volume 24 number 2 2019 european psycholog st monografico efpa 2019… · volume 24 / number 2 /...

Volume 24 / Number 2 / 2019

European Psychologist

Official Organ of the European Federation of Psychologists’ Associations (EFPA)

Editor-in-ChiefPeter Frensch

Managing EditorKristen Lavallee

Associate EditorsUlrike EhlertAlexandra FreundKatariina Salmela-Aro

European PsychologistVolum

e 24 / Num

ber 2 / 2019

Special Issue Human Rights and Psychology Guest Editors Kerstin Söderström, Polli Hagenaars, Tony Wainwright, and Ulrich Wagner

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www.hogrefe.com

Xenia Chryssochoou / Martyn Barrett (Editors)

Political and Civic Engagement in Youth Zeitschrift für Psychologie, Vol. 225/42017, iv + 76 pp., large format US $49.00 / € 34.95 ISBN 978-0-88937-545-1

Antithetical patterns of youth politi-cal and civic engagement have been observed in recent years. Many young people are uninterested in politics and political participation, whereas others are highly engaged political actors. The patterns of their engage-ment and participation are changing and new forms of activism have ap-peared with the increasing use of new technologies and social media. With the social fabric becoming en-dangered in certain areas by political

and economic changes, it is import-ant to understand young people’s po-sitions towards politics and the factors that lead some youngsters to be politically active and others not. In this collection of studies, social psy-chology partners with developmental psychology in order to focus on young people’s political and civic engage-ment and investigate how young peo-ple politicize and what factors lead to their political actions.

How young people politicize and what factors lead to their political actionsContents and topics include

• Civic and Political Engagement in Youth: Findings and Prospects

• Reducing Adolescents’ Approval of Political Violence: The Social Influence of Universalistic and Immigrant-Friendly Peers

• Young People’s Engagement With the European Union: The Importance of Visions and Worries for the Future of Europe

• Becoming Politicized: Political Socialization and Participation of Young People in the December 2008 Revolt in Greece

• Protesting Youth: Collective and Connective Action Participation Compared

• The Chicken or Egg Question of Adolescents’ Political Involvement: Longitudinal Analysis of the Relation Between Young People’s Political Participation, Political Efficacy, and Interest in Politics

• Conservative Ideological Shift Among Adolescents in Response to System Threat

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EuropeanPsychologist

Volume 24/ Number 2 /2019

Official Organ of the European Federation of Psychologists Associations (EFPA)

Special IssueHuman Rights and Psychology

Guest EditorsKerstin Soderstrom, Polli Hagenaars,Tony Wainwright, and Ulrich Wagner

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Editor-in-Chief Peter A. Frensch, Institute of Psychology, Humboldt-University of Berlin, Rudower Chaussee 18, 12489 Berlin, Germany,Tel. +49 30 2093 4922, Fax +49 30 2093 4910, [email protected]

Managing Editor Kristen Lavallee, [email protected]

Founding Editor / Past Editor-in-Chief Kurt Pawlik, Hamburg, Germany (Founding Editor) / Alexander Grob, Basel, Switzerland (Past Editor-in-Chief)

Associate Editors Ulrike Ehlert, Institute of Psychology, University of Zurich, Binzmuhlestrasse 14 / Box 26, 8050 Zurich, Switzerland,Tel. +41 44 635 7350, [email protected] Freund, Institute of Psychology, University of Zurich, Binzmuhlestrasse 14 / Box 26, 8050 Zurich,Switzerland, Tel. +41 44 635 7200, [email protected] Salmela-Aro, University of Helsinki, P.O. Box 4, 00014 University of Helsinki, Finland, Tel. +358 50 415-5283,[email protected]

EFPA News and Views Editor Eleni Karayianni, Department of Psychology, University of Cyprus, P.O. Box 20537, Nicosia, Cyprus,Tel. +357 2289 2022, Fax +357 2289 5075, [email protected]

Publisher Hogrefe Publishing, Merkelstr. 3, 37085 Gottingen, Germany,Tel. +49 551 999 50 0, Fax +49 551 999 50 425, [email protected], http://www.hogrefe.comNorth America: Hogrefe Publishing, 7 Bulfinch Place, 2nd floor, Boston, MA 02114, USA.Tel. (866) 823 4726, Fax (617) 354 6875, [email protected]

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ISSN ISSN-L 1016-9040, ISSN-Print 1016-9040, ISSN-Online 1878-531X

Copyright Information � 2019 Hogrefe Publishing. This journal as well as the individual contributions and illustrations contained within it areprotected under international copyright law. No part of this publication may be reproduced, stored in a retrievalsystem, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recordingor otherwise, without prior written permission from the publisher. All rights, including translation rights, reserved.

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Abstracting Services Abstracted/indexed in Current Contents�/Social and Behavioral Sciences�, Social Sciences Citation Index�,ISI Alerting Services�, Social SciSearch�, PsycINFO�, PSYNDEX, ERIH, and Scopus. 2017 Impact Factor 2.174, 5-yearImpact Factor 3.867, Journal Citation Reports (Clarivate Analytics, 2018)

Editorial Board Louise Arseneault, UKDermot Barnes-Holmes, BelgiumClaudi Bockting, The NetherlandsGisela Bohm, NorwayMark G. Borg, MaltaSerge Bredart, BelgiumCatherine Bungener, FranceCesare Cornoldi, ItalyIstvan Czigler, HungaryGery d’Ydewalle, BelgiumIris Engelhard, The NetherlandsMichael Eysenck, UKRocio Fernandez-Ballesteros, SpainMagne Arve Flaten, NorwayMarta Fulop, HungaryDanute Gailiene, Lithuania

John Gruzelier, UKSami Gulgoz, TurkeyVera Hoorens, BelgiumPaul Jimenez, AustriaRemo Job, ItalyKatja Kokko, FinlandGunter Krampen, GermanyAnton Kuhberger, AustriaTodd Lubart, FranceIngrid Lunt, UKPetr Macek, Czech RepublicMike Martin, SwitzerlandLucia Mason, ItalyTeresa McIntyre, USAJudi Mesman, The NetherlandsSusana Padeliadu, Greece

Ståle Pallesen, NorwayGeorgia Panayiotou, CyprusSabina Pauen, GermanyMarco Perugini, ItalyMartin Pinquart, GermanyJose M. Prieto, SpainJorg Rieskamp, SwitzerlandSandro Rubichi, ItalyIngrid Schoon, UKRainer Silbereisen, GermanyKatya Stoycheva, BulgariaJan Strelau, PolandTiia Tulviste, EstoniaJacques Vauclair, FranceDieter Wolke, UKRita Zukauskiene, Lithuania

The Editorial Board of the European Psychologist comprises scientists chosen by the Editor-in-Chief fromrecommendations sent by the member association of EFPA and other related professional associations, as well asindividual experts from particular fields. The associations contributing to the current editorial board are: BerufsverbandOsterreichischer Psychologen/innen; The Belgian Association for Psychological Sciences; Cyprus Psychologists’

Association; Unie Psychologickych Asociaci, Czech Republic; Dansk Psykologforening; Union of Estonian Psychologists;Finnish Psychological Association; Federation Française des Psychologues et de Psychologie; Societe Française dePsychologie; Berufsverband Deutscher Psychologinnen und Psychologen; Magyar Pszichologiai Tarsasag;Psychological Society of Ireland; Associazione Italiana di Pscicologia; Lithuanian Psychological Association; SocieteLuxembourgeoise de Psychologie; Malta Chamber of Psychologists; Norsk Psykologforening; OsterreichischeGesellschaft fur Psychologie; Colegio Oficial de Psicologos; Swiss Psychological Society; Turkish PsychologicalAssociation; European Association for Research on Learning and Instruction; European Association of ExperimentalSocial Psychology; European Association of Personality Psychology; European Association of PsychologicalAssessment; European Health Psychology Society.

