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COVID -19 PANDEMIC: A TIME FOR PRUDENT AND ETHICAL ACTION
L. S. S. MANICKAM
Centre for Applied Psychological Studies
Thiruvananthapuram, Kerala
Introduction
The lockdown that was announced in our country on March 24, 2020 brought public life to a complete standstill barring health, police and essential services. The impact of the COVID-19 pandemic on people’s lives has reiterated the role of psychology and its significance across all walks of life. The psychologists from India have the responsibility to make strategic plans to address the issues that are coming up to ease the burden of the professional community in our country. In this paper, I present some of the national level strategies that are needed. The ethical concerns that come up to psychologists while working in different sectors are also briefly discussed.
Lockdown- ‘World's biggest psychological experiment’
Van Hoof (2020), Professor of Health Psychology and Primary Care Psychology, Vrije University, Brussels, wrote that, 'Lockdown is the world's biggest psychological experiment - and we will pay the price'. Out of 7.8 billion people across 235 countries, a major percentage was going through 'some kind of lockdown' and he considered this as the 'largest psychological experiment ever'. The effects of the lockdown and COVID-19 on the people, it’s impact on the roles and responsibilities of professionals - the psychological fraternity in particular, are challenges that stare at the face of every psychologist in the country. Mobilizing a humongous population to learn to comply with physical distancing, helping individuals cope with their distress during isolation, and combating stigma towards those who tested positive, were some of the initial concerns. The health service providers and warriors in the frontline including police personnel were subjected to tremendous stress, a situation that has not received much consideration in our country.
To achieve Goal 3 of the sustainable development goals of UN, ‘Ensure healthy lives and promote well-being for all, at all ages by 2030’ (UN, 2015), there is an imperative need to make strategic plans for the next 6 months and perhaps for the next 5 years and beyond. Indian Council for Medical Research (ICMR, 2020) has already released documents on behavioral change expectations from people in order to contain the spread of the virus. Equally significant for psychologists is managing the fallout of this lockdown in terms of secondary epidemics of different phenomena including burnout and absenteeism and taking timely action to mitigate its adverse effects (Van Hoof, 2020).
National strategy of psychologists in responding to COVID-19.
The country of France had set up a 'psychological field' in response to the terrorist attacks and disasters in the 1990's. (Bernard-Brunel & Cholin, 2010) We need to develop a similar 'psychological battlefield' to win this battle and collectively put our ideas together to help draft a national policy. This cannot be achieved by a stand-alone approach. We need a collective effort and only the psychology associations in India can do this. Though coming together is not achievable, the associations independently have to define what each member needs to do, to clarify the role of the psychological science in responding to the COVID-19 pandemic. As scientists, one may have to take a strong stand on evidence-based methods in dealing with the situations. At the same time, one may have to encourage experiments that have not been tried out before, but have a research basis to proceed further.
It is laudable that efforts were taken by individual psychologists in different parts of the country, but we do not have any compiled reports on the action strategies. Programs of individual psychologists are announced through social media at random and there is no common repository to record, store and archive the valuable information on the activities undertaken by psychologists in India, which could be of immense value for future research. Inadequate data and lack of proper documentation of progress related to capacity building and delivery of service have affected the positioning of our psychologists in the international psychology forums.
Innovative methods
It is praiseworthy that some of the psychological associations at the national level and state level have taken the lead and have submitted their reports, which are added to this volume (Divyaprabha et al., 2020; Kumar, Jayaraman & Rangaswamy, 2020, Sharma, 2020). As we initiate new methods of coping with the current changes, it is important to keep watch on the activities from the ethical perspectives too.
Ethical Guidelines in times of COVID-19
ICMR (2020, April) in their ethical guidelines has stipulated the following while addressing the needs of the vulnerable population. The first one is the persons who are tested positive for COVID-19. Psychosocial support needs to be given to them, their families and the health workers who are in contact with them. Equally important attention is required for the persons who are in isolation or quarantine as advised by the health advisors (ICMR, 2020, March 23). In view of the enormous stress and anxiety that the person may undergo, the document emphasizes the importance of showing, “… respect, empathy and compassion and not subject them to any kind of stigma or discrimination”. It is our responsibility as psychologists to develop a strategic plan to address the large population who are in need of our service.
