University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA COLLEGE OF HUMANITIES LAY COUNSELLING IN GHANA: ETHICAL DILEMMAS AND ETHICAL CHALLENGES IN PRACTICE BY ROBERT KAKRA KETOR (10302673) THESIS SUBMITTED TO THE DEPARTMENT OF PSYCHOLOGY, UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL CLINICAL PSYCHOLOGY DEGREE DEPARTMENT OF PSYCHOLOGY SUPERVISORS: DR. ANNABELLA OSEI-TUTU PROFESSOR ANGELA OFORI-ATTA JULY, 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that with the exception of the references used which are duly acknowledged, this thesis is my own work submitted for the award of MPhil Clinical Psychology to the Department of Psychology, University of Ghana. ……………………….. Robert Kakrah Ketor …………………….. Date Supervisors: ……………………….. ……………………….. Dr. Annabella Osei-Tutu Prof. Angela Ofori-Atta (Principal Supervisor) (Co-Supervisor) ………………………… …………………….. Date Date i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to my parents; Mr. Charles Mensah Ketor and Mrs. Elizabeth Ketor for all the sacrifices you made for me to get me this far. To all my siblings for your encouragement, support and prayers for me. And also to Fortune Fiati, for your emotional support and always being there for me. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT Great is thy faithfulness O Lord. I wish to thank the Almighty God for His grace which has brought me this far. I owe all my achievement in my life to Him. I want to express my heartfelt gratitude to my supervisors; Prof. Angela Ofori-Atta and Dr. Annabella Osei-Tutu for their immense support, time, patience and guidance from the beginning of this work to the end of it. I am deeply grateful. I also want to thank all lay counsellors who participated in this study. Without your participation, this study would not have been a success. My next thanks go to my family and siblings for the sacrifices they made for me in one way or another. Also to you Fortune Fiati, for your support. I cannot end without thanking you my dear friend Mr. Francis Agyei (PhD Candidate) for all the immense help you gave me. May The Almighty God Bless You All, Amen. iii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ........................................................................................................................ i DEDICATION ........................................................................................................................... ii ACKNOWLEDGEMENT ....................................................................................................... iii TABLE OF CONTENTS .......................................................................................................... iv LIST OF TABLES .................................................................................................................... ix LIST OF FIGURES ................................................................................................................... x LIST OF ABBREVIATIONS ................................................................................................... xi ABSTRACT ............................................................................................................................. xii CHAPTER ONE ........................................................................................................................ 1 INTRODUCTION ..................................................................................................................... 1 1.1 Background to the Study ............................................................................................. 1 1.1.1 Lay Counselling in Africa and Ghana ................................................................. 5 1.1.2 Competence of Lay Counsellors .......................................................................... 7 1.2 Problem Statement ...................................................................................................... 7 1.3 Research Aims and Objectives .................................................................................... 8 1.4 Research Questions ..................................................................................................... 8 1.5 Relevance of the Study ................................................................................................ 9 1.6 Summary ..................................................................................................................... 9 CHAPTER TWO ..................................................................................................................... 10 LITERATURE REVIEW ........................................................................................................ 10 2.1 Introduction ............................................................................................................... 10 iv University of Ghana http://ugspace.ug.edu.gh 2.2 Theoretical Framework ............................................................................................. 10 2.2.1 Stages in Ethical Decision Making; (Four-Component Model of Ethical Decision-Making) ............................................................................................................. 11 2.2.2 Social Constructivism .............................................................................................. 14 2.2.3 Integrating the two models with the current study............................................. 15 2.3 Review of related studies .......................................................................................... 16 2.3.1 Ethical Dilemmas ............................................................................................... 17 2.3.2 Cultural Values and Counselling Competence .................................................. 20 2.3.3 Code of Ethics for Counsellors in Ghana .......................................................... 21 2.4 Rational for the Study ............................................................................................... 23 CHAPTER THREE ................................................................................................................. 24 METHODOLOGY .................................................................................................................. 24 3.1 Introduction ............................................................................................................... 24 3.2 Research Design ........................................................................................................ 24 3.3 Research Setting ........................................................................................................ 25 3.4 Population.................................................................................................................. 25 3.5 Selection of Participants ............................................................................................ 25 3.6 Demographic Characteristics of Participants ............................................................ 26 3.7 Interview Guide ......................................................................................................... 27 3.8 Procedure ................................................................................................................... 29 3.8.1 The Pilot Study .................................................................................................. 29 3.8.2 The Main Study.................................................................................................. 30 v University of Ghana http://ugspace.ug.edu.gh 3.9 Ethical Consideration ................................................................................................ 31 3.10 Data Analysis ............................................................................................................ 32 3.11 Quality and Trustworthiness of Data ........................................................................ 34 3.11.1 Reflexivity.......................................................................................................... 34 3.11.2 Research Trustworthiness and Data Validation ................................................. 35 CHAPTER FOUR .................................................................................................................... 36 RESULTS ................................................................................................................................ 36 4.1 Introduction ............................................................................................................... 36 4.2 Participants' of Knowledge of Ethical Codes and Training in Ethics ....................... 38 4.3 Ethical Dilemmas among the Lay Counsellors ......................................................... 38 4.3.1 Negotiating Rights and Confidentiality ............................................................. 41 4.3.2 Competency Issues............................................................................................. 52 4.3.3 Multiple Relationships ....................................................................................... 53 4.3.4 Conflicting Values ............................................................................................. 57 4.3.5 Dealing with Gifts .............................................................................................. 58 4.4 Resolution of Ethical Dilemmas by the Lay Counsellors ......................................... 60 4.4.1 Referral .............................................................................................................. 62 4.4.2 Personal Discretion ............................................................................................ 63 4.4.3 Consultations...................................................................................................... 66 4.4.4 Codes of Conducts ............................................................................................. 69 4.5 Challenges of Resolving Ethical Dilemmas by the Lay Counsellors ........................ 71 vi University of Ghana http://ugspace.ug.edu.gh 4.5.1 Lack of continuous training ............................................................................... 73 4.5.2 Cultural values ................................................................................................... 74 4.5.3 Religious values ................................................................................................. 74 4.6 Summary ................................................................................................................... 75 CHAPTER FIVE ..................................................................................................................... 76 DISCUSSION .......................................................................................................................... 76 5.1 Introduction ............................................................................................................... 76 5.2 Ethical dilemmas faced by the lay counsellors ......................................................... 77 5.3 Ethical dilemma resolution strategies and challenges ............................................... 81 5.4 Implications of the Study .......................................................................................... 83 5.4.1 Implications for Practice and Training .............................................................. 83 5.4.2 Theoretical Implications .................................................................................... 85 5.5 Limitations of the study............................................................................................. 86 5.5.1 Suggestion for future studies ................................................................................. 87 5.5.2 Conclusion ............................................................................................................. 88 APPENDICES ......................................................................................................................... 98 APPENDIX I: Ethical Clearance ......................................................................................... 98 APPENDIX II: Informed Consent Form .............................................................................. 99 APPENDIX III: Interview Guide ....................................................................................... 103 APPENDIX IV: Introduction Letter .................................................................................. 110 APPENDIX V: Coding Framework ................................................................................... 111 vii University of Ghana http://ugspace.ug.edu.gh APPENDIX VI: Participants' knowledge of ethical codes and ethical training ................. 113 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3. 1: Demographic characteristics of the lay counsellors .............................................. 26 Table 4. 1: Profile Identifiers of individual lay counsellors .................................................... 36 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Thematic network of ethical dilemmas faced by the lay counsellors ....................... 40 Figure 2: Thematic network showing how lay counsellors resolve ethical dilemmas ........... 61 Figure 3: Thematic network of challenges encountered in resolving ethical dilemmas .......... 72 x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ACA American Counselling Association APA American Psychiatric Association GES Ghana Education Service GHS Ghana Health Service GPA Ghana Psychological Association GPC Ghana Psychology Council HC HIV/AIDS Counsellor HIV Human Immunodeficiency Virus LC Lay Counsellor LMICs Low Middle Income Countries MC Marriage Counsellor PC Pastoral Counsellor Psych LC Psych Corps Lay Counsellor SC School Counsellor xi University of Ghana http://ugspace.ug.edu.gh ABSTRACT Lay counsellors play critical roles in mental health service delivery in Ghana. There is a shortage of professionally trained mental health practitioners. Lay counsellors deliver basic counselling and psychoeducation services in schools, churches, health settings and communities. Given the critical role of lay counsellors in mental health delivery in Ghana, it is imperative to understand how these lay counsellors deal with ethical dilemmas in their everyday practice. Unfortunately, there have been limited studies focusing on this group of counsellors. This qualitative study explored the ethical dilemmas experienced by a conveniently selected sample of 27 lay counsellors in Ghana and investigated how these dilemmas were resolved. Data were gathered using in-depth individual interviews and vignettes; and analysed using thematic analysis. Findings showed five thematic domains of ethical challenges faced by the lay counsellors: (1) difficulties negotiating rights and confidentiality; (2) competency issues relating to working on cases they are not trained for; (3) difficulty managing multiple relationships; (4) dealing with conflicting values; (5) and issues relating to gifts. Four thematic resolution strategies were identified: (1) referrals; (2) personal discretion; (3) consultation; and (4) use of codes of conduct. More so, three challenges were identified in terms of resolving ethical challenges: lack of continuous training; challenges religious values; and challenges with cultural values. The findings are discussed in relation to improving lay counselling practice in Ghana. Keywords: ethical dilemmas, lay counselling practice, mental health, para-professionals, Ghana xii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background to the Study Lay counsellors are those who provide psychosocial support, but are not clinical, mental health specialists (i.e. social workers, psychologists or psychotherapists) (Juen, Siller, Lindenthal, Snider, Nielsen, Muff & Wiedemann, 2013). Lay counsellors provide additional support such as offering help for people experiencing emotional problems (Martin, 2016). The Ghana Psychological Council recognizes lay counsellors as paraprofessionals (Health Professionals Regulatory Bodies Act, 2013). Tan (1997) describes paraprofessionals/lay counsellors as persons who do not possess formal credentialing, training and experience as mental health professionals but who perhaps work in the field of mental health with people who need support. Lay counsellors are also volunteers in the non-governmental sector who assist to relieve the burden of psychologists, professional counsellors and health care professionals (van Rensburg, 2008). DeMoss (1974) also defines a paraprofessional as a person doing the same tasks as a professional, but who does not have an advanced degree in that specific kind of area. Taken together lay counsellors are people who may have or not have a mental health background with little qualification but have received training to help professional counsellors and other mental health workers by providing counselling services to people. Lay counsellors provide valuable psychosocial support in many different circumstances, such as manning telephone helplines for patients, assisting people after crisis events or giving focused support to refugees or other vulnerable groups (Juen, Siller, Lindenthal, Snider, Nielsen, Muff & Wiedemann, 2013). Lay counsellors educate clients and provide emotional support, and are 1 University of Ghana http://ugspace.ug.edu.gh mostly active in fields such as trauma, psychological first aid, gender-based violence, and HIV and AIDS counselling (van Rensburg, 2008). Lay counsellors also help in times of national disasters like floods and fire outbreaks by counselling victims who may be psychologically distressed (Ghana Psychological Association, 2015). However, a report by the chief statistician of the statistical service, David Combat, disclosed that Ghana’s midyear population is now estimated at 27.9 million, up from the 24 million recorded in the 2012 national population and housing census (GhanaWeb, 2015). This increasing population is likely to seek mental health care in various ways including counselling services because urbanization affects mental health through the influence of increased stressors and factors such as overcrowded and polluted environment, high levels of violence, and reduced social support (Srivastava, 2009). Counselling is a method of relating and responding to others with the aim of providing them with opportunities to explore, clarify, and work towards living in a more personally satisfying and resourceful way (American Counselling Association, 2005). Counselling is a process of self-discovery that can help people learn how to deal more effectively with situations in their lives such as depression, addiction and substance abuse, stress, problems with self-esteem, grief, issues related to mental and emotional health, and relational problems. This process helps people feel more comfortable with themselves, others, and helps develop some of the skills needed to deal with the tensions that come from inside. Juen, Siller, and Gstrein (2011) also define lay counselling as activity that consists of active listening, information sharing, and support to take informed decisions, all with the objective of empowering the individual to cope with stressful and critical situations. Counselling practice is complex, and ethical dilemmas arise as new challenges confront practitioners (Cottone, 2001). 2 University of Ghana http://ugspace.ug.edu.gh There are different types of counsellors which include school counsellors, marriage counsellors, lay counsellors and family counsellors. The number of certified counsellors and lay counsellors from counselling-related programs in Ghana has been increasing in recent times (Ghana News Agency, 2012). This is as a result of the demand for mental health care. Although lay counselling should never replace professional counselling, thousands of lay counsellors provide an important service to vulnerable people and to their organizations – and sometimes in areas and situations where no professional counselling is available. Ethics in Counselling In every profession, practices are based on ethical decision and actions (Noel-Weiss, Cragg & Woodend, 2012). All counsellors including professionals and lay counsellors are required to abide by ethical standards of their particular professions (Bodenhorn, 2012). Generally, codes of conduct are essential in order to regulate the activities and practices of every profession so as to prevent abuse, ensure professional practices, and protect both the public and the providers of the service. Ethics refers to sets of rules, principles or ways of thinking that guide, or claim authority to guide, the actions of a particular group (Singer, 1994). Codes of ethics advise counsellors who encounter an ethical dilemma to engage in a carefully considered ethical decision-making process (American Counselling Association, 2005). Due to the complex nature of the counselling profession, counsellors often face ethical dilemmas (Constable, Kreider & Taylor, 2011). These 3 University of Ghana http://ugspace.ug.edu.gh dilemmas may be as a result of the clients that counsellors work with, the culture and institutions within which the counsellors work, as well as the theoretical orientation of the counsellor. Ethical Dilemmas An ethical dilemma is defined as circumstances when two or more options are encountered and there is a difficulty in deciding which one is better (Noureddine, 2001). A classic example is stealing to feed your family. Stealing is legally and ethically wrong, but if your family is starving you might consider this action to be morally justified (Noel-Weiss et al., 2012). This is seen as a dilemma because there is a choice between two opposing sets of values and beliefs that needs to be made. Almost every profession has its own dilemmas. It has been found that healthcare students and other professionals face dilemmas and moral distress (Monrouxe, Rees, Dennis & Wells, 2015). Most counsellors suffer from ethical dilemmas due to the complexity in application of ethical standards (Akfert, 2012). A lay counsellor’s roles in terms of duties and expectations can be different depending on where he/she is practicing, such as in the church or school setting. For example, a lay counsellor’s role in the church may be defined and assigned by administrators or pastors who may not be fully aware of the roles that lay counsellors should have. This can lead to a conflict of interest thus resulting in dilemmas that may be faced by the lay counsellor. Ghana is in the process of many changes. There is now the rural-urban drift with many towns and cities across the country being populated with individuals from a variety of cultural backgrounds. In Ghana, there are over 100 ethnic/cultural groups with about nine (9) major ethnic groups (Ghana Statistical Service, 2013). These ethnic groups have their own culture. This 4 University of Ghana http://ugspace.ug.edu.gh therefore means that, lay counsellors will be challenged dealing with the various world views of clients that will come to them for services. There may however be demands on lay counsellors to adapt to some of the challenges that come with internal migration of Ghanaians from one cultural setting to the other. An example is language barrier and the ability to adapt to the culture of help – seekers. From this, we can see that the attitude of lay counsellors as they work with Ghanaians of different ethnic backgrounds can affect the quality of services delivered. Thus the need for them to be culturally competent. 