Development of Ethical Dilemma Distress Scale for Mental Health Practitioners (EDDS-MHP)

An ethical dilemma arises when a psychologist encounters a situation where it is unable to find an immediate resolution. In psychotherapy, this situation can act as an "ethical canary," similar to a canary in a mineshaft serving as an early sign of trouble. This study aimed to create a scale for measuring the ethical dilemma distress that is experienced by mental health practitioners when dealing with ethical dilemmas in their practice. The study was conducted in three phases: Phase I involved generating items, followed by Phase II, which encompassed constructing the scale, and in Phase III, the scale underwent reliability and validity analysis. Expert review was sought from 8 experts on 75 items developed in the item generation stage. The assumptions for factor analysis were satisfied as KMO and Bartlett's test of sphericity were significant and significant correlations were found within the items. An exploratory factor analysis (EFA) with principal component analysis (PCA) was conducted on 27 items, employing Promax rotation. EFA suggested the retention of four factors, which included ethical distress in clinical practice, ethical quandaries concerning professional boundaries, ethical disclosure dilemmas, and conflicts of values leading to distress. The Ethical Dilemma Distress Scale for Mental Health Practitioners (EDDS-MHP) was thus found to be a reliable and valid tool for the assessment of ethical dilemma distress among mental health practitioners. The instrument developed can be a crucial step in timely and accurately assessing ethical dilemma distress among mental health practitioners. It may also help to develop a tailored ethical training program as well as design interventions to inculcate ethical decision-making skills.

Mental health practitioners are frequently confronted with novel situations when providing care to individuals who present a broad spectrum of mental health problems (McDonald-Sardi et al., 2020). These situations often entail ethical dilemmas, where practitioners must navigate choices that encompass not only the traditional "right versus wrong" scenarios but also more nuanced "right versus right" decisions (Murphy et al., 2018). This dual challenge of addressing diverse problems while navigating complex ethical dilemmas underscores the multifaceted nature of their professional responsibilities (Gerger et al., 2020). Failing to resolve the dilemma raises concerns about the competency of the practitioner. These dilemmas can be complex and varied, and clear-cut solutions may not always be available to them (Lewandowski et al., 2021).When encountered with such ethical dilemmas, mental health practitioners use their experience to make ethical judgement and also look up to the American Psychological Association (APA)/American Counseling Association (ACA) guidelines which are based on scientific communities and theoretical framework (American Counseling Association, 2014; American Psychological Association, 2017). These code of conduct assist in efficiently resolving an ethical dilemma (Winterberg et al., 2021).

Pakistan is among the LMIC (Low- and middle-income countries) which is struggling with many issues including the lack of mental health resources (Hamdani et al., 2021). The World Health Organization's (2011) data reveals that in Pakistan, the psychiatrist-to-patient ratio is .19 psychiatrists per 100,000 individuals which is quite low. This statistic places Pakistan among the regions with the most limited access to psychiatric care in both the World Health Organization Eastern Mediterranean Region and globally. It is important to note that while psychiatric care data is available, a specific psychologist-to-patient ratio is not readily accessible due to the absence of a licensing body for psychologists in Pakistan. This situation underscores the need for comprehensive mental health services, as more than 90% of individuals with common mental health conditions in Pakistan do not receive any treatment, primarily due to the shortage of adequately trained mental health practitioners and limited mental health facilities (Sahar et al., 2022). This treatment gap highlights the urgency of addressing mental health disparities in the country (Javed et al., 2021). In such a challenging setting, mental health practitioners frequently run into ethical dilemmas as they try to deliver the best possible care while working with limited resources. These ethical dilemmas, which are caused on by a lack of mental health practitioners and inadequate access to care and low mental health literacy may have far-reaching effects on both practitioners and those who require mental health support (Munawar et al., 2020).

An ethical dilemma can be defined as a scenario where there is no straightforward answer or apparent course of action to follow (Colnerud, 1996). Rathert et al. (2016) stated that an ethical dilemma occurs when you have to choose between two or more solutions, and each of these options comes with moral concerns or consequences that do not align with strong moral principles. Ethical dilemmas that mental health practitioners encounter are often challenging. The terms 'ethical dilemma', 'ethical quandary', 'ethical conundrum' and 'ethical predicament' are interchangeably used in literature to address the widely known term ethical dilemma.