European Psychologist (2019), 24(2) � 2019 Hogrefe Publishing

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Contents

Editorial Human Rights Matter to Psychology - Psychology Matters to HumanRights

99

Kerstin Soderstrom, Polli Hagenaars, Tony Wainwright,and Ulrich Wagner

Original Articles and Reviews The Human Rights Committee at the Norwegian PsychologicalAssociation: 20 Years of Work and Future Challenges

102

Nora Sveaass

Human Rights-Based Approach to Applied Psychology 113

Nimisha Patel

Taking Ethics Seriously: Toward Comprehensive Education in Ethicsand Human Rights for Psychologists

125

Du�ska Franeta

Critical Reflexivity and Intersectionality in Human Rights: TowardRelational and Process-Based Conceptualizations and Practicesin Psychology

136

Marco Gemignani, and Yolanda Hernandez-Albujar

The Human Right to Make One’s Own Choices - Implicationsfor Supported Decision-Making in Persons With Dementia:A Systematic Review

146

Theresa S. Wied, Maren Knebel, Valentina A. Tesky, and Julia Haberstroh

Human Rights, Dementia, and Identity 159Sarah Butchard, and Peter Kinderman

Children’s Rights and Educational Psychology 169Johanna Fee Ziemes and Eveline Gutzwiller-Helfenfinger

A Human Rights and Ethics Crisis Facing the World’s LargestOrganization of Psychologists: Accepting Responsibility, UnderstandingCauses, Implementing Solutions

180

Kenneth S. Pope

Psychology and Its Response to Major Human Rights Abuses:The Case of Australian Immigration Detention

195

Ryan Essex

� 2019 Hogrefe Publishing European Psychologist (2019), 24(2)

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Commentaries US Attitudes Toward Torture: Commentary on Kenneth S. Pope, 2019(https://10.1027/1016-9040/a000341)

204

David J. Armor and Jeremy D. Mayer

Has US Support for Torture Continued to Increase? Reply toDavid J. Armor and Jeremy D. Mayer, 2019

206

Kenneth S. Pope

EFPA News and Views Meeting Calendar 207

European Psychologist (2019), 24(2) � 2019 Hogrefe Publishing

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EditorialHuman Rights Matter to Psychology –

Psychology Matters to Human RightsKerstin Söderström1,2, Polli Hagenaars3, Tony Wainwright4, and Ulrich Wagner5

1 Division of Mental Health, Innlandet Hospital Trust, Brumunddalen, Norway2 Faculty of Health and Social Sciences, Inland Norway University of Applied Sciences, Lillehammer, Norway3 Private Practice, Amsterdam, The Netherlands4 Cedar, Department of Psychology, University of Exeter, UK5 Department of Psychology, University of Marburg, Germany

“Human Rights are of crucial importance to everyone in theworld, psychologists included”. With this statement theEuropean Federation of Psychologists’ Associations (EFPA,2013) called for psychologists and their associations toengage in protection and promotion of human rights. EFPAaims to connect psychology with Human Rights in a waythat psychology becomes more useful to the Human Rightsagenda and Human Rights become an indispensabledimension of psychology.

The modern Human Rights framework grew out of theUnited Nations’ (UN) efforts to prevent future human suf-fering following the atrocities of World War II. The Univer-sal Declaration of Human Rights (UDHR) adopted by theUN General Assembly in 1948, recognizes the inherent dig-nity and the equal and inalienable rights of all humanbeings as the foundation of freedom, justice and peace inthe world. Human Rights provide a moral and legal plat-form to protect and promote the fundamental rights andwell-being of people and peoples.

The UDHR and subsequent declarations and conventionsformulate the very basis of human needs, safety, health andwell-being and are a strong “companion” to psychologicalethics. In accordance with this, EFPA adopted the ModelCode in 2015, establishing the European Convention ofHuman Rights (ECHR) as a fundamental basis saying that:“Psychologists respect the principles of Human Rights asthese are defined by international treaties and human rightsconventions” (EFPA, 2015b). This makes the relationshipbetween ethics and human rights for psychological practicevery clear (Sveaass, 2019).

The World Health Organization acknowledges the stronglinks between health and Human Rights and prescribe ahuman rights-based approach to health policy and service

Special Issue: Human Rights and Psychology

delivery which targets “. . . discriminatory practices andunjust power relations that are at the heart of inequitablehealth outcomes” (WHO, 2017).

Despite their natural connection, there is no tradition of astrong alliance between the two fields of Human Rights andpsychology (Twose & Cohrs, 2015). This is probablybecause the two frameworks have different origins, speakdifferent “languages” – that of law and that of psychology– and are mostly played out in different arenas without rec-ognizing the mutual benefit of working together. Few wouldcontest that Human Rights are important, but it may not beself-evident what role psychologists can play or where andhow Human Rights can be embedded in psychology.

The guest editorial team consists of members of EFPA’sBoard Human Rights and Psychology whose mandate isestablished in the policy paper “Psychology matters inHuman Rights – Human Rights matter in Psychology”(EFPA, 2015a). A central aim is to raise awareness of themutual relevance of the two fields. EFPA emphasizes theunique expertise and competence of psychology and whatpsychology can add to what other social actors bring tobear. For the future of this work, EFPA has a number ofobjectives including:(1) Developing psychologists’ understanding of how the

human rights framework can inform psychology as adiscipline and practice.

(2) Providing examples of how psychology, as anacademic discipline and profession, and professionalassociations can contribute to the Human Rightsagenda.

(3) Raising awareness of historical and ongoing humanrights violations in the name of psychology and alsoof the positive initiatives psychologists have taken.

� 2019 Hogrefe Publishing European Psychologist (2019), 24(2), 99–101https://doi.org/10.1027/1016-9040/a000365

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(4) The exploration of the relationship between ethics andhuman rights in psychology and to provide directionfor future integration.

(5) The description of how human rights education andawareness can be integrated in the professional train-ing of psychologists.

This special issue is published at a significant moment forthis field. Progress on Human Rights has been impressivesince the Universal Declaration of Human Rights in 1948,but we are witnessing a reversal in this generally positivetrend as recorded in the World Justice Project report for2017–2018 where the biggest reversal was in fundamentalrights in over half the countries included (World JusticeProject, 2018).

The special issue starts with four context-setting papers.These are followed by three in applied fields: two that coverthe application of a human rights-based approach in thefield of dementia care and another focusing on children’srights and bullying as a human rights violation. The finaltwo papers consider situations where psychologists arecalled upon to directly challenge authorities in contextswhere public policy violates both ethical and human rightsprinciples.