1.1.1 Lay Counselling in Africa and Ghana In the case of Ghana, lay counsellors have been seen to help mitigate the treatment gap that exists in mental health care (Ofori-Atta, Ketor & Bradley, 2014). It has been shown that lay counsellors are easily accessible by many in communities and have been used to promote community-based voluntary counselling and HIV testing in the northern part of Ghana (Baiden, Akanlu, Hodgson, Akweongo, Debpuur & Binka, 2007). Lay counsellors have also been used in emergency situations like national disasters. For example, in the June 3, 2015 flood and fire disaster that claimed over 150 lives, mental health professionals including lay counsellors like the Psych Corps were called upon to help counsel victims who were traumatised and psychologically distressed (Ghana Psychological Association, 2015). Ofori-Atta et al (2014) identified and set up a new cadre of community workers in Ghana called the Psych Corps who work as lay counsellors in community settings. They are often based in district hospitals and work alongside community psychiatric nurses or psychologists. These Psych Corps are trained to offer lay counselling for people seeking mental health care in communities. Most churches and other faith based institutions have counselling departments or 5 University of Ghana http://ugspace.ug.edu.gh units that meet the counselling needs of their members. Also African traditional healers also engage in mental health services (Atindanbila & Thompson, 2011). The same can be said about schools and universities. Some of these schools have peer counsellors’ associations who may offer lay counselling to their peers. In other African countries like Zambia, lay counsellors have been used to help in HIV counselling and testing services. Sanjana, Torpey, Schwarzwalder et al. (2009) posited that lay counsellors were recognized by facility managers and they provided counselling and testing services thus reducing the work load on overburdened health workers. In South Africa for example, lay HIV counsellors are trained in basic counselling skills and equipped to take blood samples. The idea of task shifting was adopted to mitigate the gap in the HIV counselling (Mwisongo et al., 2015). There are many private institutions in Ghana who are offering various courses in counselling and lay counselling. Examples of some of these institutions include Akona School of Counselling, Christian Outreach Complex and some few private Universities and churches across the country. For example, in 2014, the Akona School of Counselling alone trained two hundred and six students (Andoh, 2014). This therefore may mean that the number of lay counsellors is on the increase and thus there is the need to study some of the challenges they face. In addition, the competency of these counsellors needs to be assessed. In the current study, lay counsellor was conceptualised as people who provide psychosocial support, but are not clinical, mental health specialists (Juen et al., 2013). In this study, lay counsellors encompassed marriage counsellors, school counsellors, psych corps, HIV counsellors and pastoral counsellors. 6 University of Ghana http://ugspace.ug.edu.gh 1.1.2 Competence of Lay Counsellors Competence is one of the main principles found in almost every code of conduct. Cultural competence in health care describes the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs (Betancourt, Green & Carrillo, 2002). Cross, Bazron, Dennis and Isaacs (1989) also define cultural competence as a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations. In Ghana, there are not yet specific code of ethics for counsellors and lay counsellors to follow in their practice. However, the Ghana Health Service (GHS) patient charter is what is available for most lay counsellors to follow, especially those who work in the hospital settings under the Ghana Health Service (GHS). Those who do not follow any code of ethics where one is prescribed may practice beyond allowed boundaries. For example, a lay counsellor who is not trained to do therapy and does that may be operating beyond his/her boundaries of competence. 1.2 Problem Statement Counsellors interact with clients and clients’ families, lawyers, physicians, and other mental health professionals (Cottone, 2001). As in any human services profession, lay counsellors may face a number of ethical dilemmas in their practice. When there is a disagreement over an ethically sensitive issue that is resistant to easy negotiation, there is a conflict or dilemma (Cottone, 2001). The question to ask then is how these lay counsellors resolve or respond to the challenges and dilemmas they face. The increased interest in counselling practice makes it necessary to assess the extent to which lay counselling is ethically practiced, and the need to 7 University of Ghana http://ugspace.ug.edu.gh develop ethical standards (Gong, 2003). In addition, there are few professional mental health workers in the country like psychologists (Quarshie, Annor, Tagoe, Osei-Poku, & Andoh-Arthur, 2016). In Ghana, there is no counsellor specific code of ethics for lay counsellors to work with. This therefore suggests the need for developing a code of ethics to guide the practice of lay counselling in the country (Ghana News Agency, 2012). 1.3 Research Aims and Objectives The main research aim is to find out the ethical dilemmas faced by lay counsellors and how they resolved them. The specific objectives for this study were: i. To examine the different kinds of ethical dilemmas faced by lay counsellors in their everyday practice in Ghana ii. To assess the different strategies that lay counsellors in Ghana use in resolution of the ethical challenges they encounter in their everyday practice iii. To find out the challenges they face when resolving these dilemmas and the factors which influence their ethical decision making 1.4 Research Questions Based on the objectives of the study, the following research questions were asked: i. What kinds of ethical dilemmas do lay counsellors encounter in their everyday practice in Ghana? ii. What strategies do lay counsellors in Ghana use in resolution of the ethical challenges they encounter in their practice? 8 University of Ghana http://ugspace.ug.edu.gh iii. What challenges do lay counsellors face when resolving these dilemmas and what factors influence their ethical decision making? 1.5 Relevance of the Study Adhering to ethical principles and standards has become an issue of global concern. This includes both developed and developing counties. Information obtained from this study will help document the ethical dilemmas faced by lay counsellors. It will also help demonstrate how these dilemmas are resolved in relation to our Ghanaian culture. The knowledge gained about ethical dilemmas among lay counsellors will help in the training of lay counsellors and other mental health professionals. Results will be useful in crafting a culturally relevant ethics code for lay counsellors. 1.6 Summary The need for counselling services in Ghana has become a national issue. Despite this need, most lay counsellors face many dilemmas in their work. Counsellors interact with clients and clients’ families, lawyers, physicians, and other mental health professionals (Cotton, 2001). In Ghana, there are not yet specific code of ethics for counsellors and lay counsellors to follow in their practice. Lay counsellors have also been seen to mitigate the gap that exists in mental health care. 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter has two parts. The initial part is a review of the theoretical literature that explains the theories for the present study. The second part is dedicated to the review of the literature on study variables. The second part seeks to identify the gaps in the present literature and establish the essence and contribution of the current study. The rationale for the study is also presented in this chapter and operational definition is made of the terms used in the study. 2.2 Theoretical Framework This section focuses on the various theories reviewed and include social constructivism theory (Cottone, 2001), and Rest’s theory on stages of ethical decision making (Rest, 1994). People make decisions about many things. They make political decisions, personal decisions, including medical choices, romantic decisions, and career decisions; and financial decisions, which may also include some of the other kinds of decisions and judgments. Quite often, the decision making process is fairly specific to the decision being made. Some choices are simple and seem straight forward, while others are complex and require a multi-step approach to making the decisions (Dietrich, 2010). In making all these decisions, an individual must make the decision which is ethically right. It is very important to understand how individuals go about the decisions they make, or the processes in which clinicians, counsellors, and any other individual engages in ethical decision making. If the factors that do influence these decisions are known, it will be very important in 10 University of Ghana http://ugspace.ug.edu.gh helping develop more effective ethical guidelines and educational programs. In the current study, the stages of ethical decision making model, also known as the four-component model of ethical decision making and the social constructivism of ethical decision making are used as framework for exploring ethical decision making among lay counsellors in Ghana. Each of the two models are discussed. After that, a section is provided integrating the two models conceptually into a framework and how it is related to the current study. 2.2.1 Stages in Ethical Decision Making; (Four-Component Model of Ethical Decision- Making) Rest (1994) argued that it is not only our moral judgment that helps or guides a person in evaluating a decision as either good or bad. He therefore proposed four psychological processes that are involved in ethical decision making. This is the process by which a counsellor reasons that one course of action in a particular situation is ethically right or another course of action is ethically wrong. Hence for a person to act ethically, he or she must recognize a moral issue, make a moral judgment, give priority to moral concerns by establishing a moral intent and then act on the moral concerns. Thus ethical decision-making is seen as a sequential decision-making process. This means that for a person to act professionally, it is important to act ethically (Rest 1986). The four components include; 1. Moral sensitivity (moral awareness): refers to an individual’s ability to recognize that a situation contains a moral issue. It also requires the individual’s awareness that his/her actions have the potential to harm and/or benefit other people. Counsellors in this case must be able to identify and discern problematic situations with ethical dimension. 11 University of Ghana http://ugspace.ug.edu.gh 2. Moral judgment refers to formulating and evaluating which possible solutions to the moral issue have moral justification. This requires counsellors, for example, to go beyond recognizing the ethical dimensions present in a given situation to explore which line of action is morally justified. 3. Moral motivation (moral intention) refers to the intention to choose one moral decision over another representing a different value. This requires reasoning through the possible choices and potential consequences to determine which are ethically sound. 4. Moral courage (moral action) refers to an individual’s behaviour. This component is the individual’s action in the situation. It is the ability to follow through with the moral decision. In the process of making ethical decisions, other researchers have posited that age, gender and other demographic factors influence the process (Maria, Maria, & Maria, 2007). For instance, in situations where the client is a minor, decisions to be taking by the lay counsellor can be influenced. According to Jones (1991), who reiterates the steps asserted by Rest above, for a decision maker to act ethically, he or she must recognize a moral issue, make a moral judgment, give priority to moral concerns and establish a moral intent, and finally act on the moral concerns. The four components are conceptually distinct and each stage or component constitutes a required but not sufficient precondition for the subsequent stage. Thus, recognizing a moral issue is a necessary but not sufficient condition for making a moral judgment, which in turn is necessary but not sufficient precondition for giving priority to moral concerns or acting on those concerns. Jones (1991) also identified six dimensions of moral intensity as magnitude of consequences, temporal immediacy, social consensus, proximity, probability of effect, and concentration of 12 University of Ghana http://ugspace.ug.edu.gh effect. Magnitude of consequences refers to the degree to which an individual may be harmed by or benefit from the decision maker’s action. A greater degree of harm or benefit results in an increase in moral intensity. Temporal immediacy refers to the length of time between the action and its consequences. An action that results in immediate negative consequences will cause a greater increase in moral intensity than an action for which the consequences are delayed. Social consensus refers to the degree of agreement among a social group that an action is good or bad. This social group could be society as a whole (e.g., an illegal act is not morally acceptable by society because a law prohibits it) or a smaller social group, such as an individual’s academic peers. A strong social consensus that an act is morally wrong increases moral intensity. Proximity refers to the nearness of the decision maker to the individuals potentially affected by the consequences. Proximity can be a feeling of physical, cultural, social, or psychological nearness. An increase in Proximity results in an increase of moral intensity. Probability of effect refers to the likelihood that the predicted consequences and the expected level of harm/benefit will occur. If the probability that the action will occur and cause the predicted harm is high, moral intensity increases. The final dimension, concentration of effect, refers to the relationship between the number of people affected and the magnitude of harm. If the concentration of the effect is great, moral intensity increases. Studies by Lincoln and Holmes (2011) found out that certain components of moral intensity (Jones, 1991) are significantly associated with Rest’s four moral components of ethical decision making. They also found out that other dimensions of moral intensity are likely to affect specific 13 University of Ghana http://ugspace.ug.edu.gh parts of the ethical decision-making process. This means that the characteristics of a lay counsellor’s moral issue, which is the moral intensity can influence his/her ethical decision making. Studies by Selart and Johansen (2011) indicated that situations perceived as stressful impair a person’s ability to recognize ethical dilemmas. 2.2.2 Social Constructivism Cottone (2001) proposed the social constructivism model of ethical decision-making in counselling. He defined social constructivism as an intellectual movement in the field of mental health that directs a social consensual interpretation of reality. Thus the theory explains ethical decision-making as a process involving interaction between the decision maker and reality. The social constructivist theory is the most germane for this research in terms of ethical decision making because it posits that a person’s knowledge or decisions are not generated internally, rather they are socially. Thus knowledge is thought to be influenced by social factors such as culture, religion, values and beliefs, political climate and the economic system (Philips, n.d.). Though individuals may construct meaning around a phenomena or situation, the execution of the meaning takes place within a social context. If the individual comes to agreement about the phenomena with others within a group or social context, then the meaning constructed thus becomes formal knowledge (Philps n.d.). It also implies that what is real is not objective fact; rather, what is real evolves through interpersonal interaction and agreement as to what is "fact" (Cottone, 2001). This theory thus concludes that knowledge or meaning is not discovered but constructed by the human mind within a social context (Richardson, 2003). This implies that what constitute a dilemma is not something which is only internal of the individual, rather societal and other factors outside of the individual come together for a person to experience a 14 University of Ghana http://ugspace.ug.edu.gh dilemma. Cultural factors for instance can make a lay counsellor face an ethical dilemma in the course of his or her work. Sokal and Bricmont (1999) have argued that the theory generally ignores biological influences on behavior or culture, suggesting that they are unimportant to achieving an understanding of human behavior. Thus our decisions can also be influenced by biological and cultural factors (McDonald, 2000). Our decision making can also be affected by other factors such as past experiences, a variety of cognitive biases, an escalation of commitment and sunk outcomes, individual differences, including age and socioeconomic status, and a belief in personal relevance. These things all impact the decision making process and the decisions made (Dietrich, 2010). The theory is however relevant to this study since it could explain how lay counsellors make their decisions in relation to the situation they find themselves. 2.2.3 Integrating the two models with the current study This sub-section discusses how the two models are integrated conceptually to explore ethical decision making among the lay counsellors. The basic assumption of the four-component model is that moral values are fundamental to ethical decision making. The model argues that moral values both defines what constitutes ethical dilemmas and also guide how to resolve them. Rest (1994) that posits that being morally sensitive, motivated and courageous inspires moral actions to resolve situations that are ethically inconsistent on moral grounds. The social constructivism model of ethical decision-making also makes fundamental assumption that ethical dilemmas are socially constructed and not necessarily inherent in situations. Fundamentally, what constitutes ethical dilemma in counselling practice depends, among other 15 University of Ghana http://ugspace.ug.edu.gh things, on contextual factors. The socio-cultural contexts within which practitioners work is therefore important in shaping how they define situations as ethically charged and the resources they draw on in working through ethically charged situations. These two models provide framework to explore ethical issues among the lay counsellors. Based on the social constructivism model, it is expected that the lay counsellors would socially construct what situations constitute dilemma and how to work through them. By virtue of the fact that they are not professionally trained, they would draw more on their social context of practice in shaping how they handle ethical issues. This is in line with the social constructivism model. Based on four-component model, it is expected that moral values would underpin the contextual resources that the counsellors would draw. Given the fact that the lay counsellors lack professional training and ethics of counselling practices, moral values may come to the fore of their practice. Given the socio-cultural context of their practice, they are expected to conceptualise ethical dilemmas on moral grounds, mainly drawing on cultural and religious moral values (rather than professional values) to resolve ethically charged situations they encounter in their everyday practice. 