Most commonly occurring ethical dilemmas involved informed consent (Morrison & Sigman, 2021; Trachsel & Andorno, 2019; Trachsel & Holtforth, 2019), confidentiality (Conlon et al., 2019; Hem et al., 2023; Jackson et al., 2014), competency (Brabender, 2019; Gerger et al., 2020; Murphy et al., 2018), receiving gifts (Eniola, 2018; Martínez-Taboas et al., 2014), payment and fees (Brabender, 2019; Różyńska, 2022; Wilde, 2021; Wolfson, 2019), dual relationship (Brabender, 2019; Ekberg et al., 2016; Ringstad, 2008; Wu, 2022), conflict of interest (Amaglo, 2022; Cristea & Ioannidis, 2018; Dasti et al., 2020; Jain et al., 2017; Prytz et al., 2019), boundary issues and patient autonomy (Ascherman & Rubin, 2008).

An ethical dilemma in the area of psychotherapy may function as an ‘ethical canary,’ just like a canary in a mineshaft can serve as an early warning sign of danger (Somerville, 2001). In a similar way, an ethical dilemma may point to a problem inside a group, organization, culture or society. Professionals may endure unrecognized and unaddressed ethical or moral distress that result in psychological, interpersonal, and organizational problems if they lack a way to assess ethical dilemma distress that may further lead to fatigue or burnout (Ajoudani et al., 2018; Fumis et al., 2017; Kok et al., 2021).

Moral distress is a widely studied concept in the health care sector. The idea of moral distress has a long history in philosophical literature, and Jameton's more modern version was first presented in 1984 (Jameton, 2013). The term ‘moral distress,’ as first used by Jameton (1985), refers to a situation in which a person is aware of the ethically appropriate course of action to pursue but finds it extremely challenging to act on because of organizational limitations. Moral distress has been thoroughly investigated in a range of healthcare contexts, including end-of-life care (Nicolini et al., 2020) and long-term care (Metselaar & Widdershoven, 2019; Sikora et al., 2019).

In professional contexts, mental health practitioners make ethical decisions while managing contradictions in their values (Bonnie & Zelle, 2019). The practitioner might occasionally find himself in a position where he is unable to determine which course of action is appropriate. This may result from a clash between the practitioner's moral principles and the ethical standards he is required to uphold (Elzamzamy & Keshavarzi, 2019). These conflicts result in ethical dilemmas, and when these dilemmas are not resolved in an effective and efficient manner, it results in ethical breaches, which is contradictory to the fundamental tenets of a mental health profession (Nezu, 2020).

An ethical dilemma always involves a decision-making process for the mental health practitioner while they are thinking about how to resolve the conflicts in different circumstances (Barnett, 2019). A study centered on the examination of ethical dilemmas encountered by psychologists in both Sweden and South Africa encompassed a sample of 295 psychologists from Sweden and 312 psychologists from South Africa. The results revealed that confidentiality emerged as the most common ethical dilemma encountered by psychologists, accounting for 18% of the cases. It was closely followed by challenges related to assessment (16%) and questionable or harmful therapeutic practices (16%). Ethical dilemmas arising from blurred, dual, or contentious relationships accounted for 13% of the cases, while concerns about the behavior of colleagues constituted 10% (Lindén & Rådeström, 2008). Miscellaneous ethical issues, forensic psychology, school psychology, providing assistance to financially struggling individuals, industrial-organizational psychology, research ethics, treatment records, payment sources, plans, settings, and methods, as well as competence, each represented a smaller percentage of the reported ethical dilemmas (ranging from 5% to 2%) (Johnson & Federman, 2014; Sahar et al., 2022).

