Confidentiality, informed consent, and multiple relationships in four emerging regions

There has been a rapid increase in the globalization of professions since the turn of the century, and this has been true for the psychology profession as well. Psychological research evidence, theories and practice have spread rapidly, influenced in no small part by ever-widening access of diverse people to technologies, as well as increased dissemination and sharing of training and resources. There is also an evidence base of increased mental health concerns (e.g., Furukawa & Kessler, 2019) in many contexts, and in the spread of ideas from psychology to ameliorate symptoms and tackle these occurrences more widely than before. In parallel, psychologists have faced increasing demands to demonstrate their accountability both to the people with whom they consult (often as their clients become more aware of their rights), as well as to organizational or institutional settings in which they work (Greenberg & Smith, 2008). Ethics is therefore a central element of their work.

Ethical practice is at the core of the discipline of psychology and is often one of the first modules covered in introductory training. Francis (2009) wrote of the need to expose aspiring professionals to ethics in the formative stages of their training, as a means to set the foundation of expected professional behaviors. The nature of the content of what is ethically covered in training as well as continued professional development is thus of important interest. Codes of ethics comprise an important component of ethics training. Sinclair (2012) traced a number of historical influences upon the development of ethical codes of practice, highlighting both the influence of existing medical codes, as well as events that have underscored the need for such. She noted that prior to the Modern Era, there were ethical documents such as the “Ayurvedic Oath of Initiation” from India; the Hebrew “Oath of Asaph”; the Persian “Holy Abbas’s Advice to a Physician”; the “Seventeen Rules of Enjuin” from Japan; and the “Five Commandments and Ten Requirements” influenced by Confucian thought in China. These documents all pre-date modern developments and contain elements that overlap with more recent professional ethics codes.

Unfortunately, over the past few decades many of the ethical codes for psychologists were initiated by national psychological organizations influenced by predominant thinking in the developed or “Western” world, also characterized as White, Educated, Industrialized, Rich and Democratic (WEIRD; e.g., Azar, 2010). Leach and Gauthier (2012) commented on the need for culture-centeredness of codes of ethics, because these are developed within a specific cultural milieu and are reflective of the values of that culture. That said, when developing ethics codes, there has been a lot of borrowing of ethics standards and principles across countries, but it is unknown how they are actually interpreted and implemented across countries, given the influences of different cultures. For example, though a principle such as integrity or a standard such as confidentiality may be commonly found across psychological ethics codes, because they are common components of the psychology profession internationally, the extent to which they have the same meanings given cultural (as well as political, historical, legal, and religious) contexts is unknown.

There have been a few ethical documents that are regional and assist national psychological associations with the development of their ethics codes (e.g., those provided by the European Federations of Psychologists’ Associations [EFPA]). While these types of documents offer guidance for ethical development across countries, the interpretation of specific components of national psychological ethics codes has yet to be examined. In part because of this complexity, and as more countries have developed codes of ethics over the past few decades, it became important to develop an international document to help psychologists consider their ethics from a principled perspective. A landmark event occurred through the publication of a multi-national ethical declaration, which codified core principles that appear to be shared by the majority of ethics documents internationally. This document, termed the Universal Declaration of Ethical Principles for Psychologists (International Union of Psychological Sciences [IUPsyS] 2008), contains four ethical principles, including: a) respect for the dignity of persons and peoples; b) competent caring for the well-being of persons and peoples; c) integrity; and d) professional and scientific responsibilities to society.

Leach and Gauthier (2012, p. 34) noted that the Universal Declaration “reaffirms the commitment of the psychology community to help build a better world where peace, freedom, responsibility, justice, humanity, and morality will prevail.” Because it is a set of principles, the Universal Declaration is described by Gauthier (2008) as not being enforceable as a mechanism for formal accountability. He noted that formal accountability, regulation, enforcement, and quality assurance are mandated based on laws and cultures within specific jurisdictions and therefore cannot be enforced. However, it is an important document due to its scope and ability to guide psychologists in their ethical thinking. Leach (2022) recently examined the values embedded within the Universal Declaration and assessed the number of national codes of ethics espousing these values. The 36 values noted within the four principles were fairly evenly spread across four quartiles, and he also highlighted the implementation of the Universal Declaration values found across national ethics codes.