The first paper by Nora Sveaass highlights the close con-nection between psychology and human rights through adiscussion of the Human Rights Committee of the Norwe-gian Psychological Association. It describes the politicalevents and the strengthening of the international humanrights field that inspired the establishment of the committeeand the definition of its goals. Sveaass describes the variousactivities of the committee, such as inscribing HumanRights into the National Association’s statutes, engagingin political debates and criticizing ongoing practices withinthe own profession and in society at large where HumanRights are at stake, and taking part in the UN reportingand monitoring processes; in all this the importance of ahuman rights based psychology, and human rights educa-tion for psychologists, is emphasized. This is followed byNimisha Patel’s discussion of applied psychology andhuman rights-based approaches where she proposes a pro-fessional stance of the psychologist as a practitioner-acti-vist. Her article points to the intertwined nature ofpsychology and human rights and not always in a goodway – for example, its Eurocentricity and bias towards indi-vidualism. However, the Human Rights framework and itsstatus of negotiated, international accepted legal and moralprinciples is mainly seen as ethical guidelines, commit-ments, and valuable tools for psychologists’ effort to prac-tice a human rights-based approach to health care. Thethird paper by Duška Franeta discusses the principles weshould use when teaching ethics in professional educationand, more specifically in psychology professional education.

Franeta argues that this ought not to be restricted to consid-eration of Codes but be more comprehensive, and includediscussion and debate on Human Rights. In the final paperof this context setting section Marco Gemignani andYolanda Hernández-Albújar take a critical look at the epis-temological and ontological underpinnings of human rightsand psychology and suggests important reflections on howwe need to step back and take a hard look at how we under-stand these two arenas from a critical perspective.

The second section begins with a paper authored byTheresa Wied, Maren Knebel, Valentina Tesky, and JuliaHaberstroh providing a systematic review of the empiricalevidence on supported decision-making in dementia care.As the first systematic review of this kind, this article con-tributes to the implementation of this approach in practice.Despite heterogeneous evidence, the findings have crucialimplications on enabling people with dementia to exercisetheir human right to make decisions with legal effect. Thisis followed by Sarah Butchard and Peter Kinderman’saccount of the development of the clinical applications ofthe Fairness-Respect-Equality-Dignity and Autonomy prin-ciples (FREDA) in clinical settings for people with demen-tia. The principles will provide valuable guidance for howrights based approaches can have the most impact in set-tings where rights are often at risk of violation. The articleby Johanna Fee Ziemes and Eveline Gutzwiller-Helfenfin-ger is on children’s human rights in educational settings.The authors question the idea of a value free science andcritique educational psychology for being too focused onthe individual level with the risk of eroding children’srights. Instead, they argue that educational psychology withmore ecological approaches can create opportunities forchildren to realize the normative statements of the Conven-tion of the Rights of the Child. The argument is madeconcrete by providing examples from bullying preventionand the creation of positive learning environments.

In the final section we turn to a more activist approach,beginning with Kenneth Pope’s account of the crisis ofhuman rights and ethics by psychologists’ involvement inthe so-called enhanced interrogation program in whichdetainees were tortured in Guantanamo Bay (Senate SelectCommittee on Intelligence, 2014) In Pope’s words, “A crisisof human rights and ethics has engulfed the AmericanPsychological Association, leading the APA to confrontculpability, accept responsibility, and “apologize for thisstain on our collective integrity.” The paper not onlydescribes the context and ongoing issues, but the impor-tance of how we as psychologists need to understand theway our organizations function – the section on guild ethicsis particularly revealing. We close the special issue with anaccount by Ryan Essex of the experience in Australia wherepsychologists have been faced with challenging publicpolicy on the treatment of asylum seekers and other people

European Psychologist (2019), 24(2), 99–101 � 2019 Hogrefe Publishing

100 Editorial

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in similar situations. The author provides important insightson the complexities of this work and the general lessons forall of us – the issues of asylum and refugees are universal –for contemporary practice.

In conclusion the papers in this special issue cover a widefield where human rights thinking and practice can enrichpsychology and where psychological ideas can enrichhuman rights understanding and implementation. Theyprovide inspirational examples of how psychologists canplay a significant role in human rights protection and alsoobject lessons on where violations can occur. We hope, thatthe papers will also play a part in developing the synergybetween the two fields and their increasing integration.

References

Butchard, S., & Kinderman, P. (2019). Human Rights, Dementiaand Identity. European Psychologist, 24, 159–168. https://doi.org/10.1027/1016-9040/a000370

EFPA. (2013). EFPA’s role regarding “human rights”. Retrieved fromhttp://human-rights.efpa.eu/introduction/efpa-s-role-regarding-human-rights/

EFPA. (2015a). Psychology matters in human rights – Human rightsmatter in psychology. Retrieved from http://human-rights.efpa.eu/introduction/policy-paper/

EFPA. (2015b). Model code of ethics. Retrieved from http://ethics.efpa.eu/metaand-model-code/model-code/

Essex, R. (2019). Psychology and its response to major humanrights abuses: The case of Australian immigration detention.European Psychologist, 24, 195–203. https://doi.org/10.1027/1016-9040/a000369

Franeta, D. (2019). Taking ethics seriously: Toward comprehensiveeducation in ethics and human rights for psychologists.European Psychologist, 24, 125–135. https://doi.org/10.1027/1016-9040/a000377

Gemignani, M., & Hernández-Albújar, Y. (2019). Critical reflaxivityand intersectionality in human rights: Toward relational andprocess-based conceptualizations and practices in psychology.European Psychologist, 24, 136–145. https://doi.org/10.1027/1016-9040/a000367

Patel, N. (2019). Human rights based approach to appliedpsychology. European Psychologist, 24, 113–124. https://doi.org/10.1027/1016-9040/a000371

Pope, K. (2019). A human rights and ethics crisis facing the world’slargest organization of psychologists: Accepting responsibility,understanding causes, implementing solutions. European Psychol-ogist, 24, 180–194. https://doi.org/10.1027/1016-9040/a000341

Senate Select Committee on Intelligence Report. (2014). Committeestudy of the Central Intelligence Agency’s detention and interro-gation program. Retrieved from https://www.intelligence.senate.gov/sites/default/files/documents/CRPT-113srpt288.pdf

Sveaass, N. (2019). The Human Rights Committee at the Norwe-gian Psychological Association – 20 years of work and futurechallenges. European Psychologist, 24, 102–112. https://doi.org/10.1027/1016-9040/a000368

Twose, G., & Cohrs, J. C. (2015). Psychology and human rights:Introduction to the special issue. Peace and Conflict: Journal ofPeace Psychology, 21, 3–9. https://doi.org/10.1037/pac0000087

WHO. (2017). Human rights and health fact sheet. Retrieved fromhttps://www.who.int/en/news-room/fact-sheets/detail/human-rights-and-health

Wied, T. S., Knebel, M., Tesky, V. A., & Haberstroh, J. (2019). Thehuman right to make one’s own choices – Implications forsupported decision-making in persons with dementia: A sys-tematic review. European Psychologist, 24, 146–158.https://doi.org/10.1027/1016-9040/a000372

World Justice Project. (2018). World Justice Project Rule of LawIndex 2017–2018. Retrieved from https://worldjusticeproject.org/sites/default/files/documents/WJP-ROLI-2018-June-Online-Edition_0.pdf

Ziemes, J. F., & Gutzwiller-Helfenfinger, E. (2019). Children’srights and educational psychology. European Psychologist, 24,169–179. https://doi.org/10.1027/1016-9040/a000373

Received February 26, 2019Published online June 14, 2019

Kerstin Söderström (PhD) is a spe-cialist in clinical child psychology atInnlandet Hospital trust and asso-ciate professor at Inland NorwayUniversity of applied sciences, Nor-way. Her professional and researchactivities focus on disadvantagedchildren and families in search forstrategies to promote well-being forthe world’s children and futuregenerations. She is a member of theEFPA Board of Human Rights andPsychology.

