide accurate information about their
research proposals and obtain approval prior to conducting the research. They conduct the research
publication in accordance with the approved research protocol. Informed consent is obtained from participants
where they are informed about their right to decline and withdraw from the research once participation
has begun, the potential risks and benfits of the research and whom to contact for queries. Obtain
informed consent from research participants prior to recording their voices or images for data collection
9. Psychometry Use tests that have been constructed using a scientifically valid method, and to be performed only in
the context of a defined professional relationship. Tests with obsolete or irrelevant norms cannot be
interpreted and reported on. Persons who are not qualified for test use and interpretation should not be
given access to test material or raw test data. There is a clear contract regarding who is going to be
informed about the test results in a way that is easy to understand. The client has a right to raw test
data and to have test results explained in full; reveal the potential for harm and allow client to decide if
they still want the results. When clients are too ill to make decisions, the subject is discussed with family
members and other clinicians.
10. Psychological The nature, course and other relevant details have to be discussed with the client in a language that is
understandable and considers client preferences and best interests. Informed consent is taken.
interventions Clinical psychologists do not have sexual relations with clients or with relatives of clients. If the
services are interrupted by factors such as the therapist’s illness, unavailability or relocation, suitable
arrangements for continuation of services must be made. Therapy is terminated when it becomes clear
the client no longer needs the service, is not benefiting from it, or is being harmed by it. Pre-
termination counselling, review of therapy and post-termination arrangements should be made.
 ETHICS ACCORDING TO THE REHABILITATION COUNCIL OF
INDIA (RCI):
The Council may prescribe standards of professional conduct and etiquette and a code of Infamous conduct: If a professional-
1) indulge in exaggeration of
ethics for education and rehabilitation professionals and personnel. forecasting of course of disease
2) involve in any indecent act
3) maintain improper or illicit
Rules made by the Council may specify which violations thereof shall constitute infamous relations with any PwD
conduct in any professional respect, that is to say, professional misconduct, and such provision 4) make use of harsh or rough
language with any PwD
shall have effect notwithstanding anything contained in any other law for the time being in force. 5) charge exorbitant consultation
fee or service charges
The Council may order that the name of any person be removed from the Register where it is 6) take any undue advantage from
satisfied, after giving that person a reasonable opportunity of being heard, and after such further the mental or physical affliction of a
PwD
inquiry, if any, as it may deem fit to make 7) insert, affix or adjust knowingly
any non-standard aids or appliance to
(i) that his name has been entered in the Register by error or on account of misrepresentation or a PwD
8) does not undertake the
suppression of a material fact rehabilitation or the treatment of
PwDs on regular and required
(ii) that he has been convicted of any offence or has been guilty of any infamous conduct in any intervals or proper time
professional respect, or has violated the standards of professional conduct and etiquette or the 9) neglects knowingly and
intentionally any PwD
code of ethics prescribed which, in the opinion of the Council, renders him unfit to be kept in the 10) avails or attempt to avail any
Register. benefit meant for PwDs
11) undertake practice in any field
other than his specialization.
 BEST ETHICAL PRACTICES
Barnett (2007) has discussed three important strategies for best ethical practice.