There is a need to clarify differences between ethical principles and ethical standards. Both of these must be considered within context. Principles (e.g., integrity, nonmaleficence) are often considered to be both foundational and aspirational and are overarching ways for psychologists to engage in their work. Ethical standards are generally considered to be enforceable and designed to guide practice. Leach and Gauthier (2012) noted that the purposes and emphases of codes comparatively, across national contexts, vary depending on “cultures, laws, values and interpretations” (p. 30) and often reflect the degree of development of the professional associations. As an example, standards are enforceable only to the extent that there is a regulatory body that can enforce them, and may be called something else (e.g., guidelines) in other countries without these bodies. As another example, principles may have different acceptance and inclusion levels. For example, if a national psychological association deems human rights to be a principle, other national associations may not agree that it should be a psychological principle and exclude it from their ethics code. Overall, even the ethical language found is not consistent when considering international ethics documents and interpretations.

In just over a decade following the launch of the Universal Declaration (IUPsyS, 2008), it is valuable to consider developments in ethical principles and practice in some countries where ethical codes for psychology did not exist until recent times, or perhaps existed to a limited extent. While we agree with Greenberg and Smith (2008, p. 94) that in many places, psychology as a profession “has an admirable track record of proactive engagement with ethical issues and challenges … ”; in contexts where psychology does not have a large historical “footprint,” it is likely that ethical discussions and the establishment of precedents may need further development. Knapp et al. (2017, p. 5) noted that professionals build relationships of trust with citizens, “with concurrent responsibilities to promote the public welfare and avoid or minimize conflicts of interest with their clients or patients. For psychologists, these obligations are delineated in the agreed-upon ethical standards of conduct.

Concurrent with the development of the Universal Declaration and its impact on international ethical thinking, another area of international ethics work has been completed by Leach and colleagues, comparing ethical standards found within national psychological ethics codes. The research focuses on finding common and uncommon standards across codes to determine common ethical agreement within the profession of psychology across countries. Results from these studies help solidify a profession and show agreement of underlying values found within psychology. Examples of these studies include determining common ethical standards surrounding research (Leach & Gauthier, 2012), duty to protect (Leach, 2009), and competence (Leach et al., 2016). While there is variability of ethical standards across national codes of ethics, only a small number appear to be found in most codes, including informed consent, multiple relationships, and confidentiality. Leach and Gauthier (2012) noted that the examination of the purposes and emphases of ethics codes, comparatively across national contexts, vary depending on “cultures, laws, values and interpretations” (p. 30) and often reflect the degree of development of the professional associations. Though daunting, comparing meanings across cultures is the next step in understanding ethical standards across countries.

In particular, in four articles to follow, we sought input from scholars in countries that have had only a recent, yet growing emphasis on psychology and by extension, ethics. While there will be more extensive literature bases debating ethical issues in countries where psychological practice and research have a longer history, this may not be the case in such countries that have had limited exposure to psychology, or where the discipline is newer due to the country’s emergence from political regimes that limited people’s exposure to or the independent practice of psychology. Many psychologists working in such contexts may very well have been taught ethical codes from Westernized countries in which they received training and may thus need to grapple with the application of these ethical ideas, where cultural and religious traditions, as well as legal systems, influence ethics very differently. Others may simply have been taught psychological ethics in their home countries, but these ethics codes were borrowed from Westernized countries. Regardless, the literature in non-Western psychological ethics is almost non-existent.

Authors from four different countries (China, Lebanon, United Arab Emirates, and Ukraine) were thus invited to discuss three ethical standards in their particular contexts (informed consent, multiple relationships, confidentiality). These three standards were chosen because they are commonly found within codes of ethics, and they are all culturally, legally historically, politically, and religiously influenced. Different interpretations of specific ethics standards depend on culture, laws, and professional expectations (Beauchamp, 2003). The regulation of these standards is based on the implementation of regulatory bodies and their abilities to enforce these standards, something that the authors in the four following articles will also discuss. The overall umbrella regulatory professional bodies may have been either absent until very recently, or largely uninfluential due to being in their infancy in these countries. This may influence the relative impact of ethical standards, where regulations may not be specific to psychology and counseling, and often the regulatory authorities may be located in predominantly medical, health or social care organizations.