Polli Hagenaars is a licensedhealthcare psychologist in indepen-dent practice in Amsterdam, NL. Herprofessional career focuses ondiversity, non-discrimination andhuman rights. She is the formerconvenor and still an active memberof the EFPA BHR&Psy and chair ofthe Human Rights and Psychologygroup of the NIP.

Dr Tony Wainwright is the deputyacademic director on the Universityof Exeter Doctorate in Clinical Psy-chology Programme. He is a pastchair of the British PsychologicalSociety’s Ethics committee of whichhe is still a member. He is a memberof the EFPA Board Psychology andHuman Rights.

Ulrich Wagner (PhD) is senior-pro-fessor of Social Psychology in theDepartment of Psychology at thePhilipps-University Marburg in Ger-many. His research interests areintergroup relations, prevention ofaggression and violence as well asevaluation of intervention programs.

� 2019 Hogrefe Publishing European Psychologist (2019), 24(2), 99–101

Editorial 101

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Special Issue: Human Rights and PsychologyOriginal Articles and Reviews

The Human Rights Committee atthe Norwegian PsychologicalAssociation20 Years of Work and Future Challenges

Nora Sveaass

Department of Psychology, University of Oslo, Norway

Abstract: The close connection between psychology and human rights is discussed through a presentation of the Human Rights Committee inthe Norwegian Psychological Association. The importance of human rights education for a human rights-based approach in psychology ishighlighted. The article describes the political events and the strengthening of the international human rights field that inspired theestablishment of the committee and the definition of its goals. Main areas are presented, such as the psychological needs of refugees andtheir rights in resettlement countries, including the right to rehabilitation of victims of torture and the situation for separated minors seekingasylum, and their need for protection and care. Furthermore, human rights in mental health care, focusing on the rights of persons withdisabilities, as well as children’s rights, and state obligations to prevent violence and abuse are central concerns. The right not to bediscriminated or marginalized is emphasized and the need for psychologists to be involved in protection against discrimination.An international perspective focusing on psychologists involved in human rights abuses or psychologists themselves under threat isdiscussed as part of the committee’s engagement. The close collaboration with civil society organizations has enabled the committee to workwith alternative reports to international monitoring mechanisms as part of periodic reporting, both to UN Treaty bodies and to the UN HumanRights Council (Universal Periodic Review). Finally, the importance of human rights-based psychology, and how joint initiatives can strengthenrespect and promotion of rights, are reflected upon.

Keywords: human rights, psychology, mental health, political events, human rights education

“To believe that politics can be divorced from psy-chology is to confine the field [of psychology] to arti-ficial boundaries that limit its potential for improvinghuman well-being and social justice.”

Fox and Prilleltensky (1996, p. 21)

“Talking is not enough and social action has tobecome part of the repertoire of skills of clinicalpsychologists (. . .)”

Patel (2003, p. 34)

When looking closely at the aspirations and objectives ofhuman rights, and scrutinizing the aims and ambitions ofpsychology, the relationship and similarities between thetwo are striking. Yet, there has been a gap between thetwo fields. Despite crosscutting issues and shared values,the dialogue between those engaged in protecting humanrights and those working with the fulfillment of these aimswithin professional of psychology has been limited.

Ethics holds a central place in psychology, and importantefforts to bridge the gap between ethics and human rightsare seen (Hagenaars, 2016). The aim of this article is todescribe the development and establishment of a HumanRights Committee (HRC) in the Norwegian PsychologicalAssociation (NPF) in 1998 and focus on some areas of pri-ority for the committee. Creating such a committee wasmotivated by several factors – the need to include a humanrights dialogue into psychology and psychological ethics,and the fact that major political events during this periodbrought to our attention the many psychological dimen-sions that these events entailed. Finally, the fact that thehuman rights system was growing and civil society cameto have a stronger position in the monitoring and protectionof these rights represented important events. This created asense of urgency that something had to be done with regardto psychology and human rights. This was possibly the firstcommittee of its kind, and we are not aware of any otherworking under similar mandate. Some of the political

European Psychologist (2019), 24(2), 102–112 � 2019 Hogrefe Publishinghttps://doi.org/10.1027/1016-9040/a000368

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events at this time and the development in the humanrights system in this period and after are presented.

Important Political EventsDuring the 1990s

Post-Conflict and Post-AuthoritarianSocieties

The Latin American military dictatorships had fallen in the1990s, and stories about the suffering of those victimizedand abused by the dictatorships were disclosed beyondthe countries where this had taken place. The devastatingeffects of torture, illegal executions, enforced disappear-ances, clandestine and incommunicado detention, and asystematic application of fear as a form of oppression weredescribed in ways that was novel and shocking to many(Kordon et al., 1992; Sveaass, 2009).

Psychologists and other health professionals engaged inwork with persons affected by the serious human rights vio-lations, both as caregivers and human rights activists, spokeabout the consequences of the abuses, not only on thosedirectly affected, but on their families and on society atlarge (Lira & Castillo, 1991). The victims and the organiza-tions caring for the victims expressed a strong claim forjustice and that the responsible must be held to account.Impunity and lack of justice were considered ways ofupholding violence and injustice and some even arguedthat impunity for crimes of torture was a continuation ofthe torture (see Rojas, 1995, 2000; Sveaass, 1994; Sveaass& Lavik, 2000). Lack of proper investigations and attemptsto find those disappeared after abductions and unlawfularrests are ways of keeping fear and terror alive, in additionto violating rights to truth and justice. Justice and access toreparation were presented as vital by the Latin Americacolleagues, not only for legal reasons, but as part of a heal-ing process for those who had lost and suffered. It seemedimpossible to heal the wounds in a climate of impunity, andjustice and reparations were the only possible avenues forattempts at closing the gaps, repairing what had beenbroken (Kordon, Edelman, Lagos, & Kersner, 1995).

To psychologists in different places in the world, theseobservations and reports highlighted the close connectionbetween grave human rights abuses, impunity, severe psy-chological problems, and social insecurity. What we heardabout this, combined with the direct encounter with refu-gees from the region, represented clear messages to psy-chologists in Europe and other places about the necessityto do something, both on a sociopolitical and a clinical level.Learning and understanding more about human rights

violations and their consequences seemed a priority,together with ways of relieving pain and suffering, and pro-viding opportunities after abuses, loss, and uprooting(Sveaass, 2013).

Justice and Accountability

The voices of the Latin American health professionals andhuman rights activists on justice and accountability wereheard by the international community (Rojas, Espinoza,Urquieta, & Soto, 1998). Their experiences became impor-tant arguments in the debate and work that led to an inter-national criminal justice system, such as the tribunals forwar crimes in former Yugoslavia (ICTY, established in1994) and Rwanda (ICTR from 1996), and the PermanentCriminal Court (ICC) under the Rome Statute (UN, 1998b).The principle strongly raised by the Rome Statute was thatblanket amnesty was no longer an option and that account-ability for crimes against humanity and reparation to thevictims were conditions for peace, as well as for socialand individual healing. The tribunals established calledupon witnesses who had suffered violations, and the impor-tance of supporting witnesses was acknowledged. Psycho-logical assistance and forms of psychological monitoringof the trials were developed. Furthermore, ways of provid-ing psychological support to the large groups of war-affected persons, following the end of the armed conflict,were needed (Ajdukovic, 1997).