2.3 Review of related studies This section discusses related empirical studies that have been conducted on ethical decision making in mental health contexts. The studies are discussed in three thematic areas; ethical dilemmas in counselling practices, culture and counselling competence and ethical codes of conducts in counselling practice in Ghana. 16 University of Ghana http://ugspace.ug.edu.gh 2.3.1 Ethical Dilemmas This section discusses empirical studies which have been done on ethical dilemmas facing health professionals in general, with emphasis on counsellors. Most of the evidence from practitioners in high income countries point to the fact that ethical dilemmas cohere around intricacies of institutional settings that compromise privacy and efficiency of practice. In the United States for instance, Bodenhorn (2006) reported the common ethical dilemmas of public school counsellors in Virginia to include those involving student confidentiality, dual relationship with faculty, parental rights, and acting on information of student danger to themselves or others. The study failed to assess the competency of these counsellors with respect to counselling. Another study among Turkish counsellors indicated that most of the ethical dilemmas faced by these counsellors were issues regarding confidentiality and privacy, conflicts with school principals and incidents regarding dual relationships and boundaries (ivis-Cetinkaya, 2015). Similar findings have been reported in another study in Turkey involving forty (40) psychological counsellors Findings indicated that ethical dilemmas were experienced in relation to limitations to privacy, entering into multiple relations and transfer of competence and values (Akfert, 2012). The obstacles to resolution of dilemmas were determined as “political and institutional”, “lack of competence in resolution of ethical dilemmas” and “personal reasons”. A study by Koocher and Keith-Spiegel (1998) found that one of the most important reasons for ethical violations conducted by those who work in psychological counselling profession is lack of sufficient knowledge in ethical related subjects. One disadvantage of this research was that it focused too much on the personal values of the respondents. Personal values of counsellors can interfere with the overall counselling processes if the counsellor focuses on it rather than on the 17 University of Ghana http://ugspace.ug.edu.gh ethical principles. For example, a counsellor whose religion does not support certain practices like homosexuality may find it difficult to help a homosexual who needs help. Airen (2009), is of the view that racial and ethnic differences between counsellors and clients could cause a blockade between both parties and prevent/impede the counselling process. This may be due to misunderstandings that develop due to communication discrepancies and may result in clients feeling alienated. This alienation may cause clients’ to not trust their counsellor, thus affecting their rapport. Any difference that may exist between the client and the lay counsellor can make the counselling session not work. Leuter et al. (2013) studied 374 nurses in Italy on difficulties in nursing and using ethics resources. The respondents described poor development of ethics support and difficulty of getting access to ethics training programs. The limitation if this study is that it cannot be generalized because the sample was nurses who were attending a special learning program. In low and middle income countries (LMICs) however, ethical dilemmas are both intricacies of practice, institutional barriers and socio-cultural issues. There is empirical evidence to the effect that socio-cultural contexts within which practitioners work influence the ethical dilemmas they encounter. This has been reported among various practitioners across different professional contexts. Mwisongo et al, (2015) for instance evaluated HIV counselling and testing among lay counsellor in South Africa. 32 lay counsellors were interviewed and results showed that most of the lay counsellors had adequate training. However, the lay counsellors reported a lack of standardized counselling and testing training, and revealed gaps in counselling skills for specific groups such as discordant couples, homosexuals, older clients and children. They indicated health system barriers, including inadequate designated space for counselling, which compromises privacy and confidentiality 18 University of Ghana http://ugspace.ug.edu.gh The situation in Ghana is similar to what has been reported in other LMICs. Cultural practices and beliefs have been found to contribute to ethical dilemmas for health professionals in Ghana. For instance, Donkor and Andrews (2011) in a study of how nurses approach ethical problems reported that culture is integral aspect of the ethical dilemmas they face. They were influenced by the fact that their culture is a collectivistic one. Also cultural elements like religion had an influence. Some of the ethical dilemmas looked at in relation to their practice included non- maleficence, autonomy, beneficence and confidentiality. The study would possibly have obtained more approaches to how nurses deal with ethical issues if study participants had been made to write out their own responses rather than presenting them with reasoning scores on the ethical dilemmas presented to them. Ofori-Atta and Jack (2015) also reported that ethical dilemmas among healthcare providers included determining the appropriate use of authority, making decisions about resource allocation, ensuring standards of quality of care and questioning the role or scope of the health care professional. In addition, the study highlighted the importance of family in the ethical decision process and the need for ethics education among medical professionals. The role of culture was not looked at in this study and its focus was mainly medical professionals comprising doctors and nurses. Baiden et al., (2007) also evaluated lay counsellors who have been used to promote community- based voluntary counselling and HIV testing in the northern part of Ghana. Results showed that majority of the respondents approved of the use of lay counsellors. This suggests that lay counsellors can be trained to take up simple tasks that they formerly have no idea about. This focused on rural dwellers and hence will be difficult to generalize the findings. 19 University of Ghana http://ugspace.ug.edu.gh In another study on the main dilemmas faced by clinical psychologists in Ghana, the researcher found that ethical dilemmas included those arising from third party and privacy interferences, dual relationships, fees, and motive as against moral issues, policies and practices that conflict with ethical guidelines, competence and client expectations, manipulation of the therapist and cultural competence (Oppong, 2014). This study focused just on clinical psychologists and not on counsellors in general. Also, a quantitative study of this nature could be of great importance. In addition, the cultural competence of the clinical psychologists was not looked at. The studies above showed that most of the findings in relation to ethical dilemmas and how they are resolved were affected by differences in cultural values and cultural settings. Hence there is a need to look into detail how the Ghanaian culture also influences resolution of ethical dilemmas by lay counsellors. Secondly, most of the studies were more of qualitative in nature which helped the researchers to get detailed information. 2.3.2 Cultural Values and Counselling Competence This section discusses counselling competence within cultural contexts. This based on the findings reported among different studies that culture shapes ethical experiences of mental health practitioners. Culture refers to the way of life of a group of people (Okoro, Eze & Ofoegbu, 2017). Every individual works or operates within a cultural environment. Certain cultural factors like religion, language, customs, values and beliefs tend to influence the individual. Hence these factors determine a person’s sensitivity to ethical issues in the community he/she is working. The cultural orientation of a lay counsellor is likely to influence how a person deals with ethical issues. Many African cultures are based on the extended family system (i.e. loyalties of a person to a group exceed the rights of the individual) rather than individualistic. In such collectivistic 20 University of Ghana http://ugspace.ug.edu.gh cultures, health decisions usually are not made solely by an individual but in consultation with the extended family (de-Graft Aikins, 2006). It is therefore important to become knowledgeable about local cultural traditions and to understand the family’s impact on contentious ethical issues such as privacy and confidentiality. Moreover, reflecting on how universal ethical standards and cultural values complement or conflict with each other in the culture in which one practices, or is educated, or conducts research is a requirement for ethical thoughtfulness (Donkor & Andrews, 2011). The increasing diversity of the nation brings opportunities and challenges for healthcare providers (including lay counsellors), health care systems, and policy makers to create and deliver culturally competent services. In health care delivery, cultural competence is defined as the ability of providers and organizations to effectively deliver health care services that meet the social, cultural and linguistic needs of patients (Betancourt et al, 2002). A culturally competent health care system can help improve health outcomes and quality of care, and can contribute to the elimination of racial and ethnic health disparities. When counsellors are culturally competent and sensitive, they will tend to fit well into the population in which they work. Hence for counsellors to meet the goal of being culturally sensitive or competent, there should be relevant training in cultural competence issues and also equipping them to know the principles and standards enshrined in the codes of ethics they work with. 2.3.3 Code of Ethics for Counsellors in Ghana This sub-section discusses code of ethics for counselling practice in Ghana. This is imperative to understanding the extent to which counselling practice in general and lay counselling practice in Ghana is regulated. Many countries have developed their own code of ethics which aims at 21 University of Ghana http://ugspace.ug.edu.gh guiding the activities of counsellors. An example is the American Counselling Association’s (ACA) code of ethics (2005). This serves as the counselling profession’s foundation for professional practice and ethical responsibility. The Psychological Society of South Africa (PsySSA) also has guidelines which tend to guide the activities of both psychologists and counsellors. The various ethical principles and standards are enshrined in this guideline (South African Professional Conduct Guidelines in Psychology, 2007). These principles include competence, integrity, respect for people’s human right and dignity among others. It is not just enough for a counsellor to just know the legal and ethical standards; they must also apply these standards in their profession. The South African Professional Conduct Guidelines in Psychology (2007), stress on resolving ethical issues. Though it is not specifically for lay counsellors, it serves as a guide for them. A critical look at the American Counselling Association code of ethics (2005) shows that there is an emphasis on diversity as well as cultural competence (American Counselling Association, 2005). The section A.2.c. talks about how counsellors need to develop cultural sensitivity. It states that “Counsellors communicate information in ways that are both developmentally and culturally appropriate. Counsellors use clear and understandable language when discussing issues related to informed consent. When clients have difficulty understanding the language used by counsellors, they provide necessary services (e.g., arranging for a qualified interpreter or translator) to ensure comprehension by clients. In collaboration with clients, counsellors consider cultural implications of informed consent procedures and, where possible, counsellors adjust their practices accordingly” (American Counselling Association, 2005, p. 4). 22 University of Ghana http://ugspace.ug.edu.gh This means counsellors must try and communicate as clearly as possible to their clients. In Ghana, this is not the case for lay counsellors, as most lay counsellors do not belong to any professional association. There have been calls to regulate the practices of some of these lay counsellors who present themselves as professional counsellor. Mention can be made of the counsellor George Lutterodt about whom many Ghanaians have called on the Ghana Psychological Council (GPC) to regulate his operation in the country (Lissa, 2016). 2.4 Rational for the Study Most of the studies done in ethical dilemmas focuses on health care professionals with little attention paid to mental health care professionals, specifically lay counsellors. No major study has been done to look at the dilemmas faced by lay counsellors in Ghana, and how they resolve these dilemmas. In this study, the researcher would like to find out if lay counsellors in Ghana also take into consideration the social context when they are making decisions, and how they deal with some of the dilemmas that they face in their work. 23 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Introduction This chapter explains the approaches used to carry out the research. It includes descriptions of the research setting, participant selection, design, the procedure for data collection and ethical consideration. The pilot study is also discussed briefly in this chapter. 3.2 Research Design The current study adopted a qualitative design. Qualitative research is undertaken with data collected in the form of narratives or observation using small samples of participants (Creswell & Clark, 2017). The qualitative research design was employed because the aim of the study is to explore and gain sufficient knowledge on ethical dilemmas faced by lay counsellors in Ghana. An in-depth discussion with the lay counsellors was required in order to gain deeper understanding of the issues. An interpretative phenomenological approach as suggested by (Creswell, 2009; Lindseth & Norberg 2004) was thus employed. This approach is to describe accurately the lived experiences of people, and not necessarily to generate theories or models of the phenomenon being studied. According to Creswell (2013), in-depth individual interviews are useful for exploring subjects, for understanding and describing phenomenon. This requires small number of respondents to explore their perspectives on a particular idea, program or situation. Based on the themes that emerged from a review of the literature, an interview guide was developed. 24 University of Ghana http://ugspace.ug.edu.gh Looking at the nature of the work of lay counsellors in Ghana, individual interviews were thus deemed the best approach for gathering information at a time of convenience to each counsellor. 3.3 Research Setting Research settings can be organizations or institutions, community, district, region or a country based on what the focus of the study is. The lay counsellors were interviewed from the Volta, Greater Accra and Western regions. In the Volta region, specific places included in Ho, Tokokoe, and Hohoe. In the Greater Accra region, specific places were Korle Bu, Mamprobi, Dansoman, Banana Inn, and University of Ghana, Legon campus. In the Western Region, the specific places were Takoradi, Esikadu and Kwesimintsim. The three regions were chosen by the researcher because of proximity. Lay counsellors were contacted at their place of work and their homes. 3.4 Population The population for this study comprised lay counsellors in Ghana. Lay counsellors included psych corps members, HIV/AIDS counsellors, pastoral counsellors, marriage counsellors and school counsellors. The psych corps are individuals who have completed their undergraduate education in psychology and are doing their national service in hospitals across the country. 3.5 Selection of Participants The main goal of selection is to get a smaller collection of units that is fairly representative of a much larger collection or population, study the smaller group and produce accurate 25 University of Ghana http://ugspace.ug.edu.gh generalizability about a larger group. The right selection size depends on the nature of a population and the purpose of the study (Creswell, 2013). 3.6 Demographic Characteristics of Participants The demographic characteristics of the participants are presented in Table 3.1. A total of twenty- seven (27) participants were involved in the study. Sixteen (16) of the lay counsellors representing 59.3% were males, with the remaining 11 (40.7%) being females. The lay counsellors were made up of five different categories of lay counsellors; four (4) HIV/AIDS counsellors (14.8%), four (4) marriage counsellors (14.8%), six (6) pastoral counsellors (22.2%), eight (8) psych corps (29.6) and five (5) school counsellors (18.5%). All the lay counsellors, with the exception of one person, were Christians. In addition, some of the lay counsellors said they had training in other fields aside the counselling. These areas included legal, education and business. The participants were of high educational level. Three (3) had certificate (11.1%) and twenty-four (24) had degree, representing 88.9%. Their ages ranged between 25 – 50 years, with majority (11) of them haven practiced for more than four years (40.7%). Eighteen (18) of the lay counsellors representing 66.7% practiced in urban setting. Table 3. 1 Demographic characteristics of the lay counsellors Characteristics F % Gender Male 16 59.3 Female 11 40.7 Age 20 – 30 years 11 40.7 31 – 40 years 11 40.7 41 – 50 years 5 18.5 Number of Years of Practice Below 2 years 6 22.2 26 University of Ghana http://ugspace.ug.edu.gh 2 to 4 years 10 37.0 More than 4 years 11 40.7 Level of Education Certificate 3 11.1 Tertiary 24 88.9 Type of Counsellor HIV/AIDS Counsellor 4 14.8 Marriage Counsellor 4 14.8 Pastoral counsellor 6 22.2 Psych Corps 8 29.6 School Counsellor 5 18.5 Religion Christian 26 96.3 Islam 1 3.7 Setting of Practice Primarily rural 3 11.1 Primarily urban 18 66.7 Primarily suburban 6 22.2 The sample for the study depended on the saturation point of information garnered from each type of lay counsellor (Silverman, 2016). Saturation point is the point where no new themes are emerging in an interview (Silverman, 2016). The researcher got to the point where there were no new themes coming up from the interviews. This was the factor that was considered in determining the sample size for this current study. In all twenty-seven (27) lay counsellors were interviewed. The participants were made up of both males and females. To be included in the study, a lay counsellor must be practicing for at least a year, and be willing to in the study. 3.7 Interview Guide An in-depth interview guide was used for this study. The interviewees volunteered information about their everyday experiences as lay counsellors in relation to the dilemmas they face. A semi-structured interview guide based on the literature reviewed was developed and used. The 27 University of Ghana http://ugspace.ug.edu.gh interview guide captured the participant’s knowledge about ethical dilemmas, how they resolve them and factors/challenges that influence their resolution of the dilemmas. The level of knowledge about ethical codes was also sought by the researcher. Some of the questions on the interview guide included; a. In your role as a lay counsellor, describe some difficult ethical dilemmas you have encountered. b. How often have you encountered each of these ethical difficulties? c. Describe for me how you resolved these. d. What do you consider when you encounter these dilemmas and also when you are resolving them? Vignettes Finch (1987) describes a vignette as short stories about hypothetical characters in specified circumstances, to whose situation the interviewee is invited to respond. The vignette method is a technique that can elicit views, perceptions, beliefs and attitudes from answers or explanations to stories portraying situations and scenarios. Barter and Renold (1999), posited that vignettes are useful in qualitative research for the following reasons; to allow activities in context to be explored; to provide a less personal and therefore less threatening means of exploring sensitive topics and to clarify people’s decisions. Vignettes offer a valuable method for discovering people’s views, opinions and meanings about specific issues, situations, and are especially useful for complex areas of inquiry that may not be readily assessable through other means. The researcher used vignettes to allow participants to define the situation in their own terms. 28 University of Ghana http://ugspace.ug.edu.gh Two case vignettes were used to get the views of the lay counsellors on how they were going to deal with each of the dilemmas. The vignettes were printed on a sheet of paper with the questions and space provided for the lay counsellors to write down their responses. Those who would not want to write were audio recorded as they gave their responses. These can be seen in the appendix. 