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On being ethical in unethical places: the dilemmas of South African clinical pathologists.

Prejudice and conflict are problems in many societies, but only in South Africa is racial discrimination entrenched as state policy. Apartheid laws ensure the dominance of white South Africans by denyng black groups effective political and economic power. Blacks are granted inferior social services and are subject to a vast array of restrictive legislation.

This legislation is too extensive to cover in full here, but some examples may illustrate its detrimental effects.

The Violence of Aparthieid

While white South Africans enjoy a standard of living comparable to that in Western nations, poverty is widespread amongst the black population and many experience great difficulty in obtaining adequate shelter, food, and clothing. This situation has been exacerbated by unemployment, job reservation practices, and laws forbidding movement from rural regions to more affluent industrial areas. Economic development is also hampered by an inferior education system that has earned the appellation of gutter education" and has frequently given rise to angry protest by black students.

Apartheid also disrupts family life and supportive community networks. The Group Areas Act dictates that blacks may live only in specified areas, usually far from their workplaces. Inadequate public transportation compels workers to rise in the early hours of the morning and return home late at night, leaving little time for relaxation and contact with families and friends. This act has also resulted in large-scale forced removal of black families from established suburbs to new housing estates. New townships are poorly equipped with important amenities such as water and electricity, and with housing supply lagging far behind the demand, overcrowding is a chronic problem.

In rural areas, family life is disrupted by the migrant labor system, which provides cheap labor for the gold mines upon which South Africa depends for much of its economic prosperity. Workers are required to repeatedly leave their families and live in single-sex hostels for up to a year at a time. This causes anxiety and stress for the families which, in order to survive financially, lose fathers, husbands, and elder sons. As well, workers undergo a painful separation from supportive community bonds while adjusting to an unfamiliar urban setting. Thus, the social and economic structures arising out of apartheid ideology impinge directly on the physical and mental well-being of the black population. The implementation of apartheid coupled with continual harassment by law enforcement agencies contributes to an atmosphere of fear and tension in black communities. In these conditions healthy psychological functioning and the development of self-esteem are seriously undermined. Aziza Seedat summarizes the situation:

The laws and practices of the apartheid system are themselves sources of fear, stress, and anxiety for millions of black South Africans ... Above all, apartheid society is inherently violent, relying as it does on the use of force to retain power in the hands of a minority. Such an environment must tend to undermine mental health.'

Black people thus live in deplorable social conditions and experience extremely threatening daily events. Tension and psychological distress are widespread and there is a great need for the services of clinical psychologists. However, South African psychologists face complex difficulties in attempting to meet this need. In particular, ethical practice is impeded in a broader social system that violates the profession's ethical principles.

In 1985, the South African Institute for Clinical Psychology proposed a set of Ethical Principles for Clinical Psychologists2 largely based on the 1981 American Psychological Association ethical code. The failure of these principles to account for the complex ethical decisions confronting South African clinical psychologists highlights difficulties inherent in all professional ethical codes. In particular, the South African experience illustrates that ethical codes embody particular political and social values. When there is general societal consensus on these values, ethical codes may function relatively successfully, but if the political values of the state conflict with the principles espoused by the profession, or where there is widespread political conflict, a set of ethical guidelines is likely to be plagued by recurrent dilemmas.

Common Ethical Dilemmas

The dilemmas facing South African clinical psychologists may be best illustrated through discussion of a case referred for treatment at the University of Cape Town Child Guidance Clinic. It will be assumed throughout this discussion that, like the majority of South African clinical psychologists, the psychologist dealing with this case is white.

Tommy, a twelve-year-old black child, was bothered by persistent nightmares, insomnia, and anxiety so severe that he could not be separated from his mother for more than a few minutes at a time. These symptoms began shortly after Tommy, his elder brother Jakob, and a classmate, Robert, attended the funeral of a community member shot by police. The mourners were angry, and several political speeches were made. Under government regulations, this was an illegal political gathering. The police arrived and ordered the crowd to disperse, but the mourners responded by throwing stones at police vehicles. Tear gas was fired into the crowd and Tommy and Robert turned to run, but some defiantly continued to stone the vehicles. The police opened fire and Tommy saw Robert being hit by a bullet and falling to the ground. Terrified, Tommy continued running. Robert died as a result of the shooting.