Before exploring the three key issues that we asked authors to cover in their articles (i.e. confidentiality, informed consent, and multiple relationships), certain terms and ideas need to be clarified. These include culture, the use of language, emergence from political oppression and organizational influences.

Culture can of course be defined and experienced in many different ways, and authors were asked to address this in their papers. We are sensitive to the way that the term “culture” might cover a multitude of social and societal influences and practices; and also, how usage of the term politically may be an attempt to cover over implicit racism or oppression of other groups (as used in the apartheid regime in South Africa). There is generally no one “culture” existent within a country, but rather a complexity of cultural factors, depending on levels of urbanization, wealth or poverty, technological skills, languages spoken and historical influences. Each person lives at the intersection of many of these, so the nature of the “culture” needs to be unpacked (with the term itself avoided as a “hold-all”). It is also important to clarify that cultural influences are subject to changes over time, particularly given the exposure of many (through the media) to ideas of modernity (e.g., ideas of family and shame; inclusion of family members in more collective societies; the expected role of and potential for oppression of women).

Certain countries are characterized by a wide diversity of population groups, rather than being homogenous in demographic make-up. It is interesting to discuss the degree of assimilation and possibly integration between such groups; and the nature of boundaries that perhaps exist between ethnic groups or class in societies. The influence of these on the provision of services and their relative accessibility is also an aspect that may be influential, ethically. Languages is common usage, and the means of communication are linked to this element as well. For example, if competence in the lingua franca is not widely shared, are the services of translators available and are these people trained (as in the use of “interpreters” in some medical contexts). In relation to language more broadly, an interesting issue is the translation of concepts (often from English) and whether they can be adequately articulated and understood in a very different context? It may be that there are differences in agreement on what is meant by the words used in ethical codes, whether between professionals or for the clients with whom they work (Fairburn & Fairburn, 1987). In addition, there may be limitations in the language competencies of the clients or participants with whom work is being done, implying that simple language needs to be used in documents intended for them.

Each of the articles to follow reflects on a country or collection of similar countries in a geographic region, which has emerged from or is still experiencing the effects of totalitarian or authoritarian regimes. People in these countries will have relatively recently been exposed to oppression of individual freedoms due to the lack of democratic processes and institutions. Also, in some, the dominance of the impact of religion and religious practices and rules for everyday life is very evident; profoundly impacting individual agency and decision-making, family constellations and their relative influences, relationships between people, the structures and dynamics of workplaces, and broader activities and systems.

Further aspects that are of importance ethically are the relative importance and influence of law and government policies, religious authority and power, on accepted professional practices. The degrees of coherence between the legal system and professional accountability is also of interest. In societies where patriarchal systems still prevail, the power dynamics embedded in societal structures “tend to disenfranchise women and other groups” (Knapp et al., 2017, p. 12). Then, the types of employment available for psychologists, the working conditions and nature of clientele (Pettifor & Sawchuk, 2006) may also be important factors for consideration: are their roles integrated into governmental agencies and the broader system of care for people’s well-being, or do people access psychological services privately or via employment assistance programmes? Related to this point is the question of how predominant the medical model might be, potentially impacting on the nature of psychological services. Another consideration is the degree of exposure of the general public to the role and functions of psychology, in relation to people’s expectations and understandings of their rights and the role of broad psychoeducation of potential clients.

The Universal Declaration (IUPsyS, 2008) is described by Gauthier (2008) as not being enforceable as a mechanism for formal accountability, even though it is persuasive. He noted that accountability, regulation, enforcement, and quality assurance are legally and culturally mandated in different jurisdictions. We are interested in the ways in which international influences may be reflected in psychological practice, but also on ways these are adapted and viewed in the law and customs of individual countries.

Authors were chosen because of their ethical expertise respective to their country and cultures. It is also important to gain perspectives from authors not from Western countries who can offer unique and previously unknown views of the nuances of ethical standards based on these countries and cultures. Thus, all authors spoke about historical, cultural, political, and sometimes religious influences on psychological ethical standards. An, Lin, Sang, and Qian (this issue) spoke about their knowledge and experiences in China, Khoury and Akoury-Dirani (this issue) represented Lebanon, Palii (this issue) included the influence of the war with Russia on psychological ethics, and Al-Darmaki, Yaaqeib, and Partridge (this issue) offered their perspectives on the United Arab Emirates.