Risk Defensive
Positive Ethics
Management Practices
• Striving to achieve the • Minimizing risks for • Direct protection of the
highest ethical standards the psychotherapist psychotherapist.
in the profession that may result in • It involves making
(beneficence, ethics complaints or decisions based on
nonmaleficence, fidelity, malpractice claims. reducing the possibility
justice, autonomy) and of adverse outcomes
self-care.
for the psychotherapist.
 Intersections Between Ethics and the Law
Ethics invariably intersect with legal frameworks and the changing Ethical issues related to therapeutic competence are complicated by
socio-political climate. On one hand, changes in laws might call for uncertainties regarding registration and licensing of counsellors and
corresponding modifications in ethical codes. therapists in India. Isaac (2009) highlighted concerns about reporting,
accountability and legal sanctions for ethical transgressions by
The Indian Psychiatric Society and the Karnataka psychotherapists in India. However, recent developments like the Right
Association of Clinical Psychologists have made official to Information Act, 2005 and the Consumer Protection Act, 1986 have
statements against the concept of homosexuality as a provided avenues for information-seeking and redressal. This has
increased concerns about documentation, confidentiality and related
mental illness (Orinam, 2014) and against reparative
ethical issues among practitioners and is accompanied by the possibility
treatments for homosexuality (Hemchand, 2016) but these of a shift to more defensive practice patterns.
have not been integrated into the ethics codes. Other
professional organizations in the country have been silent
on this issue and this must be viewed in the backdrop of Avasthi and Grover (2009) examined complex dilemmas related
decriminalization of Section 377 of the Indian Penal Code. to documentation of therapeutic encounters in terms of medico-
legal ramifications in India. Effective documentation of therapy
sessions can serve as a guide to practice and may even protect
The Protection of Children from Sexual Offences Act, 2012
the clinician in the event of any litigation. On the other hand, the
was notified in June 2012 and calls for mandatory reporting
sensitive personal information may be open to disclosures in a
of child sexual abuse in India, with legal sanctions for non-
court of law and this has its own ethical ramifications. Avasthi
compliance. This has significant implications for
and Grover (2009) highlighted the lack of clarity about
counsellors and therapists practising in a variety of settings
privileged communication and the limits of disclosure in the
in the country and calls for reflection on possible inclusion
Indian law.
in professional ethics codes.
 Recent research in India revealed that although practitioners were
Is there any aware of therapist–client sexual boundary violations committed by
enforcement value to colleagues (Kurpad et al. 2010), there was little clarity on reporting
ethical codes? How mechanisms within the professional organization and in the larger
much is it meant to legal system. The processes for reporting colleagues’ ethical
misconduct are ill-defined in India and even where provisions exist
monitor professional
on paper, they may be rarely used.
behaviour?
Work in forensic settings may throw up ethical challenges that differ
from those in traditional practice. Psychologists are increasingly
being called upon to conduct assessments and offer expert opinions
on psycho-legal issues. Working with children in conflict with the
law requires adequate knowledge about the legal framework for
juvenile justice in India (Jacob et al. 2014).

Contemporary professional standards and guidelines should anticipate the interlinked legal, professional,
moral and ethical factors which can inform practice in the forensic speciality area. Ethics and the law are
closely linked but not always synchronous and there is a need for more open communication between the
disciplines of mental health and the law.
CODE OF CONDUCT
 CODE OF CONDUCT
Indian Association of Clinical Psychologists (IACP) has adopted the following code of conduct
for its professional members.

⮚ PROFESSIONAL ⮚ PATIENTS WELFARE:

⮚ REFERRALS: Clinical psychologists should not ⮚ CONSENT FOR
It is a responsibility to ascertain the
COMPETENCE & basic prerequisites of psychological take up any case which is not TREATMENT:
SERVICES: assessment when a case is referred to within their competence and It includes all
Clinical psychologists a clinical psychologist. If proper should also maintain a high information about the
should keep abreast of assessment is not possible this should
regard for the patient’s integrity nature of illness, method
recent developments in be communicated to the referral
the field. source. and welfare by following an of treatment, factors
efficient and scientific treatment associated with efficacy
procedure. and risk factors.
⮚ METHOD OF EXPERT
OPINION: ⮚ COURT TESTMONY:
⮚ CONFIDENTILITY:
Clinical psychologists should Take precautions to maintain the This should be based purely on
take full responsibility for their confidentiality and privacy of clients in all forms (oral, findings and observations and
opinions under all written and electronic). Test material should not be taken
should not include bias and
circumstances. out of the clinic or laboratory except for teaching
purposes. prejudice.
 ETHICAL DILEMMAS FACED BY
CLINICAL PSYCHOLOGISTS
A study in NIMHANS (Bhola et al., 2015) highlighted the ethical dilemas that are faced by clinical psychologists in the clinical settings:
□ The sixth category included two different ethical
client’s right to autonomy and self-de- conundrums that emerged during the therapeutic process.
termination □ Therapists may question the ethical implications
6%
of defining “who is my client” when dealing with
Principle of beneficence and cases involving couples or a family.
nonmaleficence. □ Ethical responsibility to respond to and report a
8.5%
colleague’s ethical transgressions.
Appropriate negotiation of
Competence therapist–client boundaries
8.5% 37.10%
Only 57% of the
It was related to the issues participants felt that
of dual relationship, they had resolved
accepting gifts and their dilemma 34.3%
disclosure by the therapist successfully and
effectively. 45.7%
of details about themself.