In former Yugoslavia, the number of war-related rapeswas catastrophically high, and it became evident that rapehad been used systematically as a weapon of war and aspart of ethnic cleansing (Skjelsbæk, 2012). Rape was forthe first time considered a war crime and crime againsthumanity, not only as collateral damage in war (ibid.). Thiswas an important step on the international level, because itallowed for considering sexual violence against women asgrave human rights violations, and something states wereobliged to deal with. For those who had suffered, the factthat these crimes were of concern to the internationalsociety and further that witnesses were entitled to protec-tion and reparation were of great value (Stover, 2005).These events underscored the psychological complexityinvolved in justice and post-conflict and the need todevelop support and psychological assistance.

The conflicts in Rwanda and in Balkan had consisted ofbrothers and neighbors fighting each other in the most bru-tal way. This was a shocking lesson to us all, and psycholo-gists were required to ask how this could be understood anddealt with. Here, we still have a long path to go, but theactual understanding of some of our established social psy-chological insights became brutally timely and relevant andsomething that needed further exploration. The psycholog-ical aspects of genocide, and the role of those involved,


N. Sveaass, The Human Rights Committee at the Norwegian Psychological Association 103

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let alone the bystanders, had been well described by Staub(1989) in his book, “The Roots of Evil.” The relevance ofthis work became stronger than ever.

At the same time, peace processes after armed conflictsrequired reconciliation and a new start. The political ambi-tions, formulated by those negotiating the peace accords,were in starch contrast to the situation on the ground,where there was no sense of safety or security, nor a spacefor reconciling with persons with whom one recently hadbeen in conflict. From a psychological point of view, itseemed evident that political decisions and processes couldnot be successful as long as justice and truth were not takeninto account or the need for creating safety and security notdealt with (Skjelsbæk, 2012; Sveaass & Sønneland, 2015).

Truth and Reconciliation

An important event that brought energy to the psychologyfield was the way in which South Africa dealt with its brutalhistory. An apartheid government had been in power foryears, but in 1990, the world’s most famous political pris-oner, Nelson Mandela, was set free after 27 years imprison-ment. A new era could begin, and four years later, he waselected president of South Africa. Following the release ofNelson Mandela, the important process of dealing withthe past was initiated. The level of conflict was naturallyhigh, but the new leadership managed to embark uponthe first truth and reconciliation process seen. The “Truthand Reconciliation Commission” (TRC) was establishedand those responsible for atrocities as well as those whohad suffered come forward and talked about what had hap-pened (Hamber, 2002). The proceedings were broadcastedto enable everybody access to this. Those responsible forthe violence were encouraged to admit to their crimesand if possible ask for forgiveness. Legal process was initi-ated only when people refused to testify. This was of coursea very emotional process, where basic questions related toguilt, shame, loss, repentance, and forgiveness were onthe agenda. The psychological processes involved werestrong and often painful, but this unique initiative gaveroom for a peaceful transition, with a view to look aheadand reconcile.

The South African commission had given the world anew way of dealing with the painful experiences of the past.It was ground-breaking, also in terms of psychologicalapproaches to these sociopolitical events. It allowed animportant discussion to evolve, namely the relationshipbetween truth and reconciliation.

The work that later took place in El Salvador, Guatemala,Chile, and Argentina was partly modeled by the TRC thatis, to bring out the truth about what happened during thearmed conflicts in the region (Espinoza, Ortiz, & Rojas,2003). The questions raised through these commissions

were about the relationship between truth and reconcilia-tion, as reconciliation as part of the process is a contestedone (ibid). More knowledge, insight and understanding ofthis, in order to develop processes within what we knowas transitional justice, are needed (Sveaass, Agger,Sønneland, Elsass, & Hamber, 2014).

The political events described above were significant tothe understanding of the psychological aspects involved inwar and post-conflict. In particular, these events highlightedhow psychological knowledge may be applied in these pro-cesses and further, how the consequences of conflict,abuse, and human rights violations are issues to be dealtwith in psychology. The need to elaborate a better under-standing and approach with regard to human rights andpsychology became clear. The establishment of thecommittee was one response to this.

Human Rights InstrumentsAre Strengthened

Apart from the political events, international human rightsprinciples were strengthened (Buergental, 1995; Risse &Sikkink, 1999). Systems to monitor compliance of theseobligations by the states were further developed during thisperiod, and respect for human rights was considered a wayto ensure health, security, and well-being for the people inthe world. This of course also calls for more engagementfrom psychologists, as part of the group of health profes-sionals and as part of civil society.

Conventions and Declarations

Many of the most important human rights conventionswere adopted and entered into force already prior to the1990s, such as the Convention Against Torture (CAT)and the Convention for the Elimination of Discriminationof Women (CEDAW) (OHCHR, 2018a). The Conventionfor the Rights of the Child (CRC) was adopted in 1992,and the idea of a Convention for the Rights of Persons withDisabilities was born (CRPD) and finally adopted in 2006.One important event was the World Conference on HumanRights in Vienna, Austria in June 1993, attended by repre-sentatives of 171 states and 800 NGOs. The Vienna Decla-ration reaffirmed the “commitment of all States to fulfiltheir obligations to promote universal respect for, andobservance and protection of, all human rights and funda-mental freedoms for all in accordance with the Charter ofthe United Nations, other instruments relating to humanrights, and international law” (OHCHR, 2018b). For thefirst time, human rights were announced as indivisible,interdependent, and inter-related. The conference called


104 N. Sveaass, The Human Rights Committee at the Norwegian Psychological Association

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for action to protect the rights of women, children, andindigenous people and the important role and participationof civil society organizations in the work for promote andprotect human rights was established.

A number of other important UN documents and resolu-tions were adopted during this period. Of special relevanceto psychology, were resolutions on the right to restitution,compensation, and rehabilitation, on impunity of perpetra-tors of human rights violations, and on effects of impunity(UN, 2000). The issue of justice and impunity and the con-sequences this had both for individual survivors and thecommunities were highlighted by these documents.

Human Rights Defenders

The first landmark declaration on human rights defenders(HRD) was adopted in 1998, namely the United NationsDeclaration on the Right and Responsibility of Individuals,Groups and Organs of Society to Promote and ProtectUniversally Recognized Human Rights and FundamentalFreedoms (UN, 1998a). A human rights defender is anyoneworking for the promotion and protection of human rights,including professional as well as non-professional humanrights workers, volunteers, journalists, lawyers, and anyoneelse carrying out, even on an occasional basis, a humanrights activity (International Service for Human Rights,2013). The declaration was an important step for civilsociety all over the world. Human rights defenders, seekingto promote and protect a wide range of different rights, areoften threatened and persecuted for their work (UNGeneralAssembly, 2018).

The declaration underlined the importance of humanrights defenders and their need for protection. While notlegally binding, it provides an authoritative framework forthe recognition and protection of HRDs under internationallaw. The first resolution marked its 20th anniversary in2018, and in the most recent resolution on the situationfor human rights defenders, the UN General Assembly callson the Secretary General to “assist States in strengtheningthe role and security of human rights defenders” (§16–17).These resolutions, being a framework for protecting humanrights defenders against reprisals, are relevant to manyhealthcare providers in the world, as they are frequentlytargeted, directly or indirectly for their work, supportingand assisting persons who have been subjected to severehuman rights violations (UN, 2017).

Psychologists and their organizations have a role to playas part of civil society, to advocate for promotion andrespect of basic human rights, and to protect and care forthose who have been subjected to violation of the rights.

Seeing psychologists and our organizations, not only asmembers of civil society, but possibly also as human rightsdefenders, has been understood by the committee as agood approach and one that could be a good guiding prin-ciple in our work.