Muslim psychologists may face ethical dilemmas that arise from conflicts between their professional ethical codes of conduct and their religious mandates. Cultural and religious beliefs can impact ethical decision-making for Muslim psychologists. These conflicts may arise when dealing with clients who exhibit little to no devotion to fundamental Islamic rituals and precepts, as well as when the mental health practitioner have to deal with situations concerning induced miscarriage, gender identity, infidelity, drug and alcohol abuse cases (Elzamzamy & Keshavarzi, 2019), adultery (Bakri & Mustaffa, 2013; Dasti et al., 2020) LGBTQ cases (Elzamzamy & Keshavarzi, 2019; Mahmood & Abdallah, 2022).

In Pakistan one study highlighted the ethical and moral dilemmas faced by mental health practitioners while working with clients with cohabitation out of wedlock, extra marital affairs and homosexuality. Furthermore, a complex case was presented where a woman seeks therapy because she has a daughter from an extramarital affair, a hidden fact from her husband. Now, as she enrolls her child in school, her extra marital partner from the affair wants his last name on the school documents resulting in a stressful situation for her. This case resulted in an ethical dilemma for the mental health practitioner (Dasti et al., 2020). Such ethical dilemmas arise when personal values conflict with the professional values of mental health practitioners, leading to both ethical dilemma and distress (Mahmood & Abdallah, 2022).

The literature review revealed that there is a dearth of literature found on ethical dilemmas faced by mental health practitioners in Pakistan. Previous studies by Lindén & Rådeström (2008), and Ringstad (2008) explored the phenomenon qualitatively and some old researches only added a meager quantitative aspect by reporting the frequencies of commonly occurring ethical dilemmas because no scale existed to quantify the concept of ethical dilemma distress. The existing scales were mainly developed for assessing the moral distress in the field of nursing and healthcare profession and ethical issues and the distress caused by ethical dilemmas faced due to cultural differences is ignored. In the field of mental health practice an inventory was found but it focused on assessing the burnout level in counselors while neglecting the distress caused due to encountering ethical dilemmas in the field of psychotherapy (Lee et al., 2007). However, the identified gap suggested that there is no indigenous scale available to measure the ethical dilemma distress faced by mental health practitioners during their practice in Pakistani context. The present study focused on the development of an Ethical Dilemma Distress Scale for Mental Health Practitioners (EDDS-MHP). The ethical dilemmas calibrated through the scale developed in the current study on Ethical Dilemma Distress Scale faced by Mental Health Practitioners (EDDS-MHP) would help monitory body to address needs of the mental health profession in Pakistan and also highlight the areas require further professional ethical training.

Objectives

The present study aimed to achieve the following objectives:

• To develop an instrument Ethical Dilemma Distress Scale faced by Mental Health Practitioners (EDDS-MHP).
• To establish the psychometric properties of the Ethical Dilemma Distress Scale faced by Mental Health Practitioners.

Method

The Ethical Dilemma Distress Scale for Mental Health Practitioners (EDDS-MHP) was developed through a research process consisting of a qualitative investigation and a quantitative analysis. The current study was conducted into three distinct phases.

Phase I: Item Generation

Conceptualizing the Construct

To develop a comprehensive understanding of the construct extensive literature was reviewed. Data collection involved a thorough search of online databases, where the concept of an ethical dilemma in psychotherapy was explored and examined across a variety of sources, including publications, journal articles, and conference papers. The comprehensive literature review played a vital role in defining and conceptualizing the concept of ethical dilemma.

Generating the Item Pool

For item pool generation multiple approaches were utilized including extensive literature review and thematic analysis of secondary data. The secondary data based on in-depth interviews of 8 clinical psychologists was used for the purpose of extracting themes for item generation. The already collected data in the form of interviews was re-evaluated to identify the recurring themes and a pool of 75 items was generated.

Phase II: Finalization of Scale

Expert Review

Following the generation of a set of items through thematic analysis, the item pool underwent evaluation by a panel of eight experts. This panel consisted of psychometric experts, a language specialist and clinical psychologists holding PhD degrees and possessing a minimum of five years of professional experience in the field. To evaluate the content validity of the scale, the experts were requested to rate each item according to its relevance, clarity and accuracy, utilizing a 4-point scale (from 1-4) and CVI (Content Validity Index) was then calculated for each item. Items that received a high CVI score (≥ 0.8) were retained in the final selection. This process led to the removal of many items having a low CVI score in order to enhance the clarity, relevance and accuracy of the item pool.