3.8 Procedure Ethical approval from the Ethics Committee for Humanities (ECH 106/16-17) was sought. Next, an introductory letter from the Department of Psychology, University of Ghana was obtained. After the ethical approval was given, a pilot study was first conducted. The pilot study served the purpose of assessing the ability of the interview guide to bring out the right responses. Through the pilot study, some challenge(s) with the interview guide were corrected before proceeding with the main study. A tape recorder was used to record the voices of the participants during the interview. 3.8.1 The Pilot Study After the ethical clearance was given, a pilot study was conducted to assess the interview guide. Three (3) lay counsellors (1 psych corps, 1 pastoral counsellor and 1 school counsellor) were used for the pilot study. The pilot interviews were transcribed and analysed to assess how well the interview guide elicited information. It was then that the researcher realized it would be prudent to add probes to some of the questions. The results from the pilot study showed that all of the interviewees had experienced dilemmas relating to dealing with gifts. Issues of 29 University of Ghana http://ugspace.ug.edu.gh confidentiality were related by the pastoral counsellor and school counsellor. The psych corps lay counsellor reported he had a dilemma of whom to take instruction or direction from on a case as well as being assigned tasks which he was not trained for. In terms of resolution of ethical dilemmas, they all mentioned referral and consultations. Factors that influenced the resolution of dilemmas included personal values and religion. Based on these interviews, the interview guide was revised. 3.8.2 The Main Study The researcher went to the lay counsellors’ places of work to inform them of the study and requested their involvement. After they had agreed to be part of the study, a date was scheduled for the researcher to meet with each lay counsellor. Most of the participants were called on phone to confirm the date for the interview to be conducted. The researcher met with each participant at his/her places of work. The aim and purpose of the study was again explained to the participant. Informed consent was sought from the participant by asking him/her to read and sign the informed consent form. Permission was sought for audio recording. Participant was assured of privacy and confidentiality. The interview started with the researcher finding out the participant’s knowledge of ethical codes and training in ethics. The interview was in two parts. First part was about the demographic information of the participant (age, sex, qualification, religion, marital status, years of practice and formal education in ethics). Then participants were asked about their knowledge of ethical codes. The first part was followed by the face-to-face interview which lasted about 20 to 30 minutes. Next the interview guide which was developed was used to conduct the interview. The audio recording went along the interview. In addition, notes were taken during the interview. After this, two 30 University of Ghana http://ugspace.ug.edu.gh vignettes were presented to the participant to identify the dilemmas in each of the vignettes. The participants were asked to write down their responses in the space provided. Clarification was given to those who needed it. 3.9 Ethical Consideration Ethics are very critical aspects of research. Ethical considerations are meant to ensure that participants in any kind of researched are protected and free from exploitation at all times. According to Nardi (2018) all researchers are advised to adhere to some professional ethical codes and regulations while undertaking research. Creswell and Creswell (2017) also argues that research participants need to be protected to promote the integrity of research, develop trust with them, guard against misconduct and impropriety that might reflect on their organizations or institutions and cope with new and challenging problems. It is important to consider the issue of ethics when conducting any research. Some of these ethical considerations may be in relation to the subjects you are going to use whether human beings or animals (Hossain, 2011). According to Creswell (2009), any researcher should foresee or anticipate any ethical issues and make effort to address them, especially in qualitative research. Therefore, in relation to this study, the ethical consideration was in line with the American Psychological Association (APA) (2002) code of conducts and include issues of confidentiality, respect for autonomy and informed consent. Confidentiality is where the details of the participants for the study is concealed or protected. Psychologists have a primary obligation and take reasonable precautions to protect confidential 31 University of Ghana http://ugspace.ug.edu.gh information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship (American Psychological Association, 2002). Hence the researcher ensured that the privacy and identity of the participants were respected and protected. Respondents were given code numbers instead of asking them to write down their names. In relation to autonomy, participants were given the information they would need in order to decide to enter a study or not to participate. This implied that that each person was given the respect, time, and opportunity necessary to make his or her own decisions. Informed consent involves properly informing the participant about everything to do with the study: procedure, objectives, risks and benefits as a basis for consenting or not to participate. The researcher used English language throughout the study. In addition, inform consent was sort from the participants in relation to recording voices. The participants were also made to understand that they the right to refuse to participate or withdraw from the study at any time. No participant was forced or coerced to participate in the research, it was on a voluntary basis. There were no monitory incentives for participants as well. 3.10 Data Analysis Thematic analysis was used to analyse the data. The researcher used thematic analysis because he intended to identifying and analysing patterns of themes across the interviews (Braun & Clark, 2006). It also involves the active participation of the researcher to discover themes in the data which are described by the participants (Taylor & Ussher, 2001). The audio recordings were transcribed and analysed. The researcher sought the help of a second year PhD candidate from 32 University of Ghana http://ugspace.ug.edu.gh the Department of Psychology to help with the data analysis. This was to ensure credibility of the data. This student was a research assistant and has experience conducting qualitative data analysis. A transcription template was developed. Next, the researcher and the assistant coder adopted the six-stage processes of data coding and analysis by Braun and Clark (2006). The first stage involved getting used to the data. This involved reading and repeated reading of the data which was transcribed, searching for meanings and patterns. Both the researcher and the assistant did the readings after the transcriptions were done. The second stage involved generating codes across the three main themes with regards to ethical dilemmas. These were (1) the types of ethical dilemmas faced; (2) resolution of the dilemmas; and (3) the factors that influence the resolution of the dilemmas, thus the challenges in resolving the dilemmas. Coding is the process of assigning a label to a phrase, sentences, or paragraphs that holds an important meaning. This can be descriptive or summative; it can be lengthy or summative (DeMotts, 2018). The third stage involved searching for themes across the three main broad thematic areas. This was done by sorting the different codes into potential themes, and collating all the relevant coded data extracts within the identified themes. In addition, a thematic network was developed to enable the arranging and representation of common themes recognized. Stage four involved reviewing the codes and themes. The research assistant helped validate the themes that were developed by the researcher by reading through the transcription and coming out with themes until a consensus was reached and subsequently refined. An example was where we had to come to a consensus on the issue of relationships and we concluded on dual relationship with clients and third party relationships. This was to ensure validity. The fifth stage 33 University of Ghana http://ugspace.ug.edu.gh involved defining and naming the themes generated. Here, we looked at the themes we got and then named it in taking into consideration the research questions. The last stage is producing the report. Narratives from the participants are then used to support the themes identified. The vignettes on the other hand were analysed by first exploring the number of lay counsellors who responded to either a yes or no to the questions. Next the written responses to the questions were analysed in the same way as the vignettes were analysed. Responses that fell under the themes from the interviews were put together under the same theme. Those that did not fall under the same themes were eliminated. 3.11 Quality and Trustworthiness of Data The quality of the data was ensures using the principles of reflexivity, trustworthiness. 3.11.1 Reflexivity Reflexivity refers to a concept of research which refers to acknowledging the input of the researchers in actively co-constructing the situation which they want to study (Flick, 2009). The subjectivity of the researcher and of those being studied becomes part of the research process. Researchers' reflections on their actions and observations in the field, their impressions, irritations, feelings, and so on, become data in their own right, forming part of the interpretation. Here, the researcher is a professional clinical psychology under training himself and was therefore mindful of how his background in psychology could affect the findings and how data are understood. This background of the researcher helped in exploring the ethical dilemmas and ethical issues. However, the voices of the participants have been presented as they are, so that they can reflect the true meanings and experiences of the participants. Interpretations of their opinions are then provided. 34 University of Ghana http://ugspace.ug.edu.gh 3.11.2 Research Trustworthiness and Data Validation As a way of ensuring validity in the study, the researcher established trustworthiness by ensuring credibility, transferability, dependability and confirmability. It is a systematic and objective way of describing and quantifying phenomena (Schreier, 2012 as cited in Elo et al., 2014). Credibility is how confident the researcher is in the truth of the research study findings. It involves the processes that ensure that credible results are established (DeMotts, 2018). To establish credibility, feedbacks were taken from the participants during the interview sessions. Also, cross-checking was done when transcripts were read individually by the researcher and the research assistant and the themes that were generated were discussed until consensus was reached. Transferability refers to how the researcher is able to prove that the findings from a particular study can be applied to other settings. This is also referred to as external validity (Merriam & Tisdell, 2015). Transferability was ensured in this study by outlining all the processes that were involved in the entire research. The processes of data collection, and data analysis have all been provided in this study. According to Creswell (2009), confirmability is the extent to which results from the study can be sustained by other researchers. Qualitative researchers achieve confirmability by providing audit trail which highlights every step of every data analysis. This study also adopted the same process where there is a complete audit trail of the interviews and the transcripts. Finally, dependability is the degree to which the study could be repeated by other researchers as well as the consistency if the findings. To ensure this, the same interview guide was used for all the participants in the study. 35 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Introduction The current study sought to explore how lay counsellors in Ghana orient themselves towards dilemmas in their everyday practice. The study was mainly qualitative, using in-depth individual interviews. During the interviews, vignettes were also used to explore how the lay counsellors would have dealt with hypothetical dilemmas. Three fundamental objectives were explored: the first objective was to explore domains or categories of dilemmas lay counsellors in Ghana deal with; the second one was to assess how they resolve these dilemmas; and the third objective was to examine the challenges they face in dealing with the dilemmas. This chapter presents detailed findings from the study. For the purposes of clarity, the findings are presented as follows. First, the domains of the ethical dilemmas they face are presented. This is followed by their resolution strategies. Lastly, the challenges they encounter are presented and then a summary of the findings are presented. In presenting the findings, the major themes are discussed under each objective. Quotes attributed to individual lay counsellors are presented as supporting evidences. The individual lay counsellors are identified as shown on Table 4.1. Table 4. 1 Profile identifiers of individual lay counsellors No. Category of Lay Counsellor Gender Age Educational Years of Practice level Psych LC (Psych Corps) 1 Psych LC 1 M 20-25 Tertiary Below 2 years 2 Psych LC 2 M 20-25 Tertiary Below 2 years 3 Psych LC 3 F 20-25 Tertiary Below 2 years 36 University of Ghana http://ugspace.ug.edu.gh 4 Psych LC 4 M 26-30 Tertiary Below 2 years 5 Psych LC 5 F 26-30 Tertiary 2-4 years 6 Psych LC 6 M 20-25 Tertiary Below 2 years 7 Psych LC 7 M 26-30 Tertiary 2-4 years 8 Psych LC 8 M 26-30 Tertiary 2-4 years School Counsellor (SC) 9 SC 1 F 46-50 Tertiary More than 4 years 10 SC 2 M 36-40 Tertiary More than 4 years 11 SC 3 F 36-40 Tertiary More than 4 years 12 SC 4 M 41-45 Tertiary More than 4 years 13 SC 5 M 26-30 Tertiary 2-4 years Marriage Counsellor (MC) 14 MC 1 F 31-35 Tertiary 2-4 years 15 MC 2 F 41-45 Tertiary 2-4 years 16 MC 3 M 31-35 Tertiary More than 4 years 17 MC 4 F 36-40 Tertiary More than 4 years Pastoral Counsellor (PC) 18 PC 1 F 36-40 Tertiary More than 4 years 19 PC 2 M 31-35 Tertiary More than 4 years 20 PC 3 M 36-40 Tertiary More than 4 years 21 PC 4 M 36-40 Certificate 2-4 years 22 PC 5 M 31-35 Tertiary 2-4 years 23 PC 6 M 46-50 Certificate More than 4 years HIV/AIDS Counsellor (HC) 24 HC 1 M 26-30 Tertiary 2-4 years 25 HC 2 F 41-45 Tertiary Below 2 years 26 HC 3 F 26-30 Certificate 2-4 years 27 HC 4 F 31-35 Tertiary More than 4 years 37 University of Ghana http://ugspace.ug.edu.gh 4.2 Participants' of Knowledge of Ethical Codes and Training in Ethics Before inquiring about the dilemmas faced by the lay counsellors, the researcher examined participants’ knowledge about ethical codes, training in ethics and if whether they belong to any professional association or group. The findings show that majority of the lay counsellors (23, representing 85.2%) have attended training programs that had ethical practice component whiles 4 of them (14.8%) have not received any general training that included some ethics. However, more than half of them (15, representing 55.6%) have never had specific training on ethical and legal issues. A significant number of them (18) have not had continuous training in the last two years. Most of lay counsellors (18) in the study indicated that they read on ethical issues by themselves. However, 20 of them (74.1%) do not have copies of ethical codes and therefore majority (21), of them do not refer to any ethical code when making ethical decisions. Twenty-two (22) of them (81.5%) also do not belong to any professional counselling association or body. The table which represents participants' level of knowledge of ethical codes and training in ethics can be seen in appendix VI. 4.3 Ethical Dilemmas among the Lay Counsellors The first objective of the study examined the different kinds of dilemmas that the lay counsellors encounter in their everyday practice. The essence is to, among other things, understand the kinds of difficulties they deal with and how they conceptualize different dilemma situations in their counselling practice. Findings from the study showed five (5) main themes indicating 5 categories of dilemmas the lay counsellors reported dealing with. These are; (i) difficulty 38 University of Ghana http://ugspace.ug.edu.gh negotiating rights and confidentiality; (ii) competency issues; (iii) difficulty managing multiple relationships; (iv) dealing with conflicting values; and (v) dealing with gifts. These ethical dilemmas are represented in thematic network (Figure 1) for clearer understanding and are discussed in turns. 39 University of Ghana http://ugspace.ug.edu.gh Figure 1: Thematic network of ethical dilemmas faced by the lay counsellors 40 University of Ghana http://ugspace.ug.edu.gh 4.3.1 Negotiating Rights and Confidentiality Negotiating rights and confidentiality featured prominently as a major dilemma that the lay counsellors grapple with. This theme emerged strongly as almost all the lay counsellors mentioned challenges to that effect. The main dilemma they reported had to do with especially when there is a third party interest in the counselling relationship which brings about difficulties in defining boundaries /rights and maintaining privacy. Three (3) sub-themes emerged here which were; (i) parental rights versus client’s privacy; (ii) disclosure to partners; and (iii) third party intrusion. Each of these sub-themes presented different sets of dilemmas in negotiating rights and confidentiality in their everyday practice. These sub-themes are discussed below. Parental rights versus client privacy The dilemma of dealing with parents in a counselling relationship was reported by all the school counsellors, some marriage counsellors and other psych corps. The difficulty that most of them reported had to do with parents exercising rights over their children and therefore demanding information from the school counsellors. In most cases of these cases, parents wanted to know details of the counselling sessions such as confidential information from school counsellors. The parents probably saw it as their right to know whatever goes on during the counselling session. Here, most of the counsellors were tempted to compromise on the ethical principle of confidentiality, and this was the dilemma. The lay counsellors were therefore torn between maintaining parental rights and breaking confidentiality of their student-clients. This is seen in the narrative below: 41 University of Ghana http://ugspace.ug.edu.gh You are a psychologist right...How would your client feel if you break confidentiality…so it’s the same thing that happens in our work too. Many parents and even teachers from the DC (disciplinary committee) would want to know outcomes of counselling sessions…sometimes you are torn between the interest of your client or that of the parents/guardians (SC 1). Parental issues, involving the parents...the relationships… yeah, there was this child. It was the parents that actually brought him. They suspected him of smoking… But after they left, the parent took our number and then they wanted to know that is it actually true that he did it because he’s very strict on him on the kind of friends he brings and then his character… (Psych LC 8). But mostly in counselling adolescents and children. After you have assured them of confidentiality, once the parents get to know that their child has been referred to see you. The next thing is that they want to know... I will say, parents who put pressure on you to tell them whatever that their ward came to tell you. And also, sometimes you are really in a dilemma (MC 4). Some of the lay counsellors also said that sometimes, parents attempt to manipulate the counselling secession by telling them what to do. At times too, they make certain demands which compromise the counselling. Yes, another thing is when you are counselling a person and then this person goes to break school rules, then the person comes to you to go and beg on his/her behalf. Even sometimes the parents will call you to go and beg on behalf of their wards. And you see, you don’t know if you are going there as the student’s counsellor or as his teacher. And 42 University of Ghana http://ugspace.ug.edu.gh sometimes you end up with having issues with some of the members of the disciplinary committee… yeah the DC (SC 4). A vignette was presented to participants for them to identify the possible dilemmas and to also seek their views on how they were going to resolve the dilemma. Interestingly, issues of parental right versus client right came up. Vignette 1 Abena, a 15-year-old teen who is not getting along with her parents. She has run away from home twice and her parents have brought her to you for counselling and for possible mental health services. You have seen Abena alone several times. During session, Abena tells you that she is sexually active and would like some help in learning how to avoid getting pregnant. In separate conversations with Abena’s parents, you get the impression that the parents are well aware of Abena ’s sexual activity. The first vignette was about a minor who wanted birth control pills for preventing teenage pregnancy. The counsellors were then required to identify the dilemma and show how they would resolve it if they were faced with similar circumstance. Findings showed that almost half (12 out of 27) of them indicated that they would help Abena acquire the birth control pills. They gave several reasons why they would do so, mostly cohering around Abena’s right to family planning, avoiding contraction of sexually transmitted disease and preventing the negative consequences of teenage pregnancy, as exemplified by narratives below: She is sexually active and have the right to be informed about family planning (PC 1). 