Clearly, effective treatment of Tommy's symptoms would involve discussing his perceptions of these events. However, working with Tommy and his family raises a number of dilemmas that may be broadly divided into issues of trust and professional competence.

Issues of Trust

Effective treatment depends on a trusting relationship between client and psychologist. But the stereotyping and suspicion endemic to South African society present an immediate obstacle. By severely limiting social contact between blacks and whites, apartheid laws provide fertile ground for stereotyping. Since blacks are consistently socially disadvantaged, suspicion of white involvement in black affairs has also developed. Groups such as the Black Consciousness movement maintain that privileged whites cannot have black interests at hear% and white psychologists in black communities may find their motives questioned. A black patient suffering from a depressive reaction recently said to one of the authors:

All my life my color's worked against me, and that makes it difficult to be relaxed with a white psychologist. You think, can a white person really know about discrimination or seriously care about it when it works in his favor? I'm not saying I feel angry with you personally, but there's a lot of anger against white people, a lot of anti-white feeling, and it's hard to get past that.

Black resentment and suspicion are, however, rarely overtly expressed, usually emerging only after trust has already been established. The psychologist therefore needs to be aware that, though unexpressed, such feelings may impede Tommy's willingness to talk openly. Uncertainty about the psychologist's political stance is also likely to affect the establishment of trust. Many clients who have experienced trauma from the harsh measures of the security forces may fear that talking about their experiences and beliefs will be followed by lack of understanding, rejection, or even a report to the police. This too presents a dilemma for the psychologists. It is frequently held that psychologists must remain value-neutral" because their powerful position may coerce the client into accepting their value system. Clients may, however, perceive "neutrality" as threatening because of the political affiliations it might conceal; at the very least, neutrality may imply acceptance of the status quo. In practice, many cases like that of Tommy's are referred via community organizations with a clear anti-apartheid stance and the psychologist's political stance is known prior to referral. It is clear that without such knowledge clients may feel unable to talk openly, and many would not begin a therapeutic relationship.

Political Allegiance

Not all cases are as directly related to political events as is Tommy's. Where the relative contribution of social and personal or interpersonal factors is uncertain, revealing one's political beliefs may complicate understanding the client's difficulties: Susan Smith, aged nine, was becoming increasingly withdrawn and tearful. She no longer played with her friends and seemed generally unhappy. Her unhappiness stemmed from familial conflict over her two elder brothers joining a school boycott. Mr. Smith was adamantly opposed, feeling that education was vital to the boys' future prosperity, but his attempts to force them to return to school were thwarted by Mrs. Smith who supported the school boycott for political reasons. Tension within the family increased steadily, until there was very little communication between Mr. Smith and his wife and sons.

Although Mrs. Smith's support of her sons' boycott action was consistent with her genuine political beliefs, it emerged during treatment that her conflict with Mr. Smith was also conditioned by marital dissatisfaction. Political disagreement therefore acted partly as a vehicle for expressing pre-existing intrafamilial conflict.

In this case, revelation of the psychologist's political affiliation would imply agreement or disagreement with the school boycott, thereby indicating tacit support for one side of the oven conflict. This would complicate understanding the family's multifaceted difficulties. Whether, when, and to what extent a psychologist's political stance should be revealed therefore requires sensitivity to the implications for the client's progress in treatment. The fact that political opposition to the state is itself divided emphasizes the need for sensitivity. In practice it is usually advisable to espouse a nonsectarian anti-apartheid position rather than to locate oneself more precisely within the political spectrum.