Who will streamline and enforce adherence to ethical guidelines in the practice of psychology? The ethical guidelines are in place for some psychology associations. However, I am yet to see any association taking a strong stand against any member or any office bearer for violation of ethical standards. Many practicing psychologists claim that they follow the guidelines. When asked about specifics, they retort, ‘You have been in practice for so long, so you should know which one we are using’. In the context of COVID-19, APA has brought out ethical considerations for psychologists (Chenneville & Schwartz-Mette, 2020, May 21) which may be a guideline that can be used by us. Salient features of the guideline in reference to the standard guideline requires discussion.
Standard 1: Resolving Ethical Issues
These include ethical issues in relation to the workplace and one’s role. These have already been raised by several psychologists in our country especially the school psychologists who have been asked to ‘engage the class’ when regular teachers are not available, where the ethical issue of the role of the school psychologist and the organization’s interest come into play. The psychologists are assigned the tasks to benefit the organization rather than their assigned role. The ethical code suggests “Avoiding Harm” to the clients and in the COVID-19 pandemic, psychologists working in hospitals or other health care settings where access to personal protective equipment (PPE) is limited may be asked to see patients or clients without wearing PPE even after exposure to COVID-19 and one has to suggest other means to avoid ethical issues in relation to organizational conflicts.
Standard 2: Competence
In the current scenario, many psychologists have the feeling that ‘something is better than nothing’. But the code says that, “…psychologists do not extend themselves outside the realm of their own training, experience, and abilities”. In the social media, it has become very common for the ‘so called psychologists’ announcing different teaching programs, as well as services one intends to provide at this time and tend to exploit the public and the upcoming psychology students. The psychology associations and the trained psychologists have the ethical responsibility of safeguarding the profession by not letting incompetence creep into the profession.
Standard 3: Human Relations
While working with the CARCEALD population (Manickam, 2016a) in our country, the possibility of discrimination is quite high and one has to be aware of “Unfair Discrimination,”. This clause, prohibits psychologists from discriminating against people based on individual differences, like age, gender, faith, state of origin, disability, caste, and socio-economic status. It may not be possible for the psychologists and clinical psychologists working in hospitals to screen clients for COVID-19. However, following the universal precaution protocols is the best way and using ‘physical distancing’ and reverting to tele-behavioural health could be other options to avoid discrimination.
Standard 4: Privacy and Confidentiality
It is unfortunate that in several forums, clients have written about the breach of confidentiality by Indian therapists. The ethical code demands psychologists to maintain confidentiality. Since many psychologists are shifting to work online, frank discussion on the limits of confidentiality need to be discussed as part of the informed consent process of clinical service and research. As we take consent to record the sessions, in case of recording, we also need to be aware that clients can also record the tele sessions. Many online help forums have come up and as a quick fix solution several agencies have issued helpline numbers and it is important for us psychologists, if involved, to help keep the privacy and confidentiality of those who seek help.
Standard 5: Advertising and Other Public Statements
The guideline is that even in emergency situations such as COVID-19, psychologists need to be honest in pronouncing the limitations of their professional competence. Care needs to be taken to not mislead our recipients who would benefit from our services in relation to our expertise and experience. Therefore, it is imperative to provide an opportunity to professionally upgrade one’s capacities. In the hurry to respond, it is likely that one may make statements in response to the questions asked by the media. It is true that it brings the profession of psychology to the limelight. One has to be careful to not make public statements that fall outside one’s ‘expertise or are inconsistent with the existing psychological literature’. Since we do not have research findings yet on the impact of COVID-19 on mental health, psychologists should not make definitive statements about the psychological impact of COVID-19. If the psychologist is familiar with the research findings, it may be appropriate for one to make general statements about the impact of social isolation on mental health.
Standard 6: Record Keeping and Fees
Psychologists and clinical psychologists are offering free service (Divyaprabha et al., 2020; Kumar, Jayaraman & Rangaswamy, 2020, Sharma, 2020) in response to the COVID-19 lockdown situation. Some of the associations have stated that the sessions are free till a specific period of time. Unless it is made specific, the possibility of a number of people asking for free sessions even after the lockdown and the pandemic are likely to increase. Therefore, one has to be cautious about the same, especially when there are a large number of private practitioners of psychology in our country. It is important to document the calls and the session as one would do in the in-person sessions. This is important for clinicians who are trainers as well as for psychology teachers to document it as per institutional requirement.