The Human Rights CommitteeIs Established in 1998

The decision to establish a Human Rights Committee asa committee under the central board, counting sixmembers,was taken at the Convention of the Association. A moreelaborate process regarding aims and objectives could start,1

and some of the main focus areas will be described.

The Mandate

The mandate for the Human Rights Committee (hereafterHRC) was expressed in the following way, “to work forand promote the relationship between human rights andpsychology, as these are expressed in the UN Conventionsand psychological knowledge.” The ambition was tostrengthen the knowledge about human rights and the appli-cation of international human rights instruments among psy-chologists in general and in particular in theirworking settingas psychologists. Secondly, and not less important, the com-mittee should take up, discuss, and act upon situations andevents where it found that basic human rights had been vio-lated, in Norway or other situations where relevant.Responses would be writing (press), expressing opinions inpublic meetings or taking contact with relevant stakeholdersin situations where rights are challenged and/or personspossibly at risk. The following aims were defined:– Prevent human rights violations.– Promote use of psychological knowledge to help indi-

viduals and groups subjected to human rights violations.– Contribute to the development of knowledge and

insight into the relationship between psychologicalknowledge, practice and human rights.

– Strengthen awareness regarding the connectionbetween human rights, health, and quality of life.

– Contribute to the use of psychological knowledge in pro-cesses for peace and conflict resolution and that theseprocesses always include respect for human rights.

– Contribute to the prevention of use of psychologicalknowledge and methods in ways that violate the rightsof persons or in any way contribute to oppression andhumiliation.

1 As the author was one of the initiators and subsequent members, the description of the work will be from the inside and referred to as we andus.



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– Ensure that psychologists do not participate in or in anyway contribute to torture or cruel, inhuman or degrad-ing treatment or punishment, toward any individual,no matter what charges are brought before them.

– Support psychologists and psychologists’ co-workerswhen they are prevented from performing their profes-sional duties toward persons in risk or under threat.Likewise, psychologists and their co-workers must besupported when persecuted or in any other way exposedto threat and danger when performing their professionalduties and/or promoting the human rights of others.

These were our aims then, and they still represent thecentral principles and goals guiding our work.

A Human Rights-Based Approach –

What Have We Done?

Main areas of work and initiatives taken during these 20years will be described briefly.

Refugees and Asylum Seekers

Identifying Torture and Right to RehabilitationNorway receives asylum seekers on a regular basis as wellas refugees arriving to the country through the UNHCR.The refugees are re-settled directly in Norwegian munici-palities, whereas the asylum seekers are hosted in asylumreception centers.

The committee has argued for and defended the right toseek asylum, especially in situations where immigration pol-icy implied limited access and deterring persons fromcrossing borders. We have further argued to rights on arri-val. The right to health care and respect of special needshave been major principles (Brekke, Sveaass, & Vevstad,2010). The fact that there is no procedure in Norway,addressing and identifying victims of torture, nor a systemthat secures that victims of torture are attended in the waythat seems fit, has been raised with the Norwegian authori-ties several times. The need for developing good proceduresfor initial health assessment has been highlighted, and stan-dards for psychologists’ engagement in asylum procedureshave been outlined. We have further reminded the stateabout the international obligations regarding rehabilitationof torture victims and the importance of identifying torture(including by applying the Istanbul protocol2) as a way toensure rights. In alternative reports to the different UNTreaty bodies, in particular to the Committee AgainstTorture, these issues have been raised several times in

connection to the Norwegian periodic reporting to thesebodies (NGO Forum, 2018a).

Situation for Separated MinorsThis has been an area of priority. A public hearing“Childhood on wait” was organized in September 2006,where HRC invited politicians and psychologists to discussthe situation for this group of minors from psychological,clinical, and protection perspectives. Policy makers werechallenged on these issues and the hearing received greatinterest from the public. The work was followed up incollaboration with other civil society organizations workingon the rights of the minors. Among this was a parliamentaryhearing where HRC reiterated the importance of the youngasylum seekers being under child protection servicesinstead of the immigration services, to ensure protection,treatment, and care. In 2009, the Norwegian authoritiesdecided this for those under 15 years of age.

Another challenge where we have engaged is the discus-sion regarding age determination procedures and the factthat young asylum seekers can be returned at 18. We haveargued that temporary stay for adolescents of 15, with theview to return at 18, does not create the kind of stabilityand motivation for learning and developing they shouldnormally have. In different ways, we have argued againstthis situation explaining what this may mean in terms ofboth psychological development and rights.

Detention of Asylum SeekersThe practice of detaining asylum seekers who are awaitingdeportation was established in Norway in 2010, followingthe adoption of the EU Return Directive by the NorwegianParliament, which provides for periods of up to 18 months(Norwegian Ministry of Justice and the Police, 2010). Thispractice has been of great concern to HRC, and in 2015,we undertook a visit to Trandum Detention Centre,focusing on access to health services in general, and inparticular, the possibility for having mental health assis-tance. The situation for families with children was also amajor topic for the visit. A report was written, submittedto the authorities, and published. These concerns were laterraised by the Norwegian National Preventive Mechanism(NPM) after a visit to Trandum. This became an importantopportunity to reiterate the psychological issues raised by us(Menneskerettighetsutvalget, 2016).

Health and Irregular Migrants

The right to health care for those without regular staypermit in Norway has been an issue of public discussion. Ahealthcare center for “irregular migrants” was established

2 UN Manual for the effective documenting and investigating of torture and ill-treatment.



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in 2009 by a Norwegian church organization and RedCross. The activity was at first considered acts of civil dis-obedience, as the clients were “illegal” and soon to bereturned. Health professionals were warned against partic-ipating in this work, but the HRC encouraged members tosign up this voluntary service, despite the risks entailed.Fortunately, the authorities changed their position; the cen-ter was “legalized” and users were not to be arrested whilevisiting the center. The committee has given a lot of atten-tion to this work (Evang, 2011). We further participatedactively in the campaign “Nobody is illegal” with otherorganizations, also professional associations. The idea wasto protest against the authorities’ definition of irregularmigrants as “illegal” migrants, risking stigmatization andmarginalization of persons denied protection or other formsof stay in the country. This clear position by the HRCresulted in a discussion in the Journal of the PsychologicalAssociation (TNPF), where the committee was accused ofbeing political and activist. These comments were repliedto, but at the same time, we saw that participation in cam-paigns should always be well prepared and discussed(Mohn, 2011; Sveaass, 2011).

Psychiatric Patients, Human Rights,and Coercive Care

Compared to other countries, Norway has had a highernumber of involuntary hospitalizations of adults in psychi-atric care, based on the population (Statistisk Sentralbyrå,2011). Norway has until recently applied the so-called treat-ment criteria as a condition for hospitalization withoutconsent, regardless of capacity for decision. In 2017, newlegislation was introduced to ensure that persons withdecision capacity may not be hospitalized without consent(Helsedirektoratet, 2017).

The number of involuntary hospitalizations varies, andhospitals in different regions report on very different num-bers. This has been brought to the attention of the healthauthorities on numerous occasions, both from Norwegianand international bodies. The number is nevertheless, notmarkedly reduced, despite the many reports and initiativesto this end. The use of restraints in psychiatry is alsoaccording to reports a frequent one, and little reduction isobserved, despite ambitions to do so (Husum, 2011).Finally, medication without consent is frequently appliedin psychiatric clinics and hospitals, also including forcedmedication for persons not cared for in the hospitals(Husum & Nordvoll, 2014).