Construction of Scale

A set of 36 items in English language was then transformed into a scale format, utilizing a polytomous rating system. This system employed a 5-point Likert scale from 1 indicating ‘strongly disagree’ to 5 indicating ‘strongly agree.’ The scale's total score ranged from a minimum of 40 to a maximum of 200. A higher score on the scale reflected a higher level of ethical dilemma and distress encountered by mental health practitioners.

Try-Out Phase

During the trial phase, a group of 30 mental health practitioners were selected through purposive sampling to assess the scale. The purpose of this pilot testing was to evaluate both the content and face validity of the construct. Additionally, it aimed to ascertain the suitability of the language used in the scale and whether the participants encountered any challenges in understanding the scale items. It was ensured that all participants provided responses to every item on the scale. The participants took 10 to 15 minutes on average to answer the scale items.          

Phase III: Empirical Evaluation through Exploratory Factor Analysis (EFA) and Reliability Testing

To assess construct validity, Exploratory Factor Analysis (EFA) was carried out employing Principal Component Analysis (PCA) and promax rotation. The EFA was used as a method for data reduction technique. Cronbach's alpha reliability analysis was carried out to determine the reliability of EDDS-MHP. Additionally, face, content and convergent validity was assessed to ensure if EDDS-MHP was a valid tool.

Measures

For data collection, demographic questions, EDDS-MHP and the Counselor's Burnout Inventory (CBI) were used.

Demographic Information

The demographic questions were formulated following a review of existing literature. They encompassed questions about age, gender, the participant's workplace institution (public/private), their highest attained degree, and any coursework related to ethics.

Ethical Dilemma Distress Scale for Mental Health Practitioner (EDDS-MHP)

Ethical Dilemma Distress Scale for Mental Health Practitioner (EDDS-MHP) was developed in the present study to assess the level of ethical dilemma distress in mental health practitioners. It had 36 items at the stage of data collection for Exploratory Factor Analysis (EFA). EDDS-MHP had a scoring on 5 point Likert scale 1 = Strongly Disagree, 2 = Strongly disagree, 3 = Neither agree nor disagree, 4 = Disagree, 5 = Strongly agree.

Counselor's Burnout Inventory (CBI)

The Counselor's Burnout Inventory (CBI) is a 20-item self-report scale and was used to assess counselor burnout levels. This scale comprises five sub-scales: Exhaustion, Negative Work Environment, Devaluing Clients, Incompetence, and Deterioration in Personal Life. The CBI's scoring range spans from 20 to 100. Respondents provided their answers using a 5-point Likert scale: 1 for "never true" 2 for "rarely true" 3 for "sometimes true" 4 for "often true" and 5 for "always true." The CBI demonstrated high reliability, with a score of 0.88, while the internal reliability of its sub-scales ranged from .80 to .84 (Lee et al., 2007).

Sample

The Ethical Dilemma Distress Scale for Mental Health Practitioners (EDDS-MHP) was used to collect data from mental health practitioners with prior informed consent and a thorough explanation of the study's objectives. In the recruitment process approximately 500 individuals were out reached through various means, including email, social media platforms, and in-person interactions. Out of the initial 500 contacts, 275 individuals willingly agreed to participate, while the remaining either declined or did not respond. Subsequently, 41 forms were excluded from the study as they did not comply with the inclusion criteria, leaving the remaining 234 responses to be included in the final analysis resulting in the response rate of 55%. A sample comprising 234 mental health practitioners, each having a minimum of 2 years of practical experience, was included in this study. The selection criteria for participants included the ability to understand the English language and practicing psychotherapy. The data collection process encompassed institutes from both the public and private sectors. The initial screening leads to the removal of outliers and missing data (responses with incomplete or ineligible data), a final sample of 221 participants was retained.

The participants age ranges from 27 to 62 years (M = 30.82, SD = 5.73). Majority of the participants were male (90.9%), practicing in a private sector (54.3%), had a master's degree (84.2%) and had covered ethics course in university (82.8%).