Three specific ethical standards

Authors were asked to provide their perceptions of the interpretations of three aspects of Ethical Standards commonly covered in the majority of ethical codes. These specific categories were confidentiality, informed consent, and multiple relationships. Authors were asked to clarify how these are viewed and interpreted in practice at local levels. They were asked to consider the influence of culture on each of these, as well as the policies in place and their status in both the law as well as the relative influences on ethical decision-making professionally.

The relative importance of individual, collective or organizational aspects of the three categories are of interest, potentially raising questions of autonomy and choice amongst individuals as well as families and communities (Fairburn & Fairburn, 1987). In addition, there may be little or no country-specific literature as a point of reference regarding the interpretation of these standards.

Confidentiality

Confidentiality has long been a widely advocated ethical principle across the various caring professions (Fairburn & Fairburn, 1987), and issues related to confidentiality rank as one of the chief ethical dilemmas for psychologists in practice in “Western” countries sampled (Pettifor & Sawchuk, 2006). Client expectations of the privacy of privileged information may be very different from those of health professionals (especially in the medical field). The degree to which absolute confidentiality is adhered to varies according to the context and issues at stake. At its core, the degree of confidentiality in practice relates to balancing respect for clients’ autonomy, along with protection of their rights, and on the other hand, broader concerns related to beneficence, duty to protect and the limitations on confidentiality applied by other jurisdictions (e.g., the demands of law for the revelation of information, Francis, 2009). It may be difficult to maintain confidentiality in settings where people are cared for by teams of workers and where facilities are shared (e.g., Gomez & Brown, 2018). There is thus the need for the limits on confidentiality to be clearly specified for clients.

In the articles that follow, the authors were asked to specify the pertinent parameters of confidentiality for clients or research participants; and how to determine when confidentiality might be broken. For example, in the USA, the idea that psychologists can break confidentiality if there is a danger to self or others is written into most (though not all) state laws, in addition to being considered good professional practice. The parameters of confidentiality in the national context thus need to be clarified: are these specified by laws, cultures, what is considered good professional practice, or other determinants?

It is also important to know the nature of allowed disclosures of information, to whom and whether there may be differences according to age or aspects of vulnerability (e.g., individuals’ capacities for taking responsibility). For example, “confidential” information kept between a psychologist and client may differ, depending on cultural or legal influences. Some cultures allow for information to be kept only between the individual client and psychologists, whereas others may allow for close family members to be consulted. In certain political or religious contexts, ideas of confidentiality may however be conflated with secrets that are seen as threatening to the broader societal good.

Informed consent

This category is underpinned by the ethical principles of nonmaleficence (the duty to prevent harm to others) and beneficence (that is to do good). These are covered by the Universal Declaration’s principle of “caring for the well-being of persons and peoples” (IUPsyS, 2008). Before engaging in psychological work, it is necessary to gain informed consent to ensure the voluntary participation of clients or participants. Implicit aspects of informed consent involve assessing the person’s understanding of what is being discussed, including the potential risks and benefits of engagement. Ideally there needs to be participation in the process of making decisions; and the client should not feel forced to agree, due to power differentials in the relationship. Then, the process needs to be adequately documented. Respectful discussions of people’s expectations and psychoeducation about the processes that might unfold are thus fundamental to gaining informed consent. However, it is possible that during the evolving process unexpected issues might arise, which are not covered by the initial consent, leading to the need for a more iterative consent process (e.g., Paphitis & Kelland, 2018), which is sensitive to the further need for protections for those involved.

The aspect of “informed” raises questions about the volume and nature of the information to be provided. Special considerations may be necessary for people who are considered to be “vulnerable” in some way, due to having limited ability to protect themselves and thus more susceptible to harm (Larkin, 2009). A further consideration is about the age at which people are cognitively and legally seen to be able to consent (and this is likely to be variable both across contexts as well as depending on the nature of the consent). Up to a certain age, parents have legal rights to information regarding work with their children.

These ideas also relate to concepts of autonomy and agency, which are potentially impacted by cultural and religious attitudes. For example, regarding protection from harm, there may be special considerations when working with people affected by gender-based violence, or minors impacted by any form of abuse; in each of these scenarios from an international perspective there may also be cultural, legal and religious issues to be negotiated.