Trust and Confidentiality

The duty to preserve confidentiality is fundamental to establishing trust and is included in all ethical codes of the profession. In South Africa, given the harm to which clients may be exposed as a result of their revelations, this assurance is particularly vital. However, in the current State of Emergency it is one that cannot be given lightly. Medical records may be seized by the police without a warrant and information may lead to a client's arrest and detention without trial for indefinite periods. Had details of Tommy's case history been seized, for example, he and his brother would have been vulnerable to arrest for stoning a police vehicle. Treatment centers and training institutions that operate on a team basis usually rely on detailed notetaking for effective functioning. The dilemma is that while accurate notetaking is important for competent treatment, the consequences of these notes falling into the hands of the police may be extremely damaging to clients and their families.

The limits of confidentiality raise a further issue that has long concerned mental health professionals and is one of the most difficult to resolve in South Africa. This is the question of "dangerousness." According to the APA ethical code, confidentiality may be waived if clients are a danger to other members of society, in which case the psychologist must inform "the relevant authorities" or take other active steps to avert the danger. Failure to do so may lead to charges of unethical behavior (as in Tarasoff).

Let us imagine that during treatment Tommy's elder brother, Jakob, states that he is a political activist and that he and his comrades plan to avenge Roben's death by setting fire to the home of a black policeman. What would be the ethical course of action? Should the "relevant authorities" be informed? Should the policeman in question be warned? Either of these actions would have severe consequences for Jakob, his friends, and their families. Alternatively, should the psychologist attempt to dissuade Jakob from his plan? It is likely that Jakob would react by abruptly terminating treatment, perhaps convincing his family to do likewise, because he would see his plan as part of his political commitment and the only route to eventual liberation from a violently oppressive system. To further illustrate the dilemma, how would the same psychologist react were the client a policeman who revealed plans to kill the leaders of an opposition organization? It is clear that a broad ruling concerning "dangerousness" encounter-s difficulties where the potential violence is politically motivated and occurs in a setting of widespread civil conflict These dilemmas appear to be irresolvable without clear political affiliation on the part of the profession. This, as we shall discuss later, introduces further problems.

Issues of Professional Competence

Even should a trusting relationship be established with Tommy and his family, effective intervention in this case would remain problematic. Competent psychological treatment requires accurate understanding of the client's difficulties, selecting the appropriate treatment from a range of possibilities, and the technical and empathic skills to administer this treatment. South African clinical psychologists are hampered at all these levels by their background and training.

Accurate understanding and empathy is often difficult for white, middle-class psychologists who frequently find themselves in an alien setting amongst black people. Free entry into black townships is prohibited for whites and strict media censorship further conceals the reality of township experience. It is therefore difficult to comprehend the nature and intensity of black people's reactions to their debilitating social conditions and horrifying daily experiences.

The education and training of clinical psychologists does not facilitate the requisite understanding, typically being wholly oriented toward white, first-world, middle-class concerns. Most white graduates do not speak a black language and are entirely unschooled in black working-class issues. In addition, many black clients to some degree view witchcraft as a determinant of ill-fortune, and may want to protect themselves through traditional measures. These are poorly understood and the possibility for collaboration with traditional healers has not been adequately considered.

Professional training thus focuses on standard first-world diagnostic and treatment models, which may be ill-suited in South Africa. For example, what is the appropriate treatment for Tommy? A number of options are available, including individual, family, or group therapy in which South African clinical psychologists are trained and competent to offer treatment. However, given the circumstances surrounding Tommy's psychological difficulties, these approaches must be questioned. Psychological treatment is frequently criticized for focusing on individual psychological distress, helping clients to adjust to-rather than challenge difficult or unacceptable social circumstances. Tommy's symptoms are clearly a direct result of particular social conditions and the abnormality" in this case lies in these, rather than in Tommy himself. Are approaches that focus on change within the individual or family appropriate here?