Table 1: Frequencies and Percentages of Demographic Characteristics of Sample (N = 221)

Procedure

The research was conducted with due permission granted by the Research Review Committee at the University of Central Punjab in Lahore, Pakistan. Permission for the use of secondary data, consisted of in-depth interviews conducted with clinical psychologists, was obtained from the respective authors. To gain familiarity with the data, multiple readings of the interviews were carried out, and themes were extracted through a process of thematic analysis. An initial item pool of 75 items was generated and subjected to expert review. Expert opinion was sought, leading to the selection of 36 items after a thorough screening process for relevance, clarity and accuracy. Furthermore, the language expert reviewed the selected items to rectify any grammatical errors and ensure comprehensiveness. A pilot study was conducted to ensure clarity and comprehensiveness. Recruitment for the pilot study and exploratory factor analysis (EFA) was facilitated through social media platforms, email communication, and the creation of a website named "Ethics in Psychology". The data was entered into SPSS and after looking into the assumptions of the factor analysis, exploratory factor analysis (EFA) was conducted and results were interpreted.

Results

The current study focused on the development of an ethical dilemma distress scale for mental health practitioners. Initially, a reliability analysis was conducted to assess the corrected item correlation. Subsequently, for construct validity, factor analysis was performed following an assessment of its assumptions.

Assumptions of EFA

Normality tests were conducted, including the Kolmogorov-Smirnov test and the Shapiro-Wilk test to assess the assumption of normality. The results yielded p-values greater than 0.05 (p > .05), indicating that the data followed a normal distribution. This finding supports the suitability of the data for exploratory factor analysis (EFA) (Gupta et al., 2019). The Kaiser-Meyer-Olkin (KMO) value, which measures the adequacy of the data for factor analysis, was found to be .851, indicating a high level of adequacy (Hill, 2011). Additionally, Bartlett's test of sphericity was statistically significant (χ2 (378) = 1885.74, p < .000) (Wagner, 2020; Pallant, 2010; Field, 2015). The correlation matrix revealed that most items exhibited correlations above 0.3 and below 0.9 (Tabachnick & Fidell, 2001).

A reliability assessment was carried out to evaluate the corrected item-total correlations. The results indicated that eight items (items no. 5, 8, 9, 10, 11, 12, 13, and 19) displayed corrected item-total correlations below the established threshold of .30 (Williams, 2015), leading to the exclusion of these items from the scale before conducting EFA.

Table 2: Corrected Item Total Correlation of Items of EDDS-MHP

Exploratory Factor Analysis

The study involved exploring the underlying structure of a 28-item EDDS-MHP. To achieve this, Exploratory Factor Analysis (EFA) was employed, specifically employing the Principal Component Analysis (PCA) technique. Initially, six factors were identified. Communalities were assessed, and all variables with communalities exceeding 0.3 were retained (Pallant, 2010). However, one variable (item 26) was excluded from the analysis due to its commonality value falling below the established threshold of .30. Horn's Parallel Analysis was used to determine the number of factors to be retained. For this purpose, the MonteCarlo PCA for Parallel Analysis software was used (Watkins, 2006). The dataset under consideration encompassed 27 items representing variables and 221 subjects serving as participants. The software executed a total of 100 replications (Pallant, 2010). To determine the number of factors to retain, a comparison was done which involved a systematic examination of the eigenvalues resulting from the random dataset against those derived from factor analysis conducted within the SPSS software. After conducting a comparison between the actual eigenvalues derived from factor analysis and the criterion values obtained through parallel analysis factors, it was determined that the first four factors should be retained for further analysis. An exploratory factor analysis was rerun using a statistical rotation method called promax (oblique) rotation. This time the factors were fixed to four in the extraction process (Pallant, 2010).

Table 3: Exploratory Factor Analysis with Promax Rotation

Note. Principal component analysis was used for the extraction process, along with an oblique (promax) rotation. Factor loadings above.30 are in bold. All communality (h2) values are above.30.

The exploratory factor analysis (EFA) identified four factors, each named according to the content of the included items. Most of the items were linked to the initial two factors, while the rest of the items loaded onto the third and fourth factors. None of the factor contained fewer than four items. In accordance with Hinkin's (1998) recommendation, the scale's ultimate composition should ideally consist of four to six items for each construct domain.

