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Article 31
Potential Conflicts Between Cultural Values and the Role of Confidentiality When Counseling South Asian Clients
Implications for Ethical Practice
A review of the counseling literature reflects numerous articles (e.g., Chandras, Eddy, & Spaulding, 1999; Das & Kemp, 1997; Ramisetty-Mikler, 1993; Sandhu, 1997) devoted to discussion of South Asian culture and its related values. Although beneficial in understanding the world of the South Asian client, these sources make no reference to potential conflicts between South Asian cultural values and the role of confidentiality in the Western model of counseling. To be both ethical and culturally competent practitioners, counselors and trainees working with South Asian individuals and families need to understand how South Asian values directly complicate confidentiality for both client(s) and counselor. It benefits the counseling profession to explore and outline ways to reconcile the legal and ethical standard of confidentiality with the values deeply held by the South Asian client and his or her family.
Meer and Vandecreek (2002) asserted that when working with South Asian clients, “confidentiality may become secondary to other considerations” (p. 154). Drawing upon clinical experience, relevant literature, and personal experience, in this article, we discuss confidentiality as perceived by the South Asian population. We also explore the meaning of autonomy to clients for whom individuality is considered a flagrant violation of social norms; the ethics of fostering individuality in such a client even if he or she desires it; and how a counselor might proceed when the code of ethics mandates maintaining confidentiality, but to do so may adversely impact the client.
The ethical principal of autonomy refers to individual self-determination, that is, “the rights of clients to choose their own directions, act in accordance with their beliefs, and control their own lives” (Remley & Herlihy, 2001, pp. 6-7). Autonomy encompasses freedom of thought and action, provided the individual’s actions do not interfere with the rights of others (Meer & Vandecreek, 2002). Autonomy is foundational to confidentiality; respect for the client’s right to self- determination requires respect for the individual’s choices about uses and disclosure of his or her own information (Remley & Herlihy, 2001). Early in their training counselors are taught the ethical responsibility of safeguarding confidentiality, as well as the legal and ethical limits to confidentiality. They come to view confidentiality as a foundation of trust in the helping relationship. Consequently, they have expectations about how it works, and the benefits it provides for the individual. They expect that family members of adult clients will respect, or at least accept, the boundaries of confidentiality.
The American Counseling Association (ACA) and American Psychological Association (APA) ethical codes have been criticized for the high value they place on autonomy and individuality (Atkinson, 2004). The codes contain the ethical mandate to understand the cultural background of diverse clients; yet by stressing autonomy and individuality the codes reflect the culture, norms and values of Western society (Atkinson, 2004; Meer & Vandecreek, 2002). Problems may occur when a counselor fails to critique the applicability of these values in the lives of South Asian and other culturally diverse clients for whom collectivism and interdependence are fundamental aspects of life and worldview. A counselor who views individual autonomy as an indicator of developmental maturity may misdiagnose or misunderstand the experiences of a South Asian adult or late adolescent who seeks, or at least is responsive to, familial input prior to making decisions, labeling him or her as immature and/or overly dependent. Likewise, the counselor who aspires to cultural understanding while simultaneously upholding the value of individual autonomy may face ethical concerns and conflicts.
Understanding the traditional South Asian worldview is helpful in knowing how the concepts of autonomy and confidentiality are viewed by this group. The typical South Asian client is more familiar and comfortable with the concepts of collectivism and family interdependence. However, it is important not to assume all South Asians value these concepts equally; a client’s level of acculturation affects where he or she lies on the continuum of interdependence and independence. Counselors are strongly encouraged to assess the client’s worldview (Chandras, 1997).
Counseling is not widely accepted by South Asians. The preferred method of solving problems is to defer them to the authority figure in the family or extended family. South Asian clients consider decision making to be the prerogative of the head of the household, generally the eldest male. Clients do not make decisions by thinking of their individual needs exclusively. Rather what is best for them is what is best for the family (Chandras, 1997; Das & Kemp, 1997).