The committee has raised these issues as seriousconcerns directly to the health authorities, as part of alter-native reports to the UN and as comments to public hear-ings. Such questions were placed even stronger on theagenda by the entering into force of the Convention for

the Rights of Persons with Disabilities (CRPD), a conven-tion Norway ratified only in 2013. HCR as well as theOmbud on discrimination and equality (LDO) hadfrequently encouraged the state to do. Norway ratified withreservations to Art 12, 14, and 25, again resulting in fiercecriticism from stakeholders (Stang & Sveaass, 2016).These reservations relate to the informed consent and theright to enjoy full rights of persons with a disability.Again, the HRC has been active in arguing against thesepositions and has submitted written comments to thisinterpretation and practice. Norway will be reviewed bythe CRPD in 2019, and alternative reports have beensubmitted.

A special situation in Norway, that makes the need forinvolvement of and insight into human rights of personswith disabilities, is that the Norwegian mental health lawallows psychologists to decide on involuntary admittanceto hospitals of persons with psychological problems. Theassociation had worked for this with the view of reducingthe number of involuntary placements. The idea was thatpsychologists would voice alternatives, stronger and withmore effect. To this day, after 11 years, this has not hap-pened, and the numbers have not gone down (Strand,2011). The committee finds this problematic and an issuethat should be dealt, also by the association, in a moredirect way.

Another issue is the use of electroconvulsive therapy(ECT) without informed consent. According to the Norwe-gian mental healthcare law, all use of ECT should be basedon informed consent, but despite this, ECT is frequentlygiven without such consent and also to patients lackingthe ability to give informed consent and often as “emer-gency measures.” This has been criticized by the HRC aswell as at the hearing in UN torture committee in 2018(UNCAT, 2018). Other concerns voiced by the HRC in rela-tion to psychiatric care are lack of adequate registrations,lack of follow-up of complaint procedures and serious short-comings with regard to the control commission, mandatedto carry out regular visits to the hospitals and clinics. Weregard these as potential violations of the rights of personswith disabilities. The Norwegian National PreventiveMechanism (the NPM established under OPCAT), at theOmbud’s office, visits psychiatric hospitals regularly andhas published several reports, raising these problems. TheHRC forms part of the advisory board of the NPM, and thisgives a good platform and opportunity to work actively inthis area (see https://www.sivilombudsmannen.no/en/torturforebygging/).

Public Statements on Relevant Issues

Norway has frequently been criticized for overuse of isola-tion in prison, lack of specific remand prisons, and at some



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instances minors in prison. The situation of minors in con-flict with the law has been a focus point for the committee.On several occasions, we have presented written statementsand comments to public documents and plans regardingminors in detention. Information about psychological conse-quences of isolation has been provided through newspaperarticles and interviews in the media.

Discrimination is a serious experience, and persons whoare discriminated for reasons of race, ethnic background, orsexual identity find themselves in vulnerable situations andat risk with regard to mental health and well-being. Thecommittee has engaged through public statements andpresentations, taking part in seminars and contexts wherediscrimination is discussed including by participating inalternative or supplementary reports to UN Treaty bodies(Anti-rasistisk Senter, 2015).

Our challenge throughout has been to link these possiblehuman rights abuses to psychological knowledge andpractice.

Human Rights Educationand Disseminating Knowledge

Better education and training on human rights to psycholo-gists have been a major ambition. The committee hasworked systematically with this, contacting universitiesand places of higher education, providing input to teachingplans and literature, and being available as lecturers andconveners of seminars. We have also reminded the Norwe-gian state on its obligations to provide human rights trainingto professionals in different sectors. Focus has also been onincluding human rights in the training offered by the associ-ation, as part of specialization programs. Something hasbeen obtained, but there is still a long way to go. Publishingtextbooks and articles, as well as lecturing in different con-texts, has been among our many activities to strengthenhuman rights education to psychologists and disseminateinformation about the application of human rights principlesin psychology. A special edition on human rights and psy-chology, in the Journal of the Association, edited by the com-mittee, was issued in December 2009. This edition includedarticles on coercion in psychiatry, refugee rights, the prohi-bition of torture, children’s rights, and an editorial on humanrights-based psychology (TNPF, 2009).

Knowledge and oversight over human rights are impor-tant, but making a human rights informed approach inpractice possible, more has to be done in terms of aware-ness raising and practical implementation. The aim mustbe to create a clear understanding of what human rightsare, what is the relationship between these rights andpsychology, and how psychologists can practice these prin-ciples on the ground. Members of the committee havedeveloped ways of presenting a practical approach related

to these issues and ways of dealing with specific questionsand challenges that psychologists meet in their daily life(Stang & Sveaass, 2016).

Basic Principles for Psychologists

In 2010, the basic principles for Norwegian psychologistswere amended. Based on a proposal from the HRC, thefollowing text was adopted “Psychological professionalwork must ensure that basic human rights are beingrespected. Such a practice implies that one shall alwaysactively be oriented by and relate oneself to internationalconventions and relevant national legislation, and in thedaily work, aim at securing the respect for the rights ofpeople, and that it is reacted when violations of these rightstake place” (NPFs prinsipp-program, 2010, p. 4). This deci-sion was an important one. It firmly established thatpsychological practice rests on human rights and thatreporting or reacting to violations falls within the remit ofpsychologists’ professional work.

Psychology and Ethics

The relationship between human rights and ethics in psy-chology merits a constant focus. Whether human rightsshould be an explicit part of ethics or if they are comple-mentary is an ongoing discussion. The Universal Declara-tion of Ethical Principles for Psychologists (UDEPP)adopted in 2008 (IUPsyS, 2008) does not contain a clearreference to the human rights, but is formulated in a waythat encourages the inclusion of these rights when consid-ering professional ethics. Despite these principles being avaluable addition to the ethical standards, the HRC hadhoped for a direct reference to human rights in the declara-tion, not only as guiding ideas but as obligations to adhereto, in psychological practice.

Then when the EFPA Model Code of Ethics was drafted,the HRC was invited to participate in this work. The ModelCode was adopted by the EFPA Board of Ethics in 2015establishing the European Convention of Human Rights(ECHR) as a fundamental basis. The following wasincluded in the general principles: “Psychologists respectthe principles of Human Rights as these are defined byinternational treaties and human rights conventions”(EFPA, 2015). This makes the relationship between ethicsand human rights for psychological practice very clear,and the Model Code thus serves a very important purpose.

Protesting Against Abuse of Psychology

The principle of “do no harm” and fighting all forms ofabuse of and by the psychological profession, including



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abuse of psychological knowledge, were important perspec-tives when it became evident that psychologists engaged innational security issues and contributed to the so-calledenhanced interrogations as part of the war against terror.A special task force had been established by the AmericanPsychological Association (APA) in 2005 with a mandateto outline the role of psychologists in national security issuesand in particular whether the APA Ethics Code applied inthese situations (APA, 2005). The task force gave legitimacyto the participation of psychologists in such activities andargued that the work was ethical, safe, and legal(Wessells, Sveaass, Foster, & Dawes, 2017). The recommen-dations from the task force were met with concern andsurprise both from inside the APA and from other psycho-logical associations internationally. The idea of havingpsychologists participating, directly or indirectly in formsof interrogation that the UN Committee Against Torturedescribed as involving methods of torture (UNCAT,2006), had to be reacted to. The HRC together with theNPF itself and other Nordic psychological associations tookinitiatives to write letters to the leadership of the APA as wellas organize meetings with them, such as during the Interna-tional Conference of Psychology (ICP) in Berlin in 2008.