Factor 1 (Ethical Distress in Clinical Practice)

The first factor named as Ethical Distress in Clinical Practice which pertains to the distress experienced by mental health professionals when they confront ethically challenging or conflicting situations within clinical settings. This factor comprises eleven items, specifically items 20, 23, 7, 36, 38, 32, 24, 27, 29, 31, and 25. It accounts for 25.68% of the variance, with factor loadings ranging from .47 to .80.

Factor 2 (Ethical Dilemmas and Professional Boundaries)

The second factor, which pertains to Ethical Dilemmas and Professional Boundaries, encompassed a variety of complex scenarios commonly faced by mental health professionals in their practice. This factor consisted of eight items including 20, 22, 19, 17, 28, 16, 15, and 34. It accounted for 7.62% of the overall variance, with factor loadings ranging from .34 to .65.

Factor 3 (Ethical Disclosure Dilemma)

The third factor was named as Confidentiality Concerns and Ethical Dilemmas in Family Involvement. It comprised four items (3, 4, 8, 2) with factor loadings between .59 to .75, collectively explaining 6.03% of the variance.

Factor 4 (Value Conflicts and Distress)

The fourth factor was named as "Ethical Conflict and Personal Values." It encompasses scenarios in which mental health practitioners face dilemmas arising from conflicts between their personal values and their professional duties. Factor 4 comprises four specific items (35, 5, 37, and 40) with factor loadings ranging from .46 to .72, collectively explaining 5.48% of the variance.

Table 4: Factors, Labels, Items and Total Number of Items in Each Factor

The final version of the Ethical dilemma distress scale for mental health practitioners (EDDS-MHP) had 27 items along with four dimensions including ethical distress in clinical practice, ethical dilemmas and professional boundaries, ethical disclosure dilemma, value conflicts and distress. Higher scores indicate a greater level of ethical dilemma distress among mental health practitioners. No reverse items were present in the scale.

Table 5: Psychometric Statistics of Study Variables (N = 221)

Note. EDCP= Ethical Distress in Clinical Practice, EDPB = Ethical Dilemmas and Professional Boundaries, EDD = Ethical Disclosure Dilemma, VCD = Value Conflicts and Distress, (EDDS-MHP = Ethical Dilemma Distress Scale for Mental Health Practitioners), CBI = Counselor's Burnout Scale.

The findings reported in Table 5 demonstrated the good to excellent reliability of the scale and its subscales, as well as the theoretical consistency of the scale's items. EDDS-MHP demonstrated a Cronbach's alpha value of .88 and for its subscales alpha value ranges from .70 to .82.

Convergent Validity

Convergent validity of EDDS-MHP was assessed using counselor's burnout inventory. The results suggest that the scale developed in the current study named Ethical Dilemma Distress Scale for Mental Health Practitioner (EDDS-MHP) is reliable, as indicated by Cronbach’s alpha value, and valid, as it aligns well with the counselor's burnout scale which is demonstrated by a significant positive relationship between EDDS-MHP and CBI CBI (. 30, p < .001) as evidence of convergent validity.

Discussion

The main objective of the study was to develop the ethical dilemma distress scale for mental health practitioners (EDDS-MHP). It was then validated through assessing psychometric properties including Cronbach's alpha, split half reliability along with convergent validity.

In the first phase of the study an extensive literature review was done on the phenomenon of ethical dilemma and distress which revealed that there were many scales developed on moral distress (Corley et al., 2001) and they were also adapted over the period of time but all of them were specifically developed for the healthcare professionals. However, a sound scale lacks in the field of mental health yet ethical dilemmas are frequently reported in mental health practice and result in distress among practitioners serving in the mental health field. Corley et al. (2001) stated that it is concerning that the mental health profession literature doesn't pay much attention to moral distress in quantitative aspect, considering how harmful it can be.

