Viewpoint

Ethical Issues in Delivering Psychological

Therapies in Geriatric Psychiatry in India
Sridhar Vaitheswaran1 , Suhavana Balasubramanian1, Nirupama Natarajan1, Shreenila
Venkatesan1, Nivedhitha Srinivasan1, Gayathri Nagarajan1, Vaishnavi Ramanujam1 and
Subashini Sargunan1

T
he characteristic of the population have dementia now, and an increase of with mental illness. CST is a manual-
worldwide is changing dramati- over 10 million is expected by 2040.6 The ized, theme-based, brief, evidence-based,
cally with an ever-increasing num- elderly are also at increased risk of abuse and cost-effective group psychosocial
ber of older persons. It is anticipated that and neglect.7,8 Furthermore, increased intervention for persons with mild to
by 2050 there will be more persons aged prevalence of associated medical ill- moderate dementia involving 14 sessions
60 and above than those aged 16 and be- nesses, sensory impairment, increased over 7 weeks.15,16 It has been adapted for
low, and those over 60 years will consti- financial and functional dependency, use in India and is currently being studied
tute 22% of the total population.1,2 India, abuse, and neglect increase the vulnera- for implementation in low- and mid-
like the rest of the world, has witnessed a bility of the elderly population to mental dle-income countries, including India.17,18
health problems.9,10 This article highlights the ethical chal-
continuous rise in the number of elderly,
Mental health care professionals are lenges in delivering CST for persons
as the number of persons over the age of
guided by the codes of ethics and pro- with dementia in India and discusses an
60 has tripled in the previous 50 years.3
fessional guidelines when delivering ethical decision-making model to guide
With the rising numbers of older
interventions.11–13 Advancing age, associ- the practitioners when facing such chal-
persons, the burden of associated mental lenges.
ated physical impairments, mental illness,
illnesses also is potentially increasing.
cognitive impairment, gender issues,
The lifetime prevalence of mental health
lower levels of literacy, and socioeconomic
Ethical Principles
problems in persons aged 60 and above
status may influence the mental capacity In their seminal work, Beauchamp
in India is estimated to be 15.11% (14.95%– of the older person.14 The changes in the and Childress established the “Principles
15.27%) according to the National mental mental capacity and the unique issues of Biomedical Ethics,” highlighting the
health survey, 2016.4 Current worldwide mentioned above can pose significant importance of beneficence, nonmalefi-
estimates for the number of persons with ethical challenges in providing interven- cence, autonomy, and justice.19 Kitchener
dementia is 50 million and is expected to tions to this particular population. adopted these principles for applica-
increase to 152 million by 2050, with a We use cognitive stimulation therapy tion in psychology while including the
significant increase among the low- and (CST) as an exemplar to highlight the concept of fidelity.20
middle-income countries.5 In India, it is ethical challenges in delivering psycho- In the context of providing interven-
estimated that about 5.3 million people social interventions for elderly persons tions for elderly with mental health

1
Schizophrenia Research Foundation (SCARF), Chennai, Tamil Nadu, India.

HOW TO CITE THIS ARTICLE: Vaitheswaran S, Balasubramanian S, Natarajan N, Venkatesan S, Srinivasan N, Nagarajan G, Ramanujam
V, Sargunan S. Ethical Issues in Delivering Psychological Therapies in Geriatric Psychiatry in India Indian J Psychol Med. 2021;XX:1–5.

Address for correspondence: Sridhar Vaitheswaran, Schizophrenia Research Submitted: 27 Apr. 2021
Foundation (SCARF), R7/A, North Main Road, Anna Nagar West Extension, Chennai, Accepted: 3 Jun. 2021
Tamil Nadu 600101, India. E-mail: Sridhar.v@scarfindia.org Published Online: xxxx

Copyright © The Author(s) 2021

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative ACCESS THIS ARTICLE ONLINE
Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/)
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which permits non-Commercial use, reproduction and distribution of the work without further permission
provided the original work is attributed as specified on the SAGE and Open Access pages (https:// DOI: 10.1177/02537176211026970
us.sagepub.com/en-us/nam/open-access-at-sage).