Ethically, psychologists are obliged to offer treatments that have been shown to be successful. In South Africa, this is not always possible to guarantee. For example, there are many difficulties in attempting to assist ex-detainees suffering the effects of physical and psychological abuse. After their release, these persons are often persistently harassed and may be hiding from the police or vigilante groups, making them unable to attend regular appointments. An intensive approach based on a single one- to two-hour session has been developed,-, but follow-up research is almost impossible to carry out in these circumstances, thus preventing knowledge of how beneficial this intervention may be.

Addressing the Problems

In 1985, Manganyi charged that South Africa's mental health community had maintained a "pathetic silence" in the face of the effects of apartheid. This was by and large a just charge. Open opposition to apartheid may provoke state retaliation and this, in combination with uncertainty as to how the profession should respond, meant that until the early 1980s broader social problems were ignored or addressed only in limited ways. However, intensified civil conflict has highlighted apartheid's effects on mental health and professional functioning and precipitated the development of new ideas about strategy and action.

Specific needs include extensive revision of training programs that should be less oriented toward first world psychology and more to the demands of working in a developing country, with the emphasis on community intervention. Trainees must be able to speak a black language and must become familiar with the experiences and needs of black communities. White psychologists need to counter-act the effects of their own upbringing within a racist society by undergoing value-clarification and "consciousness-raising" exercises. Obviously, more black clinical psychologists must be trained. Training groups in Cape Town and johannesburg have begun to address these needs. At the University of Cape Town Child Guidance Clinic, training and practice have increasingly shifted toward a community-oriented approach, including supportive groups for "front-line" community workers and workshops teaching counseling skills to people in black communities.

South African clinical psychologists have an important role to play in conducting research to clarify the effects of apartheid on mental health and facilitate development of appropriate treatment. Such aims are not, of course, confined to psychologists. The progressive organization for Alternative Social Services in South Africa (OASSSA) unites psychologists, social workers, psychiatrists, and a range of "nonprofessionals." OASSSA takes a clear political stance, supporting democratic, nonracial, community-based organizations in working toward its long-term aim of appropriately transforming South African social services. Achievement of these long-term aims is no simple matter, requiring organization and cooperation in the face of state obstruction and hostility.

Limits of Ethical Codes

Resolving the immediate ethical dilemmas discussed above is equally difficult It appears that these arise out of lacunae or tensions inherent in most professional ethical codes. Ethical codes are intended to regulate professional conduct, providing a standard to evaluate the behavior of practitioners and protecting the public from possible harm arising from contact with members of the profession. It is apparent that in South Africa an ethical code cannot adequately serve these functions. This is partly due to the political and social circumstances particular to South Africa, but these conditions reveal that all professional codes contain fundamental problems that not only give rise to ethical dilemmas but also prevent their satisfactory resolution.

The dual ethical responsibility to give priority to individual clients while also protecting the interests of society as a whole is one such fundamental problem. Regulations that necessitate balancing the fights of individual clients against the interests of society are phrased in terms so broad as to render them meaningless. Interpretation of what is in die interests of society always depends upon reference to political and social values. Such basic values are not explicitly stated in professional ethical codes and many regulations are therefore simply rules of thumb that practitioners must interpret on the basis of their personal value systems. If there is consensus on these values within the profession and within the broader society, this may be a manageable if not entirely satisfactory-state of affairs. But the South African situation demonstrates firstly that it may be a mistake to assume that such consensus exists and, secondly, that where consensus cannot be assumed ethical codes are unable to provide a standard for conduct in many instances where important ethical issues are at stake.

This may be illustrated by considering the position of South African military psychologists. Many young conscripts suffer psychological distress as a result of their army experiences. The psychologist's task, dictated by the military authorities, is to return these men to active service whenever possible. As the South African army continues to attack neighboring countries and increasingly deploys troops in black townships, thereby conducting what is essentially a civil war, many men are resisting conscription or experiencing deep ambivalence about their involuntary role in this conflict. Military psychologists are therefore increasingly associated with coercing unwilling men into participation. On the basis of current ethical guidelines, it is difficult to accuse these psychologists of unethical behavior. Their reply might be that the intention of the South African army is to preserve social stability, which is in the interests of the broader population. They might argue that individual objections to military service may be ethically over-ridden to protect what they perceive as society's best interests.