43 University of Ghana http://ugspace.ug.edu.gh Considering the negative impact and unwanted pregnancy would have on both Abena and her unborn child as well as the relationship between her parents and herself. It will be in the best interest of both parents and Abena to prevent this problem (SC 3). Fifteen (15) lay counsellors on the other hand indicated they would not assist Abena in acquiring the birth control pills. Their reasons cohered around Abena being a minor and therefore needed parental consent and the grounds of religious values on the part of the counsellors. These are exemplified below: The parent’s consent must at all cost be sought before prescription made. Furthermore, both Abena and the parents ought to be referred to a health specialist who could advice appropriately (PC 2). Abena should be given some psychoeducation on adolescent sexual reproductive health (SC 1). It is because she is under age and the drugs may have side effects on her (Psych LC 5). The counsellors were then asked whether it is appropriate to ignore Abena’s parental values. Majority (92%) indicated that it is inappropriate to ignore the parents’ values on the grounds that Abena is still a minor. The counsellors were also asked who they were accountable to, whether Abena or her parents. Six (6) of them (22.2%) indicated they were accountable to Abena because she is their primary client. Nine (9) representing 33.3% said they were accountable to the parents because Abena was under age and it was her parents who sought for the counselling for her. Four (4) of them (14.8) said they were accountable to both Abena and her parents. Six (6) of them representing 44 University of Ghana http://ugspace.ug.edu.gh 22.2% said they were accountable to their employer/supervisor because they work with codes of ethics. One person said he was accountable to God. Disclosure to partners or spouses Dealing with partners of clients in a counselling relationships was also another dilemma that the lay counsellors encountered. This theme was more dominant among marriage counsellors and HIV Counsellors. This dilemma was found to happen in two ways. One is when partners consult counsellors for details of counselling sessions of their spouses. Most of the time, partners in either relationships or marriage want to know the confidential issues about the other person. Also the person who suggested that the client come for counselling sometimes wants to know the outcome of the session. This lay counsellors had this to say: …And I realized that the uncle who asked that I counsel this young lady wanted to know everything that went on during the counselling session. Yeah, so he kept pressuring me and also asking the lady what transpired…funny enough, the lady asked him to come and ask me…. But it can mislead you if you are not careful (MC 2). And also, there are some people who demand to know the outcome of the test results we do for their spouses. I remember some relatives wanted to know the outcome. And since it’s the right of the patients to disclose, I told them that the result was not yet ready so they should come later…what if this patient goes to infect them in the house. I felt uneasy though. (HC 2). The other dilemma is apparent in situations where the counsellors think that there is some information that the clients need to tell their spouses but they are unwilling. This was a very 45 University of Ghana http://ugspace.ug.edu.gh common dilemma among lay counsellors who work within the context of HIV counselling and marriage counselling: Sure. There was a time, a young man did not want to disclose his status to his family members after he found out that he was HIV positive. I did all I could to let him disclose, but he refused. And I didn’t know if I should go ahead to tell the family or not (Psych LC 2). According to the law, the person has to, you know, disclose to the husband in order to protect the husband. But here is the case the person is not reporting meanwhile the person is infected and we know very well that he/she has a partner and by all means might infect the partner… the person is not reporting and we are not supposed to, let’s say. disclose to the partner. So it’s a challenge that we are facing. (HC 3). Issues of cheating in marriages for example. I remember a couple came to me for counselling because their marriage was not working. After hearing both sides of the story separately, the man insisted he wants to know what the wife told me, (laughing). It’s not easy ooo, the woman too wanted to know what the man told me…this made me feel bad as if I was trying to hide something from both of them. I hope you get it. (MC 5) So in the ART unit, you have some people who will not want to disclose their status to their relatives. I had a case where the old man disclosed his status to the children but was not willing to disclose to the wife. I was torn between telling the wife or not. Because the children are not staying with them, it’s only the wife (Psych LC 4). In most of our cases, when ermm clients have to disclose to theirs partners. You know, some of them don’t want to do it. Yet this person tells you he/she is sexually active…now, 46 University of Ghana http://ugspace.ug.edu.gh the person has not disclosed to their sexual partners and you know reinfection or new infection will be taking place…so these are some of the things. So it’s a two-way thing. You want to help the client and at the same time you want to also help the family or the sexual partner who doesn’t know about the condition (HC 1). Here too, a vignette was further presented to the lay counsellors on complicated partner relationship to assess what practitioners would have done: Vignette 2 As a counsellor, your client who has been in a no-sex relationship for a year with her guy, have now decided to tie the knot. They love themselves very well. You advised them on having a sickle test of which they agreed. They came to your facility for the test to be done and because of your protocol which permits them to do all test for free, they decided to add hepatitis, HIV, blood group etc. To cut everything short, you realized from the results that your client is HIV negative whilst her guy is HIV positive. The first question was aimed at finding out whether the lay counsellors would break confidentiality to a third person. Out of the twenty-seven participants who were asked whether they would inform their clients by breaking confidentiality, twelve (12) lay counsellors making 44.4% said yes, they would inform the third party. Some of the reasons they gave were as follows; 47 University of Ghana http://ugspace.ug.edu.gh Duty-to-warn In as much as the issue of confidentiality was important to the lay counsellors, especially to maintain confidence and also keep the client/counsellor relationship, the issue of protecting others from harm was also another dilemma that most of the counsellors said they encounter. Under duty-to-warn, the following themes came up; (i) Prevention; in terms of prevention, the lay counsellors gave two reasons. The first on was to help the woman prevent herself from getting infected and secondly to help prevent the further spread of the HIV virus to other people. The second reason under duty to warn was to enable the client to make her own decision as to whether she wants to continue with the relationship or not. Most of the counsellors felt that it was their responsibility to warn or inform their client by breaking the news to them. Especially in situations where the other person was not willing to disclose. One counsellor had this to say: The fact that I asked them to go for the test and the guy is not ready to disclose, then I have the duty to warn my client so that she will not later blame me for not telling her the truth…well, if I didn’t’ know, then that is a different case. (Psych LC 6). Another lay counsellor had this to say: The lady in question is my main client, so anything that concerns her safety must be made known to her. If I disclose to her, then she will be in a better position to decide if she will continue with the guy or not (PC 2). Another lay counsellor also had this to say: 48 University of Ghana http://ugspace.ug.edu.gh Look, marriage is an issue of life. And, ermmm, here the welfare of the lady is at stake. I cannot joke with a serious issue like this. I will surely inform her…But first with the consent of the guy (MC 1). On the other hand, fifteen (15) lay counsellors representing 55.6% said No, they would not break or disclose the results to the clients, and they gave the following reasons; in the first place, it was not the duty of the counsellor to break the news. Secondly, in order to maintain confidentiality. Here they said it was not right for the counsellor to go ahead and tell the client, even if the counsellor needs to do that, she needs the permission of the man. This is what one lay counsellor had to wrote; I think confidentiality is one of the key principles that every counsellor needs to maintain (HC 3). The next question was to find out how the lay counsellors were going to resolve this dilemma. Twelve (12) lay counsellors 44.4% said they would counsel the client and the third party. Two (2) of them representing 7.4% said they would refer them to see senior counsellors, pastors or a health worker to further talk to them. Another reason for a referral would be to do a second testing. One of the lay counsellor’s put it this way; If the guy is not ready to disclose, still there will be a need for referral (HC 3). Seven (7) them (25.9%) said they would encourage the man to disclose to the woman. The rest did not respond to this question. 49 University of Ghana http://ugspace.ug.edu.gh Third party intrusion Third party intrusion was also another dilemma the lay counsellors reported dealing with. Third party intrusion in this context is conceptualized as an outsider wanting, and in most cases (as depicted by respondents) demanding to know the outcome of the counselling session. These third parties are mostly superiors or colleagues who referred cases and therefore thought they reserved the right to know the outcome of the counselling session(s). This sub-theme was more prevalent, especially within institutional counselling contexts where the lay counsellors report to superiors. This was therefore more prevalent among lay counsellors in schools and church settings. In the church where I work, though I was seen as a counsellor, there were times where the church leadership wanted to know the issues that some particular members brought to me. Since I assure my clients of confidentiality, I felt reluctant to share the information with the church leadership (MC 4). Sometimes, teachers also approach me to ask about issues that their class students bring to me. I remember, a young girl came to report a teacher who was making advances towards her. This teacher happens to be close to me. I didn’t know whether to report him to the headmaster or to just call him and warn him. It was difficult for me because, reporting him might attract a query letter from the headmaster, and I confronting him too will be something else (SC 4). Another challenge is interferences of other colleague teachers. I once headed a committee to discipline some students who misconducted themselves against the school rules. Recommendations from the committee was turned down outright without reasons. 50 University of Ghana http://ugspace.ug.edu.gh This left me in a state of confusion not to further assist in disciplinary measures again in the school (SC 3). Sometimes too the third party intrusion comes in the form of a superior insisting or practically dictating to lay counsellors what should be done: I find it difficult to work when my senior pastor is around. Because at the end of the day, he will insist of what he wants to be done. You see. If you don’t obey, then it’s like you’re being rebellion. I remember, there was an issue about giving fasting to a church member…so after the counselling session, I proposed a three-day fasting, of which the client can do it from home. That was the voice I heard. But later on, my senior pastor insisted that this client comes to stay on the church grounds and do the fast. So you then ask yourself if what you are doing is authentic or not (PC 5). And another thing is about receiving supervision. There are times two or more people will give different views about a case and then you don’t know what to do. Going according to person A means disobeying person B. So it’s a problem here (Psych LC 2). I think sometimes it has to do with supervision. Especially where you have two or more people you report to. For example, I have a psychologist and also the CPN. There are times that the psychologist will want you to handle a case in a certain way and then the CPN too will want you to go in another way, because you find yourself in the psychiatric unit, and not the psychology unit (Psych LC 3). 51 University of Ghana http://ugspace.ug.edu.gh Hmmm, my brother, sometimes…errmmm you find yourself in situations where the person who asked that you counsel the client is suggesting what you should do… I mean, sometimes your own senior pastor. (PC 5). 4.3.2 Competency Issues Competency issues also featured as a major theme among the domains of dilemmas the lay counsellors deal with in their everyday practice. This theme was more dominant among the Psych Corps group and some marriage counsellors as well. The challenge in this regard comes in two fold. On one hand, majority of them indicated that they were mostly assigned to cases they are not trained for and on the other hand they are not given any periodic in-service training. These are exemplified in the following quotes from respondents’ narratives: Ok. Yes. I remember I was once asked to help give psychotherapy to a patient who came for review because they suspected the patient to be depressed or so. And, errm, I told the nurse that I can only do counselling and that’s all. But the nurse was angry with me that I was lazy and will not work. I think he expected me to do some magic for the patient to be well. So during that time I didn’t know whether to try doing or not…. So I did what I have to do (Psych LC 1). Just to add to you know what I said earlier on, sometimes you wish you can do more than just lay counselling but you don’t have the skills or err….should I say the training to do it…I hope err you get what I mean (PC 2) Assessment?....I know there are some basic assessments that we can use to help our counselees but me like this, I have not even seen them before…so if a patient comes with 52 University of Ghana http://ugspace.ug.edu.gh say depression or phobia they expect you to help them, but I may not be able to do much (MC 1). Hmmm, well. Let’s see... I think my dilemma I had was when I began the ministry. I was then… I think a year or so. And not married. I had errm some couple come to me with issues and the woman threatening divorce (PC 4) From the above narratives, it is seen that competency issues are where the lay counsellors are assigned to tasks which they are not trained for. 4.3.3 Multiple Relationships Multiple relationships also featured as a dominant ethical dilemma among the lay counsellors. They indicated that they found it a challenge to negotiate complicated identities in their counselling relationships which impedes their effectiveness. Two main sub-themes were identified. These are dual relationships on one hand and third party identity, which relates to the rights and confidentiality discussed above. Dual Relationship The dual relationship manifested in the colliding of identities of counsellors and clients. The counsellors made references to instances of counsellor-client relationship complexities that pose challenges to them as to how to move forward with the counselling sessions. Counselling involves establishing a therapeutic alliance with your client. But in the case of lay counsellors, sometimes this therapeutic alliance goes beyond it. For instance, most of the lay counsellors, especially pastors and marriage counsellors said that, most of the people they counsel were their 53 University of Ghana http://ugspace.ug.edu.gh own church members. The main dilemma has to do with whether to consider the person as a church member or as a client. This normally compromised the therapeutic relationship. There are instances of two or more identities of the counsellors and clients which makes the counselling relationship difficult. Some of the counsellors had this to say: If you say dual relationship, then I think it is a major dilemma. Our job entreats us to counsel our members when they have problem, but then do you see him or her as a church member or as a client…I hope you get what I mean. Some of them will not do the assignments you even asked them to do, and I am sure because they see you as their pastor (PC 1). I wish I was not part of the teaching staff, … I teach CRS, assuming I fail a lazy student and later on this student comes in for counselling, how do you think the student will feel in front of me… or let’s say I lashed some students and the same student comes for counselling…its some way…yes it has happened before o (SC 1). Alright…. Yes. I remember I was asked to counsel my nephew who misbehaved in school. And I didn’t know whether to assume the role of an uncle or a counsellor (laughing) (SC 2). …yes, there was a time after I counselled a client, I then realized that this person stayed in the same area with me and we, ermm, also met in church. The next time she came, it was a difficult decision for me as to continue or let another person do it...I had already established the rapport with her too. And she kept coming (Psych LC 1). In our part of the world, you will be seen as wicked of you explain to your relatives to seek counselling from another person. Since I am a marriage counsellor, most of the 54 University of Ghana http://ugspace.ug.edu.gh family issues are brought to me and if I refer them to see other professionals, then it’s like you don’t want to help (MC 2). The fact that you hear your church members say that talk to this person or that person for me, then you already know the person. Especially some will request that you in particular should counsel the person…but you are in a fix (PC 7). And then there are instances where relationships develop between counsellors and clients of the opposite sex which makes the counselling relationship very difficult: ….hmm, you know this work sometimes you end up falling for someone. But then once you go ahead to propose or take an action, then it will be as if you have taken advantage of the person…what if that is the person God has destined for you to marry. What do you do? (SC 1). And also, some of the times too some of the things we face is transference; this is the problem with HIV, because some of them are rejected. So when they come and then they get to know they can trust you, you know, you give them all the attention, then they want to take you like as a brother or something. That too is a problem. Like my whole life this is the first person who is giving me attention, it becomes a problem (Psych LC 5). …and that one goes beyond client-counsellor relationship. The person becomes a friend… Or either you keep the person as a client or as a friend. Because sometimes they take our numbers to call and if you are not careful you develop close relations with them (HC 1). 55 University of Ghana http://ugspace.ug.edu.gh Third Party Relationship Most of the lay counsellors said that another type of dual relationship that poses a challenge is where the counsellor has a relationship with especially the person accompanying the client, or even the person who made the referral. In cases like this, it becomes difficult making some decisions. Some of the lay counsellors had this to say: I remember my deacon, who happens to be a teacher colleague referred a student to me because he was caught smoking weed in one of the classrooms. After the session, it was clear that this student will be suspended. Hmm, later he asked that I write on his file that the student is now of good behaviour so that he will not be suspended…you see that. So this are some of the issues (SC 2). Yeah…I was asked to fill a form for one of our members whose father was kind of influential. But I know the boy to be stubborn so I endorsing the form and writing out the recommendation meant I was lying. Now here is the father too, who is a very good friend of mine and our senior deacon… (PC 3). I remember, a young girl came to report a teacher who was making advances towards her. This teacher happens to be close to me. I didn’t know whether to report him to the headmaster or to just call him and warn him. It was difficult for me because, reporting him might attract a query letter from the headmaster, and I confronting him too will be something else (SC 1). 