Hence, using previously developed instruments on moral distress which were developed specifically for the nursing and healthcare profession and modifying them for mental health profession settings would not be compatible since they do not originally capture the essence of ethical dilemmas and there exist differences in the ethical dilemmas, the practitioners encounter due to different professional settings. The need for the new scale to measure ethical dilemma distress was identified in the literature. The lack of instrument in measuring ethical dilemma distress may neglect the dilemmas, the mental health practitioners face in their profession is augmenting its negative effects on their personal, professional and organizational life. The current study aimed to develop a scale to measure ethical dilemma distress for mental health practitioners (EDDS-MHP) to fill this gap in the literature and to address ethical dilemma distress quantitatively.

In the second phase of the study the Exploratory Factor Analysis (EFA) employing Principal Component Analysis (PCA) was conducted. PCA is being widely used in the process of scale development (Mubashir et al., 2023; Zaman & Naqvi, 2022; Naz et al., 2022). The exploratory factor analysis indicated the retention of four factors which were named based on the content of the items as Ethical distress in clinical practice, Ethical dilemmas and professional boundaries, Ethical disclosure dilemma, Value conflicts and distress.

The first retained factor was labeled as Ethical Distress in Clinical Practice. The items retained under this factor included lack of adherence to APA guidelines, absence of regulatory body, witnessing malpractice in field, lack of culture sensitive guidelines, unnecessary organizational prerequisites, ethically conflicting incidents at workplace, pressure to complete paperwork, organizational requirements for unnecessary prerequisites, conflicting ethical rules, ethical dilemma leads to distress. This factor contained eleven items measuring the distress that resulted due to the ethical dilemma confronted in the clinical practice. This factor mainly covered the items based on the dilemmas resulting due to organizational pre-requisites, due to less rigorous monitoring by regulatory body and culturally adapted ethical principles guidelines. Most of the dilemmas explored in the study were due to the structural issues in the mental health setup. Pakistan lacks an efficient central body for the licensing (Fatima & Ilyas, 2023a; Sahar et al., 2022). Actually the central body exists but it lacks the ability to keep a check and balance of the mental health services in Pakistan. It is a matter of concern as there is a lack of culturally sensitive protocols and training and depend on measures and therapies developed in the Western countries which lack our cultural element (Fatima & Ilyas, 2023b). "As a mental health practitioner, when faced with an ethical dilemma, I experience distress."Here the distress is referring to the moral distress or moral injury. This phenomenon has been widely studied in the healthcare field especially in nursing but the phenomenon is under addressed in the field of mental health practice. Corley et al. (2001) highlighted the significance of moral distress in the field of counseling. Factor 1 had the strongest variance compared to other factors.

The second factor was labeled as Ethical Dilemmas and Professional Boundaries. This factor retained eight items covering the content of ethical dilemmas faced during delivering religion based therapies, societal pressure for dual relationships, confidentiality vs beneficence in family therapy, diagnosing a young client, compelled to provide therapy despite lacking required competence, stigmatization regarding peer consultation. Pakistan having a collectivistic culture often expects from the mental health professionals in their family to provide them the therapeutic or counseling services. They often refer to the psychologist as 'ghar ka doctor' and wonder why they need to go out to seek mental health services when they have their very own doctor in the family. Dual relationship in therapy is considered to affect the efficacy of the treatment (Deng et al., 2015). In Pakistan, stigmatization still exists in the 21st century regarding mental illnesses (Ahmad & Koncsol, 2022). A clinical diagnosis which halts the future endeavors of a young client, it may subject the client to societal stigmatization and discrimination (Borenstein, 2020).

The third factor retained was labeled as Ethical Disclosure Dilemma. The items that were retained in this factor mainly cover the dilemma related to confidentiality and disclosure concerns. APA has provided clear guidelines regarding the maintenance of the confidentiality and have discussed the conditions in which the confidentiality can be breached for the welfare of the client. Psychologists frequently face challenging decisions regarding whether to maintain or breach confidentiality, particularly in sensitive cases involving clients with suicidal ideation, incest abuse, homicidal tendencies, and risky behavior. Psychologists frequently face challenging decisions regarding whether to maintain or breach confidentiality, particularly in sensitive cases involving clients with suicidal ideation, incest abuse, homicidal tendencies, and risky behavior. Mental health practitioners frequently face challenging decisions regarding whether to maintain or breach confidentiality, particularly in sensitive cases involving clients with suicidal ideation, incest abuse, homicidal tendencies, and risky behavior (Bhasin et al., 2022). At times sharing information with parents even leads to negative effects due to over-involvement of the parents as families in Pakistan are considered to have high levels of expressed emotions (Gerger et al., 2020).