Should these important ethical decisions be left to the individual practitioner or should the professional body intervene? The question of whether the profession has a valid political and social role has been hotly debated, one view being that psychologists are not specifically qualified for political action and should therefore concern themselves only with individual clients and their families. However, the South African situation demonstrates that professional functioning is inseparable from broader political and social issues. Here, work with individual clients is profoundly affected by social conditions; state policy undermines the well-being of the majority of the population and politics affects professional decisions at all levels. Political involvement is inevitable since, as has been illustrated, some ethical decisions simply cannot be made without reference to a political orientation.

Traditional reluctance to take a clear political stance may also be due to the fact that, inevitably, individual practitioners have differing personal value systems and political affiliations. It may be argued that the profession does not have the fight to dictate what these affiliations should be. However, this objection ignores the fact that certain political and social values are already embedded in ethical codes for the profession. These values are usually so unquestioningly accepted that many fail to recognize their existence and are under the illusion that the profession and its ethical guidelines are value-free or value-neutral. The naivety of this assumption has been amply demonstrated by the profession's situation in South Africa.

In 1985 the South African Institute for Clinical Psychology publicly condemned apartheid as an unethical system because of its violation of the profession's ethical principles. On the South African political spectrum, the profession has in general fallen within the "reformist" camp. "Reformism" may be described as a broadly liberal approach that accepts the principle of individual autonomy, criticizes the state for violating individual rights, and attempts to change aspects of the system that impinge upon these rights. However, the South African state has repeatedly disregarded reform initiatives and the profession's clear anti-apartheid position has been attacked from the radical left, which maintains that, by definition, apartheid cannot be reformed and calls for a radical restructuring of the social and political system. The radical approach involves a reevaluation of all presuppositions including the principle of individual autonomy, which is seen by some as specific to liberal or capitalist forms of social organization and inappropriate in other, for example socialist, systems.6

These difficulties amply indicate that ethical dilemmas constitute more than conflicting regulations in particular situations, and that they cannot be resolved by simple amendments or creation of further regulations. Many ethical dilemmas arise out of the lack of an explicit set of fundamental values or out of challenges to the values implicit in professional ethical codes. Their resolution requires the recognition and explication of these values and their serious reexamination in the light of prevailing social conditions.

South African clinical psychologists are faced with this difficult task of questioning both the traditional values and the traditional societal role of their profession. It is perhaps inevitable that clinical psychology will reflect the broader schisms of a deeply divided society and that resolution of professional conflicts must parallel the difficult process of working toward a just and democratic society. But in this process, the questions raised and alternatives considered might well help elucidate the nature of ethical practice and ethical dilemmas in any society in which clinical psychology is practiced.

References

1 Aziza Seedat, Crippling a Nation: Health in Apartheid South Africa (International Defence and Aid Fund for South Africa, 1984).

2 Jane Steere and Douglas Wassenaar, Ethical Principles of Psychologists (South African Institute for Clinical Psychology, 1985).

3 Herbert Vilikazi and B. Tema, "White Universities and the Black Revolution," paper delivered at Academic Support Programme Conference, University of the Witwatersrand, 1981.

4 Gillian Straker, "Post-traumatic Stress Disorder: A Reaction to State-supported Child Abuse and Neglect," Child Abuse and Neglect 12 (1988).

5 Graeme Friedman, "Counselling Exdetainees: Themes, Problems, and Strategies," OASSSA 2nd National Conference Preceedings, 1987.

6 Leslie Swartz, "Some Comments on the Draft Ethical Code for South African Psychologists," South African Journal of Psychology 18:1 1988),17-20.
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Author:Steere, Jane; Dowdall, Terence
Publication:The Hastings Center Report
Date:Mar 1, 1990
Words:3919
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