This collectivist way of thinking carries over to the counseling realm. It is not uncommon for family members of an adult South Asian client to expect or demand they be included and consulted during the therapy sessions. It is highly unlikely that they would approve of a family member going outside the extended family and community to seek assistance of any type. Problems, issues, and concerns are the family’s business (Chandras, 1997; Das & Kemp, 1997). Generally, if a problem does exist, the family decision maker unilaterally decides what course of action needs to take place. His authority is not questioned. He is respected through a display of obedience for what he perceives to be the best for the family.
As the following case study illustrates, the counselor unaccustomed to the worldview of South Asian clients and their family may face ethical challenges with respect to autonomy and confidentiality.
Neha, an 18-year-old high school senior, sees the school counselor for an issue she has been struggling with for some time. She states she is unhappy because her parents forbid her to date. Her parents are immigrants from India where dating is a taboo, and her parents abide by this social norm. When her parents and extended family decide it is time for Neha to get married, they will begin the process of locating a suitable lifelong mate for her. The family will probably not solicit Neha’s opinion regarding her future spouse. Neha will be expected to abide by what her family members decide for her.
Neha states she is unable to confide in friends in the Indian community or any members of her extended family. Friends and family members would be appalled and shocked that she was thinking these thoughts and would report it immediately to her parents. Her parents, especially her father, would be angered that she was thinking of disobeying him and would chastise her for bringing shame to the family. Sharing details with others about a family issue is not accepted in traditional Indian culture. Neha feels trapped in her situation.
The school counselor has limited knowledge of South Asian values and worldview and is unsure of appropriate options for Neha. She wants to refer Neha for outside counseling but understands Neha’s father may be angry and resistant to this suggestion. The family may wonder, “How would the school counselor know Neha needs counseling?” Speaking with the family regarding Neha’s situation may put the client in a compromising situation with her father and other family members. The school counselor decides to be a sounding board for Neha and explores various avenues with her. The counselor’s suggestions include (1) getting the family involved and opening a dialogue; (2) empowering Neha to become assertive and voice her opinion at home; (3) encouraging Neha to participate in extracurricular activities at school so she can socialize more and meet someone; and (4) suggesting that Neha apply for scholarships so she may be able to attend college outside her hometown and consequently become more autonomous. Neha insists that none of these suggestions are feasible options.
The counselor feels frustrated. She views independence as an important developmental milestone and takes seriously the ethical principle of autonomy. Supporting Neha’s right to self- determination, she views her suggestions as Neha’s way out of an oppressive situation. At the same time she makes efforts to understand Neha’s viewpoint. All these suggestions would require Neha to break tradition, step out of prescribed roles. To pressure Neha toward individual autonomy will likely do her harm. Neha, having gone to high school in the United States, is somewhat acculturated to Western values but is unwilling to risk the loss of family connection, support, and shared identity by transgressing traditional values.
Ridley, Liddle, Hill and Li’s (2001) conceptualization of multicultural responsibility, “a fusion of personal and professional commitments to consider culture during all ethical encounters,” is relevant to our discussion. Counselors may achieve multicultural responsibility through (1) examining and making explicit their philosophical assumptions about culture and ethics; (2) examining alternative philosophical assumptions (e.g., feminist and racial theories), leading them to a more inclusive philosophical approach; (3) working toward understanding how culture is always relevant in counseling; (4) developing complex thinking skills and creativity; and (5) emotionally investing themselves in multicultural responsibility (Ridley et al., p. 176).