Confidentiality
34.3% supervision/consultation with peers and pro-
fessional colleagues
Disclosure of certain information guidance from ethical codes
about clients to their family The availability, accessibility and support of the
members or the legal authorities
and the uncertainty regarding the
supervisor were considered useful by the majority of the
limits of confidentiality. trainees.
CURRENT TRENDS IN THE FIELD OF
MENTAL HEALTH
 HEALTH INSURANCE AND MENTAL ILLNESS
Section 21(4) of Mental Healthcare Act, 2017 says, “Every insurer shall make provision for medical insurance
for treatment of mental illness on the same basis as is available for treatment of physical illness.”

□ Economic burden of mental disorders and its consequences

Data from the National Mental Health Survey (NMHS) 2015-2016 reveal that mental disorders are significantly higher in
households with lesser income, low levels of education, or limited employment.

□ Need for health insurance in Psychiatry

• According to the NMHS, common mental disorders including depression, anxiety disorders, severe mental disorders,
and substance use disorders are a huge burden affecting 11% of the population anytime.

• Despite the availability of effective treatment for these disorders, a huge treatment gap exists for common mental
disorders, the highest being 86.3% for alcohol use disorders and for major depression and neurosis were identified to be
85.2% and 83.2%, respectively.

• Affordability of care was identified as one critical factor influencing treatment utilization.
Swavlamban Health Insurance Scheme:
The New India Assurance Company Limited, in association with the Ministry of Social Justice, the
Department of Empowerment of Persons with Disabilities had launched this scheme on October 2, 2015. The
aim were:
• Affordable health insurance to PwDs.
• Available for PwDs with an annual family income of Rs. three lakhs or below.
• Uniform premium of INR 357 is collected from the insured person. .
• The Out Patient Department (OPD) cover up to Rs. 3000 per annum.
• Preexisting illnesses are also covered under the scheme.
During mid 2017, the scheme was stopped, and the current status of the scheme is unclear.

National Health Protection Scheme (NHPS) of the Ayushman Bharat:

The NHPS which will subsume the ongoing centrally sponsored schemes – Rashtriya Swasthya Bima Yojana
(RSBY) and the Senior Citizen Health Insurance Scheme – was launched in 2018 by the Government of India.
It targets deprived rural and urban families as per the latest socioeconomic census data. This “Ayushman
Bharat Yojana” has a two-fold strategy.
a) comprehensive primary care accessible at a center near the community. It also aims to provide guidance
on healthy lifestyle practices.
b) Introduction of the Pradhan Mantri Jan Arogya Yojana, which provides cashless health insurance cover
up to Rs. five lakh per family (no restriction of family size) per year.
Swasthya Sathi

✔ “Swasthya Sathi” (SS) is a comprehensive health protection scheme entirely funded by the state government
was announced in cabinet on 17th February, 2016 and the scheme was officially launched by Hon’ble Chief
Minister of West Bengal on 30th December 2016.

✔ Basic health cover for secondary and tertiary care up to Rs. 5 lakh per annum per family.

✔ Paperless, Cashless, Smart Card based. Cards issued in the name of female head of the family as gender
empowerment.

✔ All pre-existing diseases are covered.

✔ There is no cap on the family size and parents from both the spouse are included. All dependent physically
challenged persons in the family are also covered.

✔ The entire premium is borne by the State Government and no contribution from the beneficiary.

✔ SS has covered over 1.5 crore families.

 Challenges
(Bijal et al., 2019)

3) Preventive and rehabilitation services:

1) Long duration of treatment:
Treatment of mental illness also includes
⮚ Package based on number of days of
hospitalization or predetermined
interventions such as psychosocial rehabilitation,
package based on diagnosis? psychotherapy, and counseling.
⮚ What happens if there are more than
one diagnoses?
⮚ Should the maintenance treatment be
considered? 4) Suicide attempts
⮚ Should all suicide attempts get
insurance cover?