56 University of Ghana http://ugspace.ug.edu.gh 4.3.4 Conflicting Values Another dilemma that was identified was the case of difficulties managing conflicting values. Lay counsellors live multiple identities; professional identities, cultural identities, religious identities, family identities and individual self-identities. Each of these identities are shaped by moral values that dictate what is right and what is wrong. Therefore, difficulties arise in their practice when some counselling situations conflicts with some of their core and long held values. This theme was very dominant among all the lay counselling groups. The participants indicated that their religious, cultural and personal moral values were sometimes in conflict with the professional ethical principles. For example, some of the lay counsellors had had this to say: … so in for example, where you know perfectly well that this your client is cheating on his wife, and they come to you. Should you tell the woman or not? You go back and then your conscience is disturbing you (MC 3). Errrrm. For example, I am a catholic and here I am in the ART unit. My religion forbids the use of contraceptive, and then I have to counsel people to use it (Psych LC 2). One of the greatest challenge or dilemma also had to do with when one of my church members was seriously ill. Though we had a revelation that it was a spiritual attack, the family wanted to send her to the hospital. I was torn between obeying the voice of God or the voice of man. It was a struggle (PC 4). Ok, sometimes for me I’m a Christian and I am not ashamed Ok. And sometimes separating my religion when I’m in the counselling session. You see when you are in the counselling session, people are usually vulnerable so you don’t have to go in with your biases and everything especially if it is religious because you may be counselling 57 University of Ghana http://ugspace.ug.edu.gh someone who is a Moslem and you are here quoting the Bible. For me I’m a Christian and sometimes I find it difficult like separating myself from my religion. So that’s one of the biggest challenges I face (SC 1). Most of the lay counsellors had dilemmas on the issue of abortion, especially among the pastors. One of them indicated that: Abortion..(paused). I don’t like to express my stand on this issues, but well. We have issues like that and most of the time, the counselees are waiting for you to make a decision for them. But remember that in counselling you only lay the choices before the client to choose…but if you ask me, my faith is against it (PC 1). 4.3.5 Dealing with Gifts Dealing with gifts in counselling relationships was found to be very challenging for the lay counsellors. This theme featured among all the lay counselling groups in the study. Their main difficulties were revolved around whether to accept or reject a gift, bearing in mind the socio- cultural context within which they practice. Some of them for instance indicated that: hahahaa…. That one “dier”, I have had a few situations where after I ended a session, the parents gave me money. Though it was hard for me to accept it. I resisted initially, but, you know in Ghana it can mean you are rude or something… And I felt someway whenever I had to counsel the boy again. (Psych LC 1). ..well, ermmm, I will say the issue of gifts. Not because I want it, but I see it as a cultural thing here. Food stuffs and things and… hmmmm. Though you know that it is not right to accept the gifts, at the same time you feel bad because you might be seen in some way 58 University of Ghana http://ugspace.ug.edu.gh “bi”. I hope you get it. Like for you, you are too known or “wo kyere wo ho” and things like that (SC 2). Sometimes a client buys you a gift or gives you tip. And you can’t say no because some of them will feel bad (HC 2). you know... accepting a gift from the members you counsel...But here you find yourself in this situation where a client offers you gifts, you are in a fix as to whether to accept it or not. It’s not easy sometimes (MC 4). Some of them alluded to the fact that receiving gifts (whether in cash or in kind) and no matter that amount and form it takes has the capacity of influencing counselling relationships and outcomes in ways that can cloud judgement of the counsellor. Some of them gave these scenarios: Yes, this is a classic dilemma I faced. So here is this client of mine we saw about some months ago. After that he got us a good humper on Christmas day. Afterwards, he passes by just to say hello. So he more or less became or friend. One day I think his brother hit someone with a car and was detained at the police station pending further investigations. He then called me to tell my boss to write a note which says that his brother has been receiving mental health care from us. In that case we were going to create a folder and then back date it with about three times visit. This was difficult for me to do (Psych LC 3). Another one has to do with counselling couples who have problems and yet you know that may be the man is at fault, and it is his same person who donates to support the church. Most of the times we face this situations (PC 4). 59 University of Ghana http://ugspace.ug.edu.gh 4.4 Resolution of Ethical Dilemmas by the Lay Counsellors The second objective of the study explored how the lay counsellors resolve the dilemmas they encounter in their everyday practice. The idea is to provide insight into how these lay counsellors try in their own capacities to deal with the dilemmas in their practice. Findings from the study showed four thematic resolution strategies employed by the counsellors. These are; (i) referrals, (ii) personal discretion, (iii) consultation and (iv) codes of conducts. These resolution strategies are represented in thematic network (Figure 2) for clearer understanding and are discussed in turns. 60 University of Ghana http://ugspace.ug.edu.gh Figure 2: Thematic network showing how the lay counsellors resolve ethical dilemmas 61 University of Ghana http://ugspace.ug.edu.gh 4.4.1 Referral Referral was found to be a very dominant strategy for dealing with dilemmas. This theme featured among all the groups of lay counsellors interviewed for the study. When it comes to resolution of dilemmas, majority of them mentioned that they would rather refer. Reasons assigned for referring cases included if it is beyond them or they cannot deal with it and when counselling relationship is compromised in one way or another. Some of them indicated that: Sometimes too, I refer the cases. I remember, one of our patients needed medication and I was the only person around. Because I can’t prescribe, I sent her to the medical director who happened to be a doctor and he wrote the prescription for me… so that’s it (Psych LC 1). …yes, ermmmm, I also refer some of the cases to the school chaplain if I realize there is a bit of spirituality (laughing) for example, there was a student who came to me that whenever she learns, it’s like the whole thing is taken out of her mind. She says she believes some of her colleagues are those taking the things from her head. Hearing this, I referred her to see the school chaplain for prayers. I also told the parents about it and advised they seek spiritual help for her… And if its health related issues, I ask the students to sign exeat and then go and see the doctor (SC 2). Yes, we were told during our psych corps training and orientation to always refer cases that we cannot handle to the appropriate people to deal with. And also since we are not psychologists, we cannot do therapy. So I remember, because the hospital knew I had a psychology background, they called me to help someone who was suspected of having panic attack. After I calmed the person down by helping with deep breathing exercise, I referred then to the CPNs since there was no psychologist in the hospital (Psych LC 2). 62 University of Ghana http://ugspace.ug.edu.gh …yes, at times too, I refer cases that I think are beyond me. For example, I once had a young boy referred to me for counselling because he was always making noise in class. After assessing him, I realized it was likely to be an ADHD case. So I referred him to go to Accra Psychiatric hospital for further care (SC 3). And also if I realize the problem is more spiritual, and the clients are willing to see a pastor, I ask them to go ahead. And in fact, I cannot do everything. Some aspects I can, but others, I cannot (MC 2). Most of the time I refer them to see an outside counsellor…if for example I realize that I have ermmm, some sort of relationship with…. I have a friend in another church whom I do refer them to (PC 4). 4.4.2 Personal Discretion Another resolution strategy identified among the lay counsellors was personal discretion. The participants indicated that in some cases, they dwell on their own judgement to make decisions in complicated counselling situations. This was a very common theme running through among all the participants. Their use of personal discretion was explained to mean drawing on their own values to make decisions. The dominant values on which they drew the most were religious values. Personal moral values were also drawn on and in few circumstances, cultural values. Religious values Religious identity was the most dominant source drawn on for values by the counsellors to deal with compromising counselling situations. The participants indicated using Christian religious values of praying, reading scriptures and faith when dealing with situations that were very 63 University of Ghana http://ugspace.ug.edu.gh difficult to resolve. This sub-theme featured among all the 27 lay counsellors interviewed for the study. The participants indicated that God is the source of all authority and so they resort to Him for guidance to address most of the dilemmas they face: Yes, in a way. Because, I am a catholic and we don’t endorse the use of contraceptives. Also, morally, it is wrong to engage in sex before marriage. So I think I considered them (Psych LC 2). Sometime, especially if it has to do with issues of morality and faith. For example, I once quoted from the book of Galatians to counsel some students who were caught in sexual immorally act. …Yes so sometimes I use my religion (SC 3). So I turn a little bit to religion…I’m not being unprofessional though but then I think it helps put the client in a position of comfort. At the end of the day, you want the person to accept the status, start ARV, you want the person to have a healthy life (HC 1). ...well, for me, I am able to resolve a dilemma if for example my client shares the same faith with me. This is because if we get to a point where we all need to agree on one thing, it then becomes easy for us all (Psych LC1). For Catholics, abortion is not one of the areas we have appreciated. We say if you’re a catholic and you are having such a situation see that you do not destroy life. Do what you can, the best you can to save life, but not to destroy it… I say “don’t abort, what you have it’s God who gave it to you” so if it is not any syndrome issue which has not been found, it tells you don’t do it… so that’s the way I will say it, if no syndrome, then you leave it. If the baby comes to society, then we have to do our best to help (PC 1). It was only at one time where a female student was planning an abortion and I got to 64 University of Ghana http://ugspace.ug.edu.gh hear of it. I was called to counsel her. It was there that I used the Bible since she was a Christian... so yes, my religion plays a role, but not in all cases (SC 2). Well...!!! For example, in the abortion case, I have to look at what is right in the eyes of God and man. And sometimes you will have to even consider what the law says. But for us, the Bible is the final authority in all matters (PC 3). If I realize the decision, what I am doing is not in line with my faith, I will stop doing it. Religion serves as a check on you sometimes, you know…the Bible for example is there to guide us as Christians (MC 4). Personal moral values ‘Personal moral values’ was the second most dominant category of values cited for personal discretion in resolving dilemmatic situations. Majority of the counsellors said they consider what is acceptable as morally right when they are faced with a dilemma: Practically, I will say I look at what I can do and what I can’t do. Then I decided on what to do… I value integrity. That is why I kept on telling the staff that I am only a psych corps and not a clinical psychologist (Psych LC 1). Yes, for example, in the case of the man who wanted the report, you know clearly that this is lying. So that was why I informed my boss about it. I did not follow to know the outcome (Psych LC 3). Well, I listen to my conscience. If what I am doing is right, and will not hurt anyone, then I will do it. For example, I know some of my colleagues may say it was wrong for me to 65 University of Ghana http://ugspace.ug.edu.gh accept the money, but that was just a one-time thing. The next time he offered, I totally rejected it (HC 4). Cultural Values Under some circumstances, one of the lay counsellors indicated drawing on cultural values to resolve dilemma: I try to figure out the motive behind it. I consider the cultural differences too. May be its just a thank you gift for ending a whole counselling, not one session. I could offend someone because it is perfectly acceptable in their culture to receive gift. And we are in Ghana oo (laughing) (MC 4). 4.4.3 Consultations Consultation was also an important resolution strategy used by the counsellors in resolving dilemma. Majority of them indicated that when they don’t know what to do in a particular situation, they world consult. Their consultation practice took three main forms (i) consulting superior colleagues, (ii) consulting peer colleagues and (iii) consulting technology-mediated sources like internet. Superior consultations Consulting superiors was the most dominant sub-theme in their consultation practice. In relation to consulting senior colleagues, almost all the lay counsellors said they do consult their senior colleagues when they are faced with challenges. With the psych corps, they said they do consult 66 University of Ghana http://ugspace.ug.edu.gh their immediate supervisors, clinical psychologists, community psychiatric nurses or the psych corps coordinator. These are exemplified in the quotes below; Ok, for now currently, I’m I’m, I’m also seeing a counsellor (laughs) to actually help me with some of the challenges I have faced. Because I believe some of them have been in the fields for years and they are professionals at what they do. So for upcoming counsellors, like myself, when we have faced such challenges, we just go back to the elders and see what they have for us (MC 1). …and aside that too, I sometimes seek advice from senior colleagues and the elderly, like someone I have taken as my role model in order to help me tackle certain issues (PC 3). ..ahaa, that was when I called the psych corps coordinator to inform him about it… yeah… as a way of making sure I was doing the right thing… well, he told me to stay within my limits, or ermmmm… (Psych LC 1). So, I’m lucky to have a lot of seniors around, some as much as 13 years of experience. So I consult them, almost all the time. Even if they are not around, sometimes we even call them to disturb them with issues like these (HC 1). Oh yes. I call the psych corps coordinator. Also, we have a WhatsApp page where Prof. Ofori-Atta and other clinical psychologists are on. So we present our cases and they tell us what to do… also, I have my in-charge and I do consult with him whenever I find myself in a tight corner. (Psych LC 7). 67 University of Ghana http://ugspace.ug.edu.gh Technology-mediated consultation Using technology-mediated sources was the next dominant consultation practice used by the lay counsellors. The indicated consulting internet sources and social media pages for advice on how to handle some dilemmas: There is a psych corps WhatsApp platform where I do post my cases or dilemmas and they get resolved there. I remember I was in doubt of whether I qualify to give an excuse duty to a student. As at that time, I was the only person in the unit so I placed it on the platform. And I got a response. Later on, I called the psych corps coordinator to also seek clarifications (Psych LC 3). ..ok, one thing is that, today the world has become a global village. You go online, you see ethical stuffs and read about them and then you try to educate yourself on it. And then try to, you know, apply it (SC 5). … ermmm, and also I read online a lot to get myself updated with issues (PC 3). Sometimes I read on the issues and then come out with some form of solution before I meet my client again (MC 2). Oh yeah, I do a lot of online reading. Sometimes any issue I see I just google and read get information (Psych LC 6). Yes! Errrmmm, I do discuss with other pastors and also my senior pastor. There are times that I read around the issue at hand just to get more knowledge on the case that I am dealing with (PC 4). Well. I mostly read from the internet to get more ideas about the cases I am dealing with. 68 University of Ghana http://ugspace.ug.edu.gh Though sometimes, you will not get what you want. Even if you do, the cultural settings are different (SC 3). ….yes, sometimes, I search online about similar cases I encounter so as to gain knowledge on what to do. Yes, so I use online resources a lot. You will always come across something new (MC 4). Peer consultations Few of the lay counsellors indicated consulting their peers or colleagues who are same level as them to help in resolving dilemmas: … Or you find some of your colleagues who can also be of help, they will also tell you their experiences when they had such a situation how they went about it. And then either you bring them together and come out with the best solution, that’s how I’ve been going about it (PC 1). Well..not really. For me I am free with my colleagues so when I am not too sure of what to do, errr, I ask them and we all think through it…oh yes! They do also ask me for advise and that kind of thing…(HC 2). 4.4.4 Codes of Conducts Following codes and conducts of institutions also featured as an important sub-theme in the consultation practice of the counsellors. This was more dominant among counsellors who practiced in formal institutions like schools, hospitals, and churches. For instance, among the dominant codes of conducts used were workplace rules and regulations, church rules and 69 University of Ghana http://ugspace.ug.edu.gh regulations, rules and regulations of Ghana Education Service. In the case of the Psych Corps, they reported relying on their training manuals for guidance on resolving dilemmas. These can be seen in the quotes below; Hey…it is difficult to get a job, so I will not do anything that will jeopardize my work or career. So I will consider what the rules at the workplace says (HC 2). Oh yes…sometimes I go by the Ghana Education code of ethics for teachers and for the students. You know we have that as a guide to regulate our work…So I stay within that limit (SC 3). In Ghana, here we don’t have any codes of ethics for counsellors that I know of. Unless there is some which I don’t know of (laughing). But the school and church constitutions also guide me in my work (MC 4). After the counselling, I had to make it known to the student that school rules were school rules. So to resolve my dilemma, I read out the school rules to him. In that case my conscience will be free (SC 5). We have a training manual given to us by Psych Corps Ghana, and I do refer to it regularly…Well, err I’ve also read the GHS patient charter and code of ethics, so that one too in a way guides the way I behave and do my work. I also go onto the internet to search for information (Psych LC 8). Normally, me that is, I always consider the ethics of the job that you are doing. So those are some of the things that will put you on your toes that what you are doing is it appropriate, is it approved or not? So if it’s not approved then that’s where you think twice in what you are about to do… (HC 3) 70 University of Ghana http://ugspace.ug.edu.gh Because I’m not in my house, I’m at work place, and the work place comes with its own rules and regulations which I must follow. If I am in my house, there are some things that I can value… Yea, so the codes of conducts are the things that put me on my toes when I’m faced with some of these dilemmas (Psych LC 7). 4.5 Challenges of Resolving Ethical Dilemmas by the Lay Counsellors The final objective of the study sought to examine the challenges that the lay counsellors face when resolving ethical dilemmas. In every profession, some inherent challenges become hidden and only become apparent when dealing with difficult situations. The essence of this objective was understand the inherent ethical challenges of lay counselling practice in Ghana. Among other things, this would help to reveal areas of training and retraining of lay counsellors in Ghana that need urgent attention. Findings from the study showed three main thematic challenges; (i) lack of continuous training, (ii) challenges surrounding religious values and (iii) challenges surrounding cultural values. These challenges are represented in thematic network (Figure 3) for clearer understanding and are discussed in turns. 