Standard 7: Education and Training
The ease with which the psychology community incorporated innovative methods in responding to the current scenario in providing psychological services gives the hope that the current generation of psychologists is adept in using technology to overcome the barriers. Another concern which directly impacts the psychology fraternity is the sudden lockdown of teaching institutions, and with it the inability of students to access labs and internship programmes. Many psychologists have taken to online teaching, online interviewing for the intake of new admissions and online assessments. It is not yet confirmed how the trainees who are about to complete their training will carry out their data collection required for submission of research reports. Clinical training was depending heavily on in-person interaction and with the restrictions in contact, how the research projects as well as the supervised practicum experiences are to be directed for the current batches of trainees who are undergoing training is yet another challenge. Telehealth can be used, but it would be difficult for the clients to access the services like those staying in the wards and even those at home, where privacy issues also become a concern and require standard guidelines.
Standard 8: Research and Publication
Telepsychotherapy and online counseling using both video and telephone have come into prominence and may be facilitated more through the apps that are being developed by individuals and organizations. Institutional approvals have become a norm with the research proposals being approved by a registered institutional review board (IRB). The completion of research through a different mode would require a modification by the IRB and ICMR (2020, April) as per the latest guidelines provided to the ethical committees. There are reports of Psychologists initiating research without experience and supervision need to be checked to prevent human rights violations. which can be considered as a bold step. Though many of our psychology departments are yet to constitute IRB, the future of research in psychology, especially when it comes to publication in indexed journals will get affected if one does not produce the certificate from the IRB. Practicing psychologists and others who intend to conduct research may be encouraged to get affiliated with institutes where IRB’s are in place in order to facilitate more scientific research in psychological science.
Standard 9: Assessment
How far will the clinician be able to effectively administer cognitive function assessments and projective tests while maintaining ‘physical distance’ and how the use of PPE would impact the rapport and therapeutic relationship, are questions that need to be answered. Using tele psychology tools to conduct assessments remotely also raises the issues of confidentiality which was mentioned earlier. Administering tools online may also pose several challenges including that of copyright issues. As Chenneville and Schwartz-Mette (2020) observed, “When transitioning to remote assessment, psychologists must carefully examine their existing tools and procedures for various referral questions to determine whether they can translate these directly online”. Since many of the norms have not been prepared for conducting tests using telepsychology, care has to be taken while interpreting the results and informing the clients about the results. This becomes complicated when it comes to assessments of children, less motivated clients and those who are not proficient with any form of formal assessments.
Standard 10: Therapy
As we use more of these platforms, we need to keep a watch on privacy, boundary and ethical practice. We need to discuss with the clients about the limits of confidentiality, and be realistic in communicating about the potential risks and the probable benefits. With many practicing psychologists shifting to work online, the clinician needs to be aware of the service providers at the locality of the client. The location of the client and therapist, and in case of trainee and novice therapist, the location of the supervisor should also be disclosed and discussed in order to take care of risks that the clients may experience. It is timely that Indian Association of Clinical Psychologists has formed a task force to develop practice guidelines on Telecounseling and Telepsychotherapy (Kumar, 2020).
Capacity building and Training of the Responders
Globally, psychologists are realising that psychological damage requires emergency care, just as physical damage does. (Van Hoof, 2020). The health emergencies programme of WHO (October, 2018) had developed a learning strategy to prepare the workforce of excellence. It highlights that the learning and training need to be coherent, high quality, coordinated and standardized. National level psychology associations in collaboration with Governmental agencies will be able to create a workforce of excellence for health emergency work at the national level. Even when locally initiated, adopting this framework in the learning strategy will help develop sustainable programs. We are yet to think of responding to those who are in quarantine, their relatives, people who are in isolation and relatives of those who are in isolation. People from different states of our country are living abroad and some of them are unable to return home (Thomas, 2020). The situation is similar in relation to people who are living in other states within our country, other than their home state which causes added stress. The increasing number of suicides of people who are COVID-19 positive is also of great concern. It is possible that we can develop a standardized, high quality and coherent strategy with the coordination of all the psychology associations (Manickam, 2016a) solely for responding to the pandemic.
Psychological field to take on
To conclude, the challenges for the psychologists in India are far higher than many other countries. The psychology associations need to come together, communicate, develop a consensus in responding to COVID-19 and collectively work to tide through this pandemic. It is for the psychologists in India to take a lead in creating a psychological field, mobilize the entire community of psychologists in our country, liaise with our Governments, initiate a dialogue with the policy makers and create the psychological field to combat the present and future adversities.
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