⮚ 2) Willful noncompliance to
treatment by patients:
5) Providing medical records to the insurance
⮚ What if a person wishes to be
company:
treated in a manner that is more
There are no guidelines or regulations
expensive than the other equally
regarding how much medical records can be
efficacious alternatives available?
shared with insurance companies.
 Online Interventions
❖ Digital technologies take confidential information that was once confined to a paper chart
kept under lock and key and spread it over electronic networks.
The question of
❖ Carelessness, human error, and hacker ingenuity make these networks vulnerable to a whether online
communications
growing cascade of breaches. Liu, Musen, and Chou (2015) reported that 29 million records are ethical at all
as a form of
containing confidential patient information had already been breached between 2010 and service mostly
2013. stem from the
concern that
remote
❖ As confidential patient information is housed in distant servers, sent through many networks, communications,
such as text or
and carried around in our laptops and personal digital assistants, it becomes ever more telephone, may
vulnerable to theft and other forms of loss. be insufficient or
less effective than
f2f, inoffice
❖ Technology presents other potential problems. Clinicians' careless tweets, blogs, and posts encounters.
to social media sites have piled up unprofessional public comments about patients,
colleagues, and settings (e.g., Kesselhiem, Batra, Belmonte, Boland, & McGregor, 2014).
These public comments can affect clinicians' careers.
❖ Digital technologies also provide the opportunity to make information about psychological
tests—including the test items themselves and scoring guides—widely available to anyone
who can access the Internet.
 Questions to Assess Uses of Digital Media

❑ Where Is the Computer?

❑ Is the Computer Protected From Hackers?
❑ Is the Computer Protected From Malicious Code That Can Access
Confidential Information?
❑ Is Confidential Information Encrypted?
❑ Is Your Computer Protected From Viruses and Other Malware?
❑ Is the Computer Protected Using a Strong Password?
❑ How Are Confidential Files Deleted?
❑ How Are Computer Disks Discarded?
❑ How Do You Guard Against Human Error in Handling Confidential
Information?
❑ How Do You Make Sure That Only the Intended Recipient Receives
Your Confidential Information?
❑ Do Your Clients Clearly Understand the Ways in Which They Can or
Can't Communicate With You via E-Mail, Text Message, or Other
Digital Means?
❑ Are You Aware of the Professional Guidelines for Teletherapy, Internet
Therapy, and Other Clinical Services Provided Through Digital
Media?
 ETHICAL CONSIDERATIONS FOR ONLINE PRACTICE
A NEW MEDIUM: KNOW THE Following are some situations in which online consults are not recommended:: If a
POTENTIAL, RECOGNIZE LIMITS, client has thoughts of hurting or killing him/herself/another, in a life-threatening
AND INFORM CLIENTS or emergency situation of any kind, has a recent history of suicidal, violent, or
abusive behavior, holds what others may consider unrealistic beliefs (delusions) or
sees or hears things that others don’t (hallucinations), is actively abusing alcohol
or drugs. Clinicians should discuss with the client the effectiveness, limits, and
risks, as well as point out the availability and effectiveness of alternative
treatment.
THE POSSIBILITY OF IN-OFFICE An initial intake in the actual office be potentially more beneficial, but online
CARE AND A CONTINGENCY clinicians also need to recognize that the f2f modality may be required at some
ARRANGEMENT point. Although a client may not actively be in crisis when contracting the service,
anyone might sometimes experience an emotionally overwhelming situation that
requires more intensive care.
WHY IT IS IMPORTANT TO KNOW The first consideration is the client’s safety: it is necessary to enable the clinician
THE IDENTITY OF AN ONLINE to offer concrete intervention if/when such is needed. The second reason clinicians
CLIENT online need to know the identity of their clients is to avoid dual relationship.
UNDERSTANDING RISKS TO Often an inexpensive way to protect yourself is to download one of the email
CONFIDENTIALITY OF ONLINE encryption software packages. Communicate using an online counseling platform
COMMUNICATIONS that already provides an extra measure of privacy for secure chat and email. To
maintain ethical service, online clinicians should inform themselves about and
advise clients of the potential risks to confidentiality in regard to Internet
transmissions.
KEEPING PRIVATE By law, clinicians and organizations are now required to keep clients’ private information
COMMUNICATIONS secure and private. Thus, when considering a venue or product through which to conduct
AND DATA SECURE online consultations, clinicians should make sure that it includes a way to protect the security
of confidential data transmissions and storage. Sites and products that allow authorized access
with a password usually also mention the level of encryption security that is used.
Occasionally updating security features for communications and data will help ensure that
privacy is adequately protected.
WHO COVERS THE Text-based consults are still mostly not considered a reimbursable service by many insurance
COST OF carriers. As a result, most users of the new medium have to cover the expense of consultation
TREATMENT online out of their own pocket. Clinicians who provide online consults should clearly explain
ONLINE? current reimbursement policies to their clients.
QUALITY Licensed clinicians must provide accurate information about their credentials, license,
ASSURANCE AND training, or certification to clients. will post information about their professional standing for
DISPUTE the public to view, as well as show links to agencies that govern or supervise their work and
RESOLUTION license. Display of such links and information will allow patients to conduct further inquiries,
in case a dispute about the quality of service, treatment procedure, diagnosis, billing practices,
or any other issue cannot be resolved directly between the clinician and the client.
RECORD KEEPING There should be no difference between the way clinicians keep and safeguard treatment
records when communications take place online, over the telephone, or in f2f encounters.
Online clinicians maintain records of clients who receive their service online using standard
office procedures
MASTERY OF THE To ensure mastery and understanding of the medium, online clinicians must acquire technical
NEW MEDIUM skills, get consultation, or contract to practice under an experienced supervisor prior to
providing professional services online.