Along with examining and making explicit her own assumptions about culture and ethics, Neha’s counselor could explore concepts such as relational autonomy, which would lead her toward a more intentional and inclusive perspective. Relational autonomy, which emerged from feminist critiques of traditional conceptions of autonomy and individual rights, is grounded in awareness that the person is socially embedded. Identity is formed within the context of social relationships and shaped by the intersection of forces such as race, ethnicity, and social class. The focus of a relational approach to autonomy is to analyze the implications of the social dimensions of selfhood and identity for conceptualizations of individual autonomy (Mackenzie & Stoljar, 2000). Relational autonomy may be a more relevant and realistic concept than individual autonomy in the lives of clients such as Neha and her family whose traditional cultural values view selfhood as being defined through relationships with others and self-determination as collective rather than individual.
Ridley et al.’s (2001) ethical decision-making model provides the counselor with a framework for working toward ethical resolution of cultural conflicts such as Neha’s. The model describes two partially overlapping processes: ethically considering cultural data, and ethically resolving cultural conflicts. Each process contains two partially overlapping stages: critical reflection and creative problem solving. The partial overlap suggests the two processes, and likewise the two stages, “are separate but sometimes occur simultaneously in an integrative fashion” (p. 177).
To begin the process of resolving the ethical conflicts proposed in the case study, we have selected one of the two stages, creative problem solving, to discuss in more depth. Ridley et al. (2001) proposed four strategies for creative problem solving. We identify each strategy along with its application to the case study.
Be vigilant to view ethical conflicts from multiple perspectives resulting in more possibilities. Counselor and client could conceptualize the situation from the parents’ perspective to gain additional information
Be open to sharing the ethical conflict with others, possibly through supervision or consultation. The counselor could consult with a colleague more experienced with South Asian clients.
Include all involved parties in exploring how the conflict occurred and in brainstorming solutions. The counselor could work collaboratively with Neha in identifying similar situations that have occurred in the community and in understanding what resolutions were reached.
Match each possible solution to the ethical conflict, analyzing goodness of fit. The counselor learned that in a similar situation, a respected individual from the South Asian community served as an intermediary between the client and the family. Client and counselor could further explore this option to evaluate its use in this particular case.
The model and its application to this situation, serve as a reminder that ethical conflicts usually have multiple solutions.
Through applying a multiculturally responsible ethical decision-making model such as that proposed by Ridley and his colleagues (2001), counselors equip themselves in being better able to conceptualize cases of cultural complexity when the ethical codes may indirectly conflict with the value system of the client. Doing so allows for improved client care through the diligent use of the ethical codes in conjunction with honoring the client’s values and worldview.
References
Atkinson, D. R. (2004). Counseling American minorities (6th ed.). Boston: McGraw Hill.
Chandras, K. V. (1997). Training multiculturally competent counselors to work with Asian Indian Americans. Counselor Education and Supervision, 37, 50-59.
Chandras, K. V., Eddy, J. P., & Spaulding, D. J. (1999). Counseling Asian Americans: Implications for training. Education, 120, 239-246.
Das, A. K., & Kemp, S. F. (1997). Between worlds: Counseling South Asian Americans. Journal of Multicultural Counseling and Development, 25, 23-33.
Mackenzie, C., & Stoljar, N. (Eds.). (2000). Relational autonomy: Feminist perspectives on autonomy, agency, and the social self. New York: Oxford University Press.
Meer, D., & Vandecreek, L. (2002). Cultural considerations in release of information. Ethics and Behavior, 12, 143-156.
Ramisetty-Mikler, S. (1993). Asian Indian immigrants in America and sociocultural issues in counseling. Journal of Multicultural Counseling and Development, 21, 36-49.
Remley, T. P., Jr., & Herlihy, B. (2001). Ethical, legal, and professional issues in counseling. Upper Saddle River, NJ: Prentice-Hall.
Ridley, C. R., Liddle, M. C., Hill, C. L., & Li, L. C. (2001). Ethical decision making in multicultural counseling. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (2nd ed., pp. 165-188). Thousand Oaks, CA: Sage.
Sandhu, D. S. (1997). Psychocultural profiles of Asian and Pacific Islander Americans: Implications for counseling and psychotherapy. Journal of Multicultural Counseling and Development, 25, 7-22.