71 University of Ghana http://ugspace.ug.edu.gh Figure 3: Thematic network of challenges encountered in resolving ethical dilemmas 72 University of Ghana http://ugspace.ug.edu.gh 4.5.1 Lack of continuous training Lack of continuous training and education revealed itself as a serious challenge for the lay counsellors which becomes apparent when faced with ethical dilemmas. This was a very dominant theme that featured in narratives of majority of the participants. Well, I think more training must be done for counsellors. Also there should be a strong association for counsellors, which will see to the affairs of counsellors in the country (PC 2). Not really. But I just want to suggest that in your submission, indicate that more training needs to be done for counsellors, especially the pastors and those in ministry. Now almost every pastor claims he is a pastor and then you see on their signboards counselling time. I wonder the type of training they had… I hope you know what I am talking about (SC 3). I will say because there is no form of continues training or workshops on some of these issues, it sometimes becomes difficult to deal with them…I can’t remember the last time I went for a training on a professional refresher course apart from the one that the local church organizes for the leaders (MC 2). Yeah, errmm I just did as a course and that’s all. So, if I have to be a full counsellor I think I need the proper training for it so that I can do it professionally. This one you know reading a course during your major, you are just being introduced to it (SC 5). 73 University of Ghana http://ugspace.ug.edu.gh 4.5.2 Cultural values Some of the participants also indicated that sometimes they face the reality of how their cultural values and orientation pose a challenge to them in their field of practice. They realize that sometimes their cultural values complicate counselling relationships: Errrrmmmm, may be because you don’t want a client to feel bad, you may end up accepting the gifts they give you. So I will say our cultural orientation (Psych LC 1). And if I should say, the culture of the place also counts. Look, I was in the north and here you are you find someone with two, three wives and the person is coming for counselling. Would you say because the Bible doesn’t encourage polygamy so you will not help them? (MC 2). 4.5.3 Religious values Religious values were also identified by the participants as a challenge: Errmmm, yes. For example, with the abortion case like this, me I am a Christian and my religion does not allow that. Also, morally, it is not good to abort a baby. So these things do influence my decision making process (SC 4). Its difficult to to sometimes errm separate your religion from some of the cases you are dealing with…personally, it serves as a kind of obstacle when I have a solution. For example, do I have to continue to lie because I want to be confidential…sometimes I see it as a sin (PC 2) 74 University of Ghana http://ugspace.ug.edu.gh 4.6 Summary The findings from the study are summarized as follows. Five domains of ethical dilemmas were identified among the lay counsellors. These were difficulty negotiating rights and confidentiality, competency issues where they are mostly assigned to cases they are not trained for, difficulty managing multiple relationships, dealing with conflicting values, and conceptualising and relating to gifts Four thematic resolution strategies were identified to be employed by the counsellors. These are, referral of cases of ethical nature, personal discretion of drawing on values to make decisions of ethical consequences, consultation for assistance in handling ethical dilemmas, using codes of conducts of institutions to resolve ethical dilemmas. Three main thematic challenges were identified to be made apparent in the face of ethical dilemmas. These are lack of continuous training which limits their capacity for practice, challenges surrounding religious values conflicting with professional ethics and challenges surrounding cultural values conflicting with professional ethics. Majority of the lay counsellors lack training on ethics and also do not have access to ethical codes. 75 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Introduction Lay counsellors play key roles in mental health delivery, especially in low and middle income countries (LMICs) where there is a large treatment gap due to shortage of professionally trained mental health personnel. In Ghana for instance, there are woefully inadequate numbers of trained mental health professionals who will see to the mental health needs of the people (Quashie et al., 2016; Ofori-Atta et al., 2010). There are few trained psychologists, psychiatrists and psychiatric nurses and they are mostly based in the urban centres. This has created a situation where majority of the population do not have access to trained mental health practitioners (Ae-Ngibise et al., 2010). In response to the increasing gap, there has been a call to adopt a task shifting approach to meeting the mental healthcare needs of LMICs (Leman, Van Damme, Barten & Sanders, 2009). The task shifting approach ensures that some basic mental health skills are taught to middle line staff who are already in touch with the people. Lay counsellors therefore bridge the gap between professionally trained mental health practitioners and mental health needs of the people. They help in delivering basic counselling and psycho-education services to individuals in need of these services in schools, churches, health settings and communities as a whole. The field of mental health practice is fraught with several challenges. The key of these challenges is dealing with and managing complicated ethical dilemmas (ivis-Cetinkaya, 2015). This is very critical because depending on how these ethical dilemmas are handled, there can be several mental health consequences not just for the client but also on their families and even 76 University of Ghana http://ugspace.ug.edu.gh institutions where they work and communities where they live (Leman et al. 2009). It is therefore imperative that complex ethical dilemmas in counselling situations are handled with utmost care and expertise. Given the critical role of lay counsellors in mental health delivery in Ghana and the way the practice is characterized by ethical dilemmas; it is imperative to understand how these lay counsellors deal with ethical dilemmas in their everyday practice. Unfortunately, there have been limited studies among this group of counsellors. This study was therefore aimed at exploring the ethical dilemmas experienced by a sample of 27 lay counsellors in Ghana and how they resolve them. This chapter provides detailed and in-depth discussions of the findings and their implications for mental health care in general and the role played by lay counsellors in particular in Ghana. The discussion is organized around the two main themes. The first theme addresses objective 1 by discussing the domains of ethical challenges that the lay counsellors face. The second theme integrates objectives 2 and 3 by discussing strategies for resolving the ethical challenges and challenges associated with their resolution strategies. After that, the practical, research and/or theoretical implications of the findings in the current study are discussed. The chapter also presents some limitations of the current study and recommendations made for future research. 5.2 Ethical dilemmas faced by the lay counsellors Depending on the kind of mental health practitioner that a person is and the categories of cases handled, there may be differences in the kind of ethical challenges faced. The first objective of the study examined the different kinds of dilemmas that the lay counsellors encounter in their 77 University of Ghana http://ugspace.ug.edu.gh everyday practice. This was to provide insight into the various kinds of difficulties they deal with and how they conceptualize different dilemma situations within the context of their counselling practice. The findings showed that the lay counsellors are exposed to five different kinds of ethical challenges. These are difficulties negotiating rights and confidentiality, competency issues where they are mostly assigned to cases they are not trained for, difficulty managing multiple relationships, dealing with conflicting values and conceptualising and relating to gifts. This shows that the lay counsellors experience several ethical difficulties in their everyday practice. Understanding these difficulties is essential. In a sense it provides insight into the sources from where these dilemmas emerge. These dilemmas reflect both the socio-cultural and religious context of their practice and also the context of power dynamics within the institutions where they practice. These two contexts interact in complex and insidious ways in shaping lay counselling practice. The socio-cultural context of practice is very powerful in shaping counselling decisions that have ethical implications (Grönlund et al., 2011). The finding of negotiating rights and confidentiality for instance brings to bear how the social-cultural context of practice poses severe challenge to lay counselling practice. The issue of client rights and parental rights for instance is shaped by a socio-cultural context that assigns parents with ultimate rights over their children. In Ghana for instance, parents have absolute rights over their children (Gyekye, 1996). This makes parents exercise right to information over their children in counselling relationships. This creates a situation where sometimes some parents find it difficult accepting that their children also have their privacy. They are therefore unable to understand why and how the ethics of the practice requires that not all information about their children can be divulged to them. 78 University of Ghana http://ugspace.ug.edu.gh The socio-cultural and religious contexts account for the ethical challenges that the lay counsellors face. This is because the ethical issues the participants identified were mainly those that went contrary to either their religious values, cultural values or both. The social-cultural context in Ghana, just like everything else, is value-laden. That is not the actual issue. The critical issue is that there are several socio-cultural values that are inconsistent with the professional ethical values of counselling practice. For instance, when it comes to the issue of dealing with gifts during practice; gifts hold high symbolic power within the socio-cultural context of Ghana. Gifts, sometimes single-handedly shape relationships and this was found clearly in this study. In Ghana, gifts constitute a socio-cultural framing for gratitude (Gyekye, 1996). People give gifts, not only as an altruistic gesture but also to cement relationships. Because of this, there are several social psychological consequences associated with rejecting a gift. People may not take it kindly if their gifts are rejected and therefore personalize it. Among other things, the gift giver could misinterpret it to mean you have rejected them as individuals and their offer of relationship. The ethical challenges identified among the lay counsellors are in line with what other studies have also identified among other health practitioners in general and mental health practitioners in particular. For instance, Oppong (2014) reported among clinical psychologists in Ghana, that their main ethical challenges include those arising from third party and privacy interferences, dual relationships, fees, and motive as against moral issues, policies and practices that conflict with ethical guidelines, competence and client expectations, manipulation of the therapist and cultural competence. Other studies have also reported among Turkish counsellors that most of the ethical dilemmas faced by these counsellors were issues regarding confidentiality and privacy, conflicts with 79 University of Ghana http://ugspace.ug.edu.gh school principals and incidents regarding dual relationships and boundaries (ivis-Cetinkaya, 2015). Donkor and Andrews (2011) reported among nurses in Ghana that their approach to ethical problems is influenced by their local institutional setting and cultural environment. Some of the nurses were influenced by the fact that their culture is a collectivistic one. Also cultural elements like religion had an influence. However, the aspects of this study that are contrary to what has been reported among professional mental health practitioners is the issue of how power shapes their ethical practice (Ofori-Atta & Jack, 2015). Professionally-trained practitioners (e.g. psychologists, medical doctors, nurses etc.) are found to be able to resist institutional pressures to maintain their ethical principle in their practice (Donkor & Andrew, 2011). However, in the current study, most of the lay counsellors are affected by power imbalance within their institutions of practice that limit their willingness and capacity to uphold ethical standards. They are usually overruled by their superiors who themselves are not professionally-trained mental health practitioners (e.g. pastors, headmasters, disciplinary committees). The school counsellors for instances recounted several instances where their suggestions for rehabilitation are pushed aside by disciplinary committees and headmasters. The marriage and pastoral counsellors similarly hinted on several occasions where their senior pastors dictate to them how they should handle a particular situation. This situation has been identified to be very problematic in institutionalized settings. Ofori-Atta and Jack (2015) for instance have argued that critical components of ethical dilemmas among health practitioners is determining the appropriate use of authority, decision-making and questioning the role or scope of the health care professional. This means that practitioners without the necessary power for making decisions cannot always ensure ethical practice because their superiors can always step in to overturn everything they do. These findings speak to the 80 University of Ghana http://ugspace.ug.edu.gh critical role that power plays in ensuring ethical mental health practice, especially in institutionalized settings. 5.3 Ethical dilemma resolution strategies and challenges Different professionals, when encountering difficult ethical situations in their professional practice, adopt different strategies. The same can be said of mental health practitioners, whether professional or lay. The second objective of the study explored how the lay counsellors resolve the dilemmas they encounter in their everyday practice. The idea is to provide insight into how these lay counsellors try in their own capacities to deal with the dilemmas in their practice. Findings from the study showed four thematic resolution strategies employed by the counsellors. These were; referral of cases of ethical nature, use of personal discretion of drawing on values to make decisions of ethical consequences, consultation for assistance in handling ethical dilemmas and using codes of conducts of institutions to resolve ethical dilemmas. These findings suggest that the lay counsellors draw on diverse strategies in dealing with the ethical challenges of their practice. The sources constitute some of the best practices provided in mental health training manuals and ethical codes of different mental health associations. These resolutions have been found to be employed by other professionally trained mental health practitioners both in Ghana (Ofori-Atta & Jack, 2015; Oppong, 2014) and elsewhere (Grönlund et al., 2011; ivis-Cetinkaya, 2015). This suggests that the lay counsellors are aware of the best practices for resolving complicated ethical issues in ways that do no damage to client, counsellor and the counselling relationship. 81 University of Ghana http://ugspace.ug.edu.gh That notwithstanding, some challenges were identified among the participants when it comes to resolving their ethically complex counselling situations. This is in line with the argument that mental health practice in general is characterized by some hidden, inherent challenges which only become apparent when dealing with difficult situations (Ae-Ngibise et al., 2010). The findings show three main thematic challenges that become apparent in the face of ethical dilemmas; lack of continuous training which limits their capacity for practice, challenges surrounding religious values conflicting with professional ethics and challenges surrounding cultural values conflicting with professional ethics. The challenges bring to bear two fundamental difficulties the lay counsellors grapple with. First is the issue of limited competency with which they practice. Not only are the competency limitation exhibited in handling cases they are not trained for, but sometimes they have limitations resolving conflicts. The limited competence for practice is very critical because it shapes the relationship that other practitioners in institutionalized settings relate with the lay counsellors. Some of the psych corps groups for instance lament that the nurses get angry when they (nurses) assigned cases to them (psych corps) and they turn them down because it is not within their competency. This defines how the lay counsellors are seen by the other practitioners they work with, which reduces the standards and in some cases the respect they hold for them. The challenge with dealing with values was also found to be critical. This usually becomes apparent when the lay counsellors have to draw on their personal discretion to resolve ethically- charged counselling situations. It was observed that the lay counsellors draw heavily on religious values and sometimes on personal moral values in dealing with the ethical challenges. However, as indicated by some of the participants, the two are mostly inseparable. They indicated that they 82 University of Ghana http://ugspace.ug.edu.gh draw on their religious values in shaping their personal values. Invariably, the lay counsellors were found to draw on their religious values in resolving all cases of ethical nature. This situation can be accounted for by the fact that almost all the lay counsellors interviewed for the study identified themselves as Christians. Their Christian identity was so central to their practice that almost all of them indicated that they pray with their clients before and after counselling sessions. The situation appears to be working for them so far, because apparently most of the clients they see also share their Christian faith. Their religious identity is drawn on almost always as their professional identity in their everyday practice. Nonetheless, the situation also constitutes a time bomb of crisis in competence when they are confronted with the challenge of conflicting religious and moral values. The lay counsellors might have difficulty separating their professional and religious identities and that could cause problems. 5.4 Implications of the Study This section discusses the implications based on the findings from the current study. The implications are discussed in two areas. First, implications of the findings for practice are discussed. Next, the implications of the findings for theory are discussed. 5.4.1 Implications for Practice and Training Based on the findings from the study, several recommendations are made in order to improve lay counselling practice in particular and by extension mental health delivery in general in Ghana. First of all, the study found that majority of the lay counsellors lack training on ethics and also do not have access to ethical codes. This can affect the competency of the lay counsellors as well 83 University of Ghana http://ugspace.ug.edu.gh as the effectiveness of the counselling sessions. A lay counsellor without knowledge in ethical issues could end up breaking ethical rules which will in turn affect their clients. It is recommended that ethical training be provided to them and also ethical codes made available to them to guide their decisions in counselling situations that have ethical consequences. Secondly, the findings show that the lay counsellors who work in institutionalized settings have grave difficulties in upholding ethical standards within those institutions. They are overruled or dictated to by their superiors. This is not always healthy for ethical counselling practice. It is imperative that these power imbalances in institutions where lay counselling is practiced are addressed. This can be done through sensitizing and educating these heads of institutions about the roles and limitations of the lay counsellors. It will also help lay counsellors not to practice beyond their boundaries. It is recommended that the Ghana Psychological Council (GPC) and other counsellors’ association must bring together lay counsellors and empower them. This among other things can provide avenues for continuous competency training for them. This can also help them to renegotiate power within their institutions of practice so that they can always ensure high ethical practice. The registration of lay counsellors and other paraprofessionals with the GPC should be decentralized so as to make it easy for those in other regions to be registered members (Quashie et al., 2016). Furthermore, special competence training attention needs to be paid to the lay counsellors. The social and psychological challenges—conflicting religious morals, interferences, emotional, stress, professional role and identity—could be the focus for continuous education. Presently, continuing competence is not officially monitored or regulated and so lay counsellors draw on their religious values in handling almost all their ethically-charged situations. 84 University of Ghana http://ugspace.ug.edu.gh There is also the need for public education on the ethical requirements in counselling practice. Some of the challenges the lay counsellors identified, especially relating to client privacy and gift giving are as a result of ignorance on the part of the people concerning ethical requirement in counselling practice. The lay counsellors can team up with for instance the GPC to design such public education. This will help inform the public so that they can understand certain things when they are entering into counselling relationships. 