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2021 1

Vaitheswaran et al.
problems, Fitting described fidelity, values.24 Virtue ethics complement the were often met with irritation and anger.
autonomy, and beneficence as the core principle ethics and helps the individual He, however, could not clearly explain the
“principle” ethical concepts that are therapist to choose the most appropriate reason for his anxiety, discomfort, and
binding, suggesting that each should be principle when two or more principles anger because of his cognitive difficul-
upheld and should be “overridden only if conflict.25 ties. We presumed after discussing with
there is a strong moral obligation.”21 The his wife that these symptoms were prob-
concept of fidelity deals with the quality Ethical Challenges ably because of the new environment
of the relationship between the ther- and the presence of strangers. Given his
Mental health practitioners working
apist and the client. Trust and loyalty reluctance to participate, we asked him
with elderly clients are likely to face
are the hallmark features of this profes- if he would like to stop attending the
ethical challenges under the following
sional relationship. Autonomy describes sessions. While he was ready to stop, his
circumstances:22,26
the right of the elderly client to make wife mentioned that he was usually slow
1. When there are competing ethical
decisions and choose options regarding to warm up to strangers and new situa-
principles.
matters that affect their lives, including tions and asked if he could come for a few
2. When ethical, legal, and/or orga-
their treatment. The elderly client should more sessions, and if he continued to be
nizational requirements are pitted reluctant, we could stop his participa-
be involved in the decision-making
against one another. tion. She also mentioned that he seemed
process and should not be railroaded by
3. When facing a relatively new area of more alert and communicative on the
others. However, Asian societies accord
clinical practice and the ethical codes days that he attended the sessions after
cultural importance to collectivism.
or laws do not provide adequate reaching home.
The individual is not seen as a separate
guidance. Mr M was benefiting from attending
entity but part of a larger network such
as the family or society. The principle of 4. When the practitioner is required to the CST sessions, though he remained a
autonomy may be difficult to adhere to. rely on his/her judgment. reluctant participant. We asked the wife
Furthermore, the respect accorded to the Geriatric mental health practitioners not to force him to come but to encourage
elderly in Asian cultures may also influ- commonly face ethical challenges in him gently to attend the sessions. Over
ence autonomy as an ethical principle in their day-to-day work in the context the next two weeks, Mr M appeared more
certain circumstances. Beneficence refers of completing assessments, delivering relaxed during the sessions, and his wife
to the need for therapists to prevent any interventions, providing consultations mentioned that he was looking forward
harm to their clients and primarily keep in hospitals or care homes, and when to the sessions. He participated more
the clients’ best interests in the forefront conducting research. We present a few actively during the sessions over time.
when evaluating decisions. scenarios commonly encountered in our A common ethical dilemma in the
In addition to the aforementioned clinical practice delivering psycholog- clinical practice of geriatric mental
three principles, nonmaleficence, justice, ical interventions for the elderly with health practitioners is the requirement
and general beneficence have been dementia that highlight the ethical to balance the patients’ autonomy with
described as important biomedical and challenges. their welfare (beneficence).27 While
moral-ethical principles.22,23 Nonmalef- the practitioners wish to support their
icence is related to beneficence, and it Challenge 1: Participation in patients’ rights to make independent
decisions regarding their treatments,
defines the concept of doing no harm Psychological Interventions often, when patients are incapacious
to the client. It dictates that the mental
health practitioner should not cause Mr M was diagnosed with moderate and their decisions can be contradictory
any harm to the client by delivering any dementia in Alzheimer’s disease, late-on- to their welfare, the practitioners find it
intervention, or the harm should not set, and was recommended to attend challenging to support these decisions.
be disproportionate to the benefit of group CST sessions. Though he agreed In these circumstances, awareness about
the intervention. It also states that the to attend and participate in the CST ses- the patients’ lifetime values and wishes
mental health practitioner should not sions when discussed in the clinic, he was can help resolve the conflicts.
allow harm to be caused to the client resistant when he started attending the
through neglect. The principle of justice sessions. His wife, the primary caregiver, Challenge 2: Delivering
relates to the importance of providing reported that he complained about the Group Psychological
fair, equitable, and appropriate treat- long travel to the center and was reluc-
tant to get ready to come to the sessions.
Interventions
ment for the clients as needed by them.
General beneficence identifies the impor- His wife persuaded him, made the neces- Mrs N is a retired head-teacher with vas-
tance of the therapist’s responsibility to sary transportation arrangements, and cular dementia. She has always been an
society and the public at large. accompanied him for the sessions. During independent and strong-willed person.
While the described “principle” ethical the first few sessions, he asked to leave While participating in CST groups, she
concepts are considered obligatory, soon after he arrived at the center. He also was often dominant and sometimes dis-
“virtue ethics” deals with the charac- appeared to be anxious and uncomfort- missive of other participants. She also
ter traits and nonobligatory ideals that able. Persuading him to attend and not had been noted to be more disinhibited
facilitate the health care professional to to leave the sessions, introducing a new in her speech and behavior, making
choose the principle based on their moral activity or a new member to the group rude remarks about the mistakes other
2 Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2021
 Viewpoint
participants make and about their not be the best option just to provide challenging ethical issues. Often the
appearances. Despite the facilitators’ socialization. After a discussion with challenge is in balancing the competing
efforts, Mrs N continued to disrupt the her and her family, she was shifted to ethical principles of patient autonomy
group. Her family reported that she another group that met every week just and beneficence.
appeared to benefit from attending the for socialization. She appeared to enjoy
sessions as she was happier at home this new group and continued to attend Obligations Owed to