In the articles to follow, authors were asked about the role of informed consent with clients, and whether any specific information is mandated for inclusion. In addition, the timing of consent needs consideration; there may be other culturally informed norms of negotiation required or needed before the informed consent process can occur. There may also be legal aspects to informed consent that need to be considered.

Multiple relationships

A further common source of complaint in relation to psychologists violating ethical codes relates to multiple relationships (sexual and nonsexual; Knapp et al., 2017) or dual relationships (Pettifor & Sawchuk, 2006). This issue highlights the conflicts of interest that may occur when a psychologist tries to assume more than one role in a relationship (e.g., as a therapist and as a friend). Francis (2009, p. 166) noted that the issue relates to the “boundaries of psychological practice.” In urban settings with high population densities, it is likely that psychologists may very well be able to maintain strictly professional boundaries. However, in rural or smaller communities or organizational (e.g., military) settings with fewer people, where one is more likely to have overlapping social and religious circles and affiliations, the challenges of multiple relationships become more evident.

Johnson (2018) highlighted examples of multiple relationships that are generally associated with the likelihood of causing harm to clients and should be strictly avoided However, Johnson also described situations where “the contours between friend, client, and colleague can become blurred” and that the professional might “find themselves assuming clinical roles with colleagues or administrative, supervisory or evaluative roles with clients without … much in the way of informed consent” (p. 8). In such cases, the client’s best interests should be placed first in order to minimize harm, rather than those of the organization or community; however, this may not be as clear-cut in other cultural settings. Additionally, a multiple relationship ethical standard is often conflated with conflicts of interest, and the degree to which they are separated in ethics documents internationally has yet to be determined. They are considered separate constructs though, in many Western-focused ethics codes.

Multiple relationships are of concern because they impact issues of confidentiality and power relationships. That said, due to cultural values such as collectivism it would be expected that multiple relationships may look and play out differently than when considered from an individualism value perspective. In some countries, there are models for ethical decision-making, which can be of assistance (Leach & Gauthier, 2012) but again, these models are typically constructed from Western frames. In the articles to follow, authors were asked to comment on the attitudes embedded in their professional codes regarding multiple relationships, and how these may be related to the general societal expectations and norms.

Conclusion

The study of professional psychological ethics from an international perspective is still in its nascent stage. Very little is understood about how ethical standards are considered in different cultural, legal, and religious contexts. Compounding the issue is the idea that ethical standards found in ethics codes are often borrowed from other codes with perhaps little consideration as to whether and how they actually apply within these contexts. These can lead to ethical dilemmas within these contexts, with little resulting guidance due to larger values such as individualism and collectivism. Consideration of ethical dilemmas are important in the ongoing professional education of psychologists; these may contribute to deeper deliberations about “taken-for-granted” positions in different contexts. Suggestions in recent texts relate to the supportive roles of consultation and supervision (e.g., Welfel & Leach, 2018), or the establishment of “communities of practice” (Treharne et al., 2018), in order to enhance ethical decision-making. More progressive rather than only legalistic positioning may lead to more open discussions of the challenges that psychologists face in everyday practice.

Greenberg and Smith (2008, p. 95) write of “cultural competence,” “construed as a coherent way of being that is a composite of content and conceptual knowledge, interpersonal skill and sensitivity, personal values, and tolerance for the values of others … evidenced through proactive approaches that emphasize mutual respect and engage a process that parallels the ethical decision-making model.” It is through articulating the ideas that have been explored above that greater competence is encouraged. The relative emphases of ethical codes and standards are expressed through their preventative (to reduce poor practice) or educative roles to promote optimal practice morally (Leach & Gauthier, 2012).

Finally, the four articles that follow do not attempt to be representative of all “non-Western” countries, some of the aspects described may very well also be found in developing countries, where practice and research in psychology are very recent phenomena. For more collectively organized societies, some of the principles of community respect and processes of engagement might seem to clash with the relative emphases of “Western” ideas rooted in the promotion of individual autonomy and responsibility. It is to be hoped that the articles will open up further discussions of the current status and aspirations of countries and regions, through considering the past, present, and future developments of ethical codification, standards and practice. The comparisons and differences that come to light have the potential to contribute positively to enhanced levels of ethical conduct and enable psychologists to promote both individual and social well-being (Knapp et al., 2017).