Source: Kraus, R. (2004). Ethical and Legal Considerations for Providers of Mental Health Services Online. In R. Kraus, J.S. Zack & G.
Stricker (Eds) Online Counseling: A Handbook for Mental Health Professionals, Elsevier Academic Press, London.
 The following groups may be offered tele-
psychotherapy services after assessment of need,
suitability and consideration of alternate options.
Some factors to be considered in the decision to offer
(i) Pre-registered clients, for whom detailed tele-psychotherapy services include:
evaluation has been completed earlier and a
provisional diagnosis already arrived at. They may (i) Client factors such as cognitive abilities and
have also completed a psychotherapy intake session current clinical status and their comfort with using this
in-person. method. Those with severe psychopathology and/or
suicide risk are not suitable for tele-psychotherapy
(ii) Clients who have accessed helplines and are sessions.
referred for more intensive/longer-term
psychotherapy services. (ii) Technology and Logistical factors such as access
to and comfort with technology, and reasonable level
(iii) Clients who are referred for psychotherapy of privacy for the client in the home setting.
by health professional colleagues/organisations/
others or those who seek psychotherapy services (iii) When clinical psychologists/trainees are working
directly. in multidisciplinary teams/with other professional
colleagues/consultants, it is advisable to include these
members in the decision about tele-psychotherapy
Source: Guidelines for telepsychotherapy services. (2020). NIMHANS, services planned for each client.
Bengaluru.
 CONCLUSION
The primary difference To increase the ethical behaviour of clinical
Having a formal code with behavioural between the Indian and psychologists, we need to develop a uniform
specifics seems to decrease unethical American ethical code is that of mechanism by which they can be held
behaviour (Tubbs & Pomerantz, 2001). accountable for their behaviour. If we do not
accountability. take adequate steps soon, this role may be
However, challenges related to
taken over by consumer courts or other
therapist–client interactions and
groups.
interventions through the digital media
and the internet may not be adequately
addressed by all professional ethical RPWD Act, 2016, discusses the formation of Special Courts and also
codes. appointing of Special Public Prosecutor for the purpose of implementation
of the legislation. Similarly, MHCA 2017 discusses having the Mental
Health Review Boards at each District for providing justices to the PMI.
This is a duplication of services and waste of resources. Synchronizing
both the legislation would help share the resources and enable
implementation of both the acts effectively.

In a country like India, mental health care is usually not perceived as an important aspect of public health care,
and in the current global financial crisis, people with mental disorders are among the most vulnerable, and programs for
their social inclusion are not always regarded as a priority by local administrators.
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THANK
YOU

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