and looked forward to the sessions regularly. Stakeholders
each time. However, other participants More specifically, for the mental health
were less participatory around her, and practitioners working with older adults, Identifying the obligations towards the
they also started complaining about her various stakeholders pertinent to the sit-
the ethical principles of “futility of treat-
behavior. uation while keeping the patient at the
ment” and “non-abandonment” become
In this instance, while Mrs N ben- center of all decision-making processes
relevant in their routine practice.26 With
efited from the intervention, her helps in understanding the relevant
advancing dementia or changing cir-
participation in the CST harmed the ethical challenges within context.
cumstances, specific interventions may
other participants. While her behavior become futile. Under such situations,
may have been driven by disinhibition the therapist must recognize the “futil-
Resources
secondary to the neurodegenerative pro- ity of treatment” and aim to modify or The following necessary process is to
cesses intrinsic to vascular dementia, the discontinue interventions when their identify appropriate resources that can
ethical challenge for the geriatric mental patient no longer benefits from the help and guide the ethical decision-
health practitioners is to balance the interventions. “Non-abandonment” making process for the practitioner. Four
“autonomy” of Mrs N, the “beneficence” refers to the therapist’s responsibility to issues have been identified as necessary
of receiving the intervention, and the ensure that appropriate care is provided in delivering ethical psychological inter-
code of “non-maleficence” towards other to the patient that is beneficial and not ventions for the elderly: professional
participants. After a discussion with Mrs harmful to them. In the case of Mrs S, competence, balancing the ethical princi-
N and her family, she was offered indi- it was decided that continuing mainte- ples, limitations in the evidence base for
vidual CST sessions. She continued to nance CST was futile, and attending a various assessments and interventions,
meet the group that she was part of ini- “socialization group” was more appro- and working with interprofessional
tially, on an informal basis, during her priate and fitted with the principle of teams and families.26 Mental health
visits to the center but was moved to a “non-abandonment.” professionals must be competent in
separate room for individual CST. delivering psychological interventions.
Guiding Practitioners The guidelines developed by professional
Challenge 3: Discontinuing bodies and awareness of legal require-
Towards Delivering Ethical
Interventions ments can help the practitioners navigate
Psychological Interventions the ocean of professional practice. Also,
Mrs S is an elderly lady with dementia in
Alzheimer’s disease, late-onset. She com-
for Elderly regular supervision and self-evaluations
act like lighthouses and compasses to
pleted one round of CST and a round of A structured ethical decision-making help the professionals safely negotiate
maintenance CST.28 Following these, she process can help mental health practi- the challenging courses and assist them
continued to come to the center once tioners working with the elderly when in delivering ethically balanced inter-
every week for nearly two years, and she facing ethically challenging situations, ventions. Resources like the Pikes Peak
was participating in the weekly main- as described before, to choose an appro- Competencies Assessment Tool can
tenance CST sessions. Over time, it was priate course of action. Identification
assist in this regard.30
evident that her cognitive functions and of the problem, development of alter-
In India, the National Medical Council
activities of daily living were declining. natives, evaluation of alternatives,
has stipulated that all medical practi-
She could no longer participate meaning- implementation of the best option,
tioners are required to follow the code
fully in group activities. This appeared and evaluation of the results have been
of medical ethics, including codes for the
to negatively impact other participants identified as necessary five steps to
character, conduct, quality of care, and
in the group, as the facilitators were review several ethical decision-mak-
reporting of unethical conduct or care.31
spending more time helping Mrs S and ing models.29 We found that a specific
It also recommends that medical prac-
other participants felt ignored. However, ethical decision-making model pro-
titioners should follow the law of the
her family reported that she appeared posed by Bush, Allen, and Molinari has
land. Specifically for the psychiatrists,
to enjoy being out of the house. On the integrated elements from various other
the Ethics Subcommittee of the Indian
days that she attended the sessions, she such models most helpful in our prac-
Psychiatric Society has stipulated 13 prin-
was more cheerful. While being aware of tice.26 The model includes the following
ciple code of ethics statements. These
seven steps (mnemonic CORE OPT):
the futility of the maintenance CST for include the patient’s wellbeing being
Mrs S, the facilitators of the group also the paramount criterion of treatment,
believed that socialization and being out
Clarify the Ethical Issue professional competence, maintenance
of her house helped her emotionally. It The crucial first step is to analyze of discretion, consultations, and collab-
was agreed that maintenance CST might the clinical situation and clarify the orations with professional colleagues
Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2021 3
Vaitheswaran et al.
as needed, maintenance of profession- Options, Solutions, and Declaration of Conflicting Interests
alism in all interactions, maintenance
of patient rights and confidentiality, Consequences; Put the Plan The authors declared no potential conflicts of
interest with respect to the research, authorship,
regular knowledge updating, treating into Practice; Take Stock and/or publication of this article.
other professionals respectfully and
acting appropriately when encounter-
and Evaluate Funding
ing unethical actions of another pro- Once an appropriate plan is made to The authors received no financial support for the
fessional, upholding the dignity of the manage an ethically challenging situ- research, authorship, and/or publication of this
medical profession, raising awareness ation, the next obvious steps are to put article.
about mental illness among the general the plan into action and evaluate the out-
ORCID iD
public, adhering to the ethical principles comes. Documenting all the processes
Sridhar Vaitheswaran https://orcid.org/0000-
of academic and research conduct, and involved in arriving at the plan, com- 0001-7848-7638
abiding by all the laws that apply in the municating the plan to all the relevant
context of one’s clinical work.12 stakeholders, systematically executing
The Mental Health Care Act 2017 that the plan, and evaluating the outcomes
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