Furthermore, HRC engaged in numerous discussions,panels, and workshops at the European Congresses forpsychology and others, on this issue. Our position at all theseevents was that psychologists’ engagement in what wasregarded as serious human rights abuses was absolutelyunacceptable. The committee also wrote to the Director oftheAPAEthics Office directly, Stephen Behnke, arguing thatpsychologists must never work in irregular places of deten-tion such as Guantanamo and Abu Ghraib (MRU, 2009).The only exceptionwould be “if they are part of independentteams to monitor, report or provide health care, and underthe command of other bodies than thosewho are responsiblefor the detention settings themselves” (MRU, 2009, p. 1).The HRC also encouraged APA to establish an independentinvestigation on the participation in national security opera-tions. The letter from the committee was never replied to.The APA ethical director continued presenting and defend-ing APA positions blatantly and in full collision with thehuman rights principles, in particular with the absolute pro-hibition against torture. It was only in 2014 that APA itselfinitiated an investigation on the role of APA in these opera-tions. The Hoffman report, based on an independent reviewof APA ethics guidelines, national security interrogations,and torture, was published in July 2015 (Hoffman Report,2015; Sveaass, 2015). This resulted in major changes in theAPA and finally allowed those who had criticized this policyto receive the praise and admiration they merited, for long-standing opposition and harsh treatment. The chair of theHRC was interviewed for this report, based both on priordiscussions and membership in the UNCAT.

Civil Society Collaboration

Being part of a network of human rights organizations hasbeen important for the committee. This has allowed for aregular communication with the Norwegian authorities oncompliance to human rights obligations and on reportingto the different mechanisms and bodies in the UN. Thenetwork, called the NGO forum, has regular contact withministries, with the Norwegian Ombuds and NationalHuman Rights Institution of Norway (NIM) (NorwegianHelsinki Committee, 2018). This enables the HRC to bepart of public statements, provides input to Norwegian statereports to the UN, and contributes to alternative reportswhen Norway’s periodic reports are reviewed in therelevant treaty bodies. As part of the consideration ofNorway in the UN Human Rights Council (the so-calledUniversal Periodic Review, UPR), the HRC presented infor-mation and recommendations to the council on the right torehabilitation of torture victims, the need to identify anddocument torture, separated minor asylum seekers, lackof informed consent with regard to hospitalization, use ofECT, and on isolation in detention (NGO Forum, 2013,2018b).

International Collaboration, Conferences,and Panels

International collaboration has always been essential to ourwork, both through bilateral contact with groups of psychol-ogists and others engaged in defending and assistingpersons in conflict situations and under threat and by par-ticipating on international conferences. We have had thechance to visit colleagues and collaborate with psycholo-gists in the Palestine, in Cambodia and Vietnam, and inLatin American, in particular, Chile, Argentina, and Peru.

The collaboration with the European Conferences of Psy-chology (ECP) with regard to organizing peace and humanrights tracks at the conferences has been valuable. The firstpeace track took place in 2009 when the ECP was in Oslo.Later the human rights track was initiated, and today thistakes place at all the ECPs, bringing together colleaguesfocusing on a human rights orientation in psychology. TheHRC has further been active in panels and presentationsat other conferences contributing to a stronger focus onpsychology and human rights. The HRC was also engagedwhen EFPA was preparing a human rights task force.

The committee has on several occasions been informedabout colleagues who have protested against violations ofpeople’s rights and assisted and supported those who haveexperienced abuse, and who find themselves at risk ofpersecution and threats. In such cases, we have tried toexpress solidarity by letters and other actions of supportfor colleagues.



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The Members

The HRC consists of 6–8members, elected at the NPF con-ventions, all psychologists and members of the association,usually clinical psychologists, also engaged in research.Interestingly enough, this research has been on issues suchas refugees, human rights and psychosocial care, PTSD andpsychotherapy, use of restraints in Norwegian psychiatricinstitutions, and coercive measures in drug treatment.One has been a children’s ombud in Norway and onemember of UN Treaty bodies. Others have contributed toestablishing civil society organizations to defend refugees’rights and health care to irregular migrants and all activelyinvolved in teaching, public lecturers, media contributions,and international collaboration with colleagues.

A Human Rights-Based Approachto Psychology – Psychologistsas Human Rights Defenders

Working from a human rights perspective means to be will-ing to look critically at our own practice and role as a psychol-ogist. A particular focus has been on situationswhere there isa risk of abusing power or positions and forgetting the primeobligation to those seeking our attention and assistance. The“do no harm perspective” is vital, and in situations of dualloyalties, where rights of persons may be endangered, ourobligations are to defend rights and oppose systems thatdeny rights or abuse them (Sveaass, 2013).

The committee has wanted to strengthen psychologists’role and participation in public debates with regard torespect for human rights and make clear that our positionis on defending these rights based on psychological knowl-edge and practice. All this is related to what we have had asan important perspective, namely identifying and elaborat-ing what may be regarded as a human rights-based psychol-ogy (Hagenaars, 2016).

We have highlighted the role of the human rights defen-der and argued that psychologists may regard themselves aspossible defenders of human rights. The fact that the firstUN Declaration on human rights defenders was adoptedthe same year as the establishment of our committee hasmade this relation even clearer to us. We must always beaware, that colleagues in countries with weak democraciesmay risk their own safety when assisting people subjectedto human rights abuses, if these are regarded as enemies,in opposition, as unwanted or marginalized.

Joining forces in order to strengthen human rights-basedwork by psychologists as well as other health professionalsis a necessary strategy. Close collaboration between civilsociety organizations, nationally as well as internationally,

and a further development of mechanisms and organiza-tions within the professional associations worldwide shouldenable psychologists to be aware and informed about thechallenges as well as the options with regard to humanrights protection. The establishment of the EFPA BoardHuman Rights and Psychology represents an important stepin the process of strengthening and further developing ahuman rights-based approach in our daily work as well asa platform for action (Hagenaars, 2016).

We therefore hope that in the future, with more humanrights training, awareness and engagement in this area,our vision of what is good psychology in the defense ofpersons’ right to integrity, safety, and security, will developand strengthen. We also hope that identifying ourselves aspart of a human rights defender movement may constituteaspects of our professional approach to psychology andthose who we collaborate with and for.

Closing Comments and Recommendations

The following are recommendations for strengthening ahuman rights-based psychology and refers to action andresponsibilities of the institutions in charge of educatingpsychologists as well as of professional associations andinterest groups.1. Human rights education for psychologists must be

strengthened on all levels, and the educationalprograms and curricula must be tailored to the profes-sional reality in which psychologists work. Such train-ing must thus form part of the basic education ofpsychologists as well of postgraduate training andspecialization programs.

2. Develop aims and strategies for a human rights-basedapproach in psychology. This includes an understand-ing of how ethics and human rights may supplementeach other and provide guidance to professional work.The development of awareness as to responsibilitiesfor reporting or in different ways pointing at acts orsituations that may be in violation of human rights isof essences.

3. All psychological associations should establish humanrights committees or boards. These should have aclear mandate and be provided an independent func-tion within the association and collaborate closely withboards of ethics and other relevant working groups inthe associations. Such committees may have impor-tant role advocating for human rights education withinthe association as well as at university level andprovide public input and perspectives on relevantquestions regarding psychology and human rights.

4. A human rights-based focus in psychology should beoriented toward national as well as international issuesand provide relevant information and guidance in



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situations where psychological knowledge may repre-sent contributions in the field of preventing abuse aswell as protecting, supporting, and assisting individu-als and groups in vulnerable situations.

5. Close collaboration with colleagues in other