5.4.2 Theoretical Implications This section discusses the theoretical implications of the findings. The major theoretical contribution of this study has to do with how power imbalances shape ethical practice in lay counselling. This suggests that upholding ethical standards goes beyond the knowledge and competence levels of the individual practitioners. Most of the studies conducted among professionally trained mental health practitioners (such as psychologists and psychiatrists) do not usually report these findings (Oppong, 2014). The essence is that their positions and expertise are usually respected and that empowers them some form of power to uphold ethical decisions. The lay counsellors on the other hand are usually overruled by their superiors who are also not professionally-trained mental health practitioners (e.g. pastors, headmasters, disciplinary committees). In most cases, their suggestions for rehabilitation are pushed aside. This means that power is critical in ensuring ethical mental health practice, especially in institutionalized settings. This needs further research among other groups of mental health practitioners to provide deeper understanding. 85 University of Ghana http://ugspace.ug.edu.gh 5.5 Limitations of the study The current study suffers from some limitations that need to be taken into consideration in the interpretation and applications of the findings. Some of them are: The majority of research participants were Christian. About 26 out of the 27 participants identified themselves as Christians. Given that religious values play a critical role in bringing about and resolving ethical dilemmas, this comes as a limitation that needs to be taken into consideration when generalizing the findings of the study with respect to religious values in the context of this study. The second limitation was that all the lay counsellors used for this study practiced within institutionalized contexts. Some of them practice in schools, churches and hospital settings. Community-based counsellors were not included in the sample. For example, council of elders in the community, family heads, and traditional faith healers (van der Geest, 2015). Some people may have no other option than to patronize the services of some of these community based counsellors (Atindanbila & Thompson, 2011). Findings therefore need to be interpreted with caution. The third limitation is that the lay counsellors were unusually highly educated. All of them reported having tertiary education. Therefore, their views and experiences might be qualitatively different from lay counsellors with lower levels of education. Again, the participants worked within urban settings. Therefore, those in rural communities might have views and experiences that are qualitatively different. Finally, the study did not assess the characteristics of a lay counsellor’s moral issue, which is the moral intensity and how it can influence his/her ethical decision making. 86 University of Ghana http://ugspace.ug.edu.gh 5.5.1 Suggestion for future studies Notwithstanding the limitations discussed above, the current study makes substantial contribution to lay counselling practice and research, within the broader task shifting agenda for mental health delivery in Ghana. It is therefore imperative that future studies build on this to provide deeper understanding and to improve on lay counselling practice in Ghana. The following suggestions are therefore made for future studies: First of all, for theoretical development, future studies should focus on exploring how power dynamics in institutionalized settings shapes ethical mental health practice. Different mental health practitioners (both lay and professional practitioners) in different institutions (e.g. general hospitals, psychiatric hospitals, schools, churches etc.) can be studied to understand how power shapes their mental health practice within their institutions of work. Secondly, for deeper understanding of religious values in mental health practice, it is important for future studies to consider comparative analysis of practitioners from different religious backgrounds (e.g. Christians, Muslims, and Traditional African Religion) on how they make ethical decisions in their practice. Future studies should also consider examining ethical experiences of lay counsellors who are engaged in community-based practice. Such studies should include lay practitioners from both urban and rural community settings in order to provide holistic understanding. Future studies can also consider validating the training models to resolving ethical dilemmas that lay counsellors and other mental health professionals encounter in their work. Future studies can also look at how lay counsellors cope with the challenges they experience. 87 University of Ghana http://ugspace.ug.edu.gh 5.5.2 Conclusion There is the need for strengthening lay counselling practice in Ghana, if we seek to make progress with mental health delivery in the country. This calls for evidence-based research that informs policy and practice surrounding lay counselling practice implementation in the country. Using in-depth individual interviews, this study has provided the context of ethical challenges in lay counselling practice in Ghana. The findings have provided insight into how lay counsellors orient themselves around ethical challenges within the context of their practice. The study has revealed five thematic domains of ethical challenges the lay counsellors face; difficulties negotiating rights and confidentiality, competency issues where they are mostly assigned to cases they are not trained for, difficulty managing multiple relationships, dealing with conflicting values and conceptualising and relating to gifts. Four thematic resolution strategies have been identified; referrals, personal discretion, consultation and codes of conducts. Three challenges were identified to result from resolving ethical challenges; lack of continuous training, challenges surrounding religious values and challenges surrounding cultural values. Among other things, there is the need to strengthen their capacity for practice through frequent capacity training and addressing the power imbalances within institutions where lay counselling is practice. In addition, ethics training and adherence to ethical standards by lay counsellors should be strengthened. A major limitation is that the study relied on institutionally-based lay counsellors (e.g. schools, hospitals, churches) and so the perspectives of community-based counsellors were not captured. As side that sample size was small and all were tertiary educated. As such, interpretation and application of the findings should be done with care. Nonetheless, these findings speak to the relevance of paying adequate attention to lay counselling practice in Ghana in the attempt at bridging the mental health gap. 88 University of Ghana http://ugspace.ug.edu.gh REFERENCES Ae-Ngibise, K., Cooper, S., Adiibokah, E., Akpalu, B., Lund, C., Doku, V., & Mhapp Research Programme Consortium. 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Defining lay counselling. New Voices in Psychology, 4(2), 5-13. 97 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX I: Ethical Clearance 98 University of Ghana http://ugspace.ug.edu.gh APPENDIX II: Informed Consent Form UNIVERSITY OF GHANA Official Use only Protocol number Ethics Committee for Humanities (ECH) PROTOCOL CONSENTFORM Section A- BACKGROUND INFORMATION Title of Study: Ethical Dilemmas Faced by Lay Counsellors in Ghana. Principal Robert K. Ketor Investigator: MPhil Psychology Student Certified Protocol Number Section B–CONSENT TO PARTICIPATE IN RESEARCH General Information about Research The main research aim is to find out the ethical dilemmas faced by lay counsellors and how they resolve them, as well as their cultural counselling competency in relation to ethical principles found in other ethical codes. This study will help document the ethical dilemmas faced by lay counsellors. It will also help bring out how these dilemmas are resolved in relation to our Ghanaian culture. Finally, the knowledge about ethical dilemmas among lay counsellors will help in the training of lay counsellors and other mental health professionals. 99 University of Ghana http://ugspace.ug.edu.gh The study will contribute to the efforts at building collaboration among the various mental health practitioners by providing insight into the framework that the various stakeholders are willing to work with in helping bridge the high mental health treatment gap in Ghana. Participation will involve responding to individual in-depth interview and a self-report questionnaire which will last for about 25 to 30 minutes. Benefits/Risk of the study The study does not involve any known risks except the time and effort spent during the interview or responding to the questionnaire. The study has no direct benefit for participants. However, it will help participants know about some of the dilemmas they face in the course of their work. Confidentiality Any and all information obtained from you during the study will be confidential. The in-depth interview will be taped-recorded with the permission from participant. Apart from the principal student investigator, other groups that may have direct access to the research records include principal and co-supervisors, research assistants at the point of doing transcription or data entry. All data collected will be used for academic purposes only and as such ethical principles of privacy and confidentiality will be ensured. Compensation There will be no form of compensation for participants who participate in the study. Participation is voluntarily. The researcher will however send the soft copies of the Mental Health Act to participants who don’t have access to it as a way of appreciation. Withdrawal from Study 100 University of Ghana http://ugspace.ug.edu.gh Your participation is entirely voluntary. You may refuse to participate in this research. Such refusal will not have any negative consequences for you. If you begin to participate in the research, you may at any time, for any reason, discontinue participation. Contact for Additional Information Should you have any concerns for further clarifications, you can contact the researcher on 0247706505/0201595094 or through the mail at ketrob23@yahoo.com. You can also write to the Department of Psychology, University of Ghana, Legon. If you have any questions about your rights as a research participant in this study you may also contact the Administrator of the Ethics Committee for Humanities, ISSER, University of Ghana at ech@isser.edu.gh / ech@ug.edu.gh or 00233- 303-933-866. Section C-VOLUNTEER AGREEMENT "I have read or have had someone read all of the above, asked questions, received answers regarding participation in this study, and am willing to give consent to participate in this study. I will not have waived any of my rights by signing this consent form. Upon signing this consent form, I will receive a copy for my personal records." ________________________________________________ Name of Volunteer _________________________________________________ _______________________ 101 University of Ghana http://ugspace.ug.edu.gh Signature or mark of volunteer Date If volunteers cannot read the form themselves, a witness must sign here: I was present while the benefits, risks and procedures were read to the volunteer. All questions were answered and the volunteer has agreed to take part in the research. _________________________________________________ Name of witness ________________________________________________ _______________________ Signature of witness Date I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this research have been explained to the above individual. __________________________________________________ Name of Person who Obtained Consent ___________________________________________ ______________________ Signature of Person Who Obtained Consent Date 102 University of Ghana http://ugspace.ug.edu.gh APPENDIX III: Interview Guide INTERVIEW GUIDE ON A QUALITATIVE RESEARCH ON THE ETHICAL DILEMMAS FACED BY LAY COUNSELORS Interview begins Region: ……………………………………. Introduce to participant that the interview will be recorded and transcribed verbatim. Seek participants consent and ask if they want to sign the form before interview proceeds. 1. What kind of population do you work with (probe e.g. Students, Children, Adults etc)? 2.Have you had any exposure to other fields related to your practice? (E.g., legal, medical, religious, social work, etc.) Ethical Dilemmas Facing Lay Counsellors Ethical dilemma is a complex situation that involves an apparent mental conflict between moral imperatives in which to obey one would result in transgressing another. In other words, they are circumstances when two or more options are encountered and there is a difficulty in deciding about which one is better; as a result of the existing necessities that cannot be met by present alternatives (Lindsay & Clarkson 1999; Noureddine, 2001). 3. In your profession as a lay counsellor, tell me the ethical dilemmas you have encountered. 4. Now let‘s focus more on some of the most difficult ethical dilemmas you have encountered in your profession? (At least 3) of them (first let him/her list the three and then ask questions) (a)........................................................................................................................................... 103 University of Ghana http://ugspace.ug.edu.gh (b)........................................................................................................................................... (c)………………………………………………………………………………………………… …………………………………… For each of the most difficult ethical dilemmas probe and ask the following questions i. How often (frequency) do you encounter this ethical difficulty. ii. Why do you perceive that as a difficulty? iii. What did you do with this difficulty? iv. Did your religion play a role in the resolution of the dilemma? Solutions to Ethical Difficulties (resources). Introduce participants to the importance of resources in their professional practice. 5. As part of your work, tell me the consultations you have with (e.g., former supervisors, senior practicing counsellors) in handling ethical dilemmas. 6. Can you tell me the practical steps you adopt in solving the ethical dilemmas? 7. In your attempt to solve ethical dilemmas what do you consider? (e.g., personal values, beliefs, religion/moral convictions, reputation, expertise, etc) 8. Please could you tell me the relative importance of these considerations in your resolution of the dilemma? 104 University of Ghana http://ugspace.ug.edu.gh 9. What role does religion play in the ethical decisions people make? 10. How do your own religious values play a role in ethical decisions you make? 11. How satisfied were you with the solution to the dilemmas? Factors Influencing Ethical Decision Making 12. What were the obstacles for solving these ethical dilemmas? 13. What were the opportunities available? (Probe) 14. Is there anything else about these dilemma or how it was resolved that we haven‘t discussed that you think is important for me to know? VIGNETTE 1 As a counsellor, your client who has been in a no-sex relationship for a year with her guy, have now decided to tie the knot. They love themselves very well. You advised them on having a sickle test of which they agreed. They came to your facility for the test to be done and because of your protocol which permits them to do all test for free, they decided to add hepatitis, HIV, blood group etc. To cut everything short, you realized from the results that your client is HIV negative whilst her guy is HIV positive. 1. Do you think you should inform your client? Yes [ ] No [ ] Why? ……………………………………………………………………………………………………… 105 University of Ghana http://ugspace.ug.edu.gh ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 2. Considering the rules and laws protecting our work, patients right to privacy and your client’s life, what would you do? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… VIGNETTE 2 Abena is a 15-year-old teen who is not getting along with her parents. She has run away from home twice and her parents have brought her to you for Counselling and for possible mental health services. You have seen Abena alone several times. During session, Abena tells you that she is sexually active and would like some help in learning how to avoid getting pregnant. In separate conversation with Abena’s parents, you get the impression that the parents are well aware of Abena’s sexual activity. 3. Should you help Abena obtain birth control pills, even though her socially conservative parents have told the social worker that they are against birth control? Yes [ ] No [ ] Why? 106 University of Ghana http://ugspace.ug.edu.gh ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 4. Is it proper for you to ignore the parents’ values? Yes [ ] No [ ] Why? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 5. Put differently, to whom are you accountable and why? ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… …………………………. Demographic Data 1. Gender: Male [ ] Female [ ] 107 University of Ghana http://ugspace.ug.edu.gh 2. Current Age: a. 20-25 years b. 26-30 years c. 31-35 years d. 36-40 years e. 41-45 years f. 46-50 years g. Above 50 years 3. Number of years of Practice: a. Below 2 years b. 2 to 4years c. More than 4years 4. Religion: a. Christian b. Muslim c. Traditionalist c. Other………………………. 5. Educational level: ………………………………………………………………………. 6. Which setting best describes your setting of practice a. Primarily rural b. Primarily urban c. Primarily suburban 7. Please indicate the level of background knowledge you have about ethical issues and ethical codes by checking as many of the following that apply to you by ticking Yes or No: STATEMENT YES NO I I had a general course in my training program that included some ethics II I had a specific course in my training program that focused on ethical and legal issues III I have attended conference or continuing education sessions within 108 University of Ghana http://ugspace.ug.edu.gh the last two years on ethical issues IV I have read articles and books on dealing with ethical issues V I have a copy of the ethical code readily accessible VI I refer to the counselling ethical code frequently VII I belong to a professional body/group of counsellors’ association 109 University of Ghana http://ugspace.ug.edu.gh APPENDIX IV: Introduction Letter 110 University of Ghana http://ugspace.ug.edu.gh APPENDIX V: Coding Framework Global Themes Emergent Themes Minor Themes Ethical Dilemmas Handling gifts from clients  Conceptualizing a gift  Receiving money  Receiving or rejecting  Receiving presents Competency Issues  Not well trained for the work they do  Being assigned duties which they are not trained for Multiple relationships  Dual Relationship  Third party intrusion  Manipulation by superiors  Influence from those who refer clients Negotiating rights and  Parental Rights privacy/confidentiality  Disclosure to third parties  Disclosure to partners Values  Religion values  Personal moral values Resolving Ethical Referral 111 University of Ghana http://ugspace.ug.edu.gh Dilemmas Consultation  Vertical consultation - Consulting Supervisors - Consulting senior colleagues  Peer Consultation - Colleague counsellors  Technology-mediated consultation - Contacting counsellors on WhatsApp group platform - Internet/Education Codes of conduct/rules and  Workplace rules regulation  Church rules  G.E.S. rules and regulations Personal Discretion  Cultural values  Personal moral values  Religious values (prayer, Word of God) Challenges in Cultural orientation resolving dilemmas Religion 112 University of Ghana http://ugspace.ug.edu.gh Lack of continuous training and education APPENDIX VI: Participants' knowledge of ethical codes and ethical training Description Yes No N (%) N (%) I had a general training program that included some 23 (85.2%) 4 (14.8%) ethics I had a specific course in my training that focused on 12 (44.4%) 15 (55.6%) ethical and legal issues I have attended conferences or continuing education 9 (33.3%) 18 (66.7%) sessions within the last two years I have read articles and books on dealing with ethical 18 (66.6%) 9 (33.3%) issues I have a copy of ethical codes readily accessible 7 (25.9%) 20 (74.1%) I refer to counselling ethical code frequently 6 (22.2%) 21 (77.8%) I belong to a professional body/group of counsellor’s 5 (18.5%) 22 (81.5%) association 113 University of Ghana http://ugspace.ug.edu.gh APPENDIX VII: Responses to Vignettes Presented to Participants Characteristics N % Vignette 1 Informing Client Yes 12 44.4 No 15 55.6 Why? Not the duty of the counselor 3 11.1 To maintain confidentiality 14 51.9 Prevention 6 22.2 Help client make decision 4 14.8 What will you do? Counselling 12 44.4 Refer 2 7.4 Encourage to disclose 7 25.9 Duty to warn 1 3.7 Vignette 2 Help Abena get control pills? Yes 12 44.4 No 15 55.6 Why? Advice Abena 4 14.8 It’s her right 5 18.5 114 University of Ghana http://ugspace.ug.edu.gh Prevention (STI’s and pregnancy) 3 11.1 Abena is a minor/under age 10 37.0 Because of personal values 1 3.7 Can have side effects on her in the future 2 7.4 Psychoeducation for Abena 2 7.4 Accountability Abena 6 22.2 The parents 9 33.3 Both Abena and her parents 4 14.8 Employee or supervisor 6 22.2 God 1 3.7 Why? Because Abena is the client 5 18.5 Abena is under age 8 29.6 Working with code of ethics 4 14.8 115