The fourth factor retained was labeled as Value Conflicts and Distress. This factor mainly contains the items related to dilemmas that result due to the conflict in values of the mental health practitioner and client. In many societies religion acts as culture and shapes the norms and perspective of the people of that culture (Rosser, 2018). Value conflicts may arise for mental health practitioners when they work with the clients who hold beliefs that are contrary to the practitioner's own value system i.e. working with homosexual clients, clients with substance use disorder, clients with extra marital affairs and clients with gender reassignment surgery (Dasti et al., 2020; Elzamzamy & Keshavarzi, 2019). In the third phase the psychometric properties were assessed using Cronbach's alpha and convergent validity which revealed that EDDS-MHP is a reliable and valid tool.

Limitations and Future Recommendations

The current research had certain limitations. Face, content and convergent validity was established using different scales but due to time constraints, the study was unable to validate the instrument by using a Confirmatory Factor Analysis (CFA) on a different sample. This may compromise the tool's ability to be completely validated. The instrument may be further validated by employing CFA in order to guarantee accuracy and effectiveness. The secondary data (in-depth interviews) were solely conducted with female clinical psychologists so ethical dilemmas faced by male mental health practitioners may have overlooked. The interviews also did not include the trainee psychologists. So future researches may discover ethical dilemmas faced by trainees and male mental health practitioners. Additionally, the study focused on the distress experienced by mental health professionals as a result of ethical dilemma, but it did not explore the concept in-depth on how this distress caused by ethical dilemma affected them over the long term or how it affected their professional practice. Identifying the long-term effects can provide a holistic picture of the ethical dilemmas in the field of mental health practice. The psychometric tool developed in the present study was a self-report measure used in the assessment of ethical dilemma distress. Due to the self-report nature of the scale it can be sensitive to practitioner subjectivity and perception.

Implications

This study looked at ethical dilemmas experienced by mental health practitioners in their practice. It's the first time this phenomenon has been explored quantitatively in the context of mental health practice, so the results are quite significant. The development of a scale to assess ethical dilemma distress among mental health practitioners is an essential step to understand the prevalence and impact of these dilemmas. Assessing the phenomenon may help detect and prevent the negative consequences like fatigue and burnout and many other factors in mental health practitioners, which are currently unrecognized but can have serious negative repercussions. However, more research is needed in this field as this study is the one of its kind and is the first step in measuring ethical dilemmas and distress in mental health practice. This study highlights the need for further investigation. The instrument developed can be a crucial step in accurately assessing and preventing ethical dilemma distress for mental health practitioners. It may also help in developing a tailored ethical training program as well as design interventions to ensure ethical decision making skills in the mental health practitioner.

Conclusion

The development of a EDDS-MHP followed a systematic process to assess the ethical dilemmas and distress levels encountered by mental health practitioners in their professional practice. The initial stages involved conceptualizing the construct by drawing upon existing literature and secondary data based on in-depth interviews conducted with clinical psychologists. Subsequently, a comprehensive pool of items was generated, and expert opinions were sought to refine the scale. To ensure the appropriateness of the factor analysis, several assumptions were rigorously met, including having an adequate sample size and conducting both the Kaiser-Meyer-Olkin (KMO) test and Bartlett's test of Sphericity. Following these preliminary steps, factor analysis was executed. Parallel analysis was employed to determine the number of factors to be retained in the scale. Ultimately, the items were allocated to four distinct factors based on their factor loadings, utilizing promax rotation. These four factors were labelled as follows: Ethical Distress in Clinical Practice, Ethical Dilemmas and Professional Boundaries, Ethical Disclosure Dilemma & Value Conflicts, and Distress. Reliability and Validity of the scale was established by conducting further analysis. It was concluded that Ethical Dilemma Distress Scale for Mental Health Practitioners (EDDS-MHP) is a reliable and valid scale.

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Received 25 October January 2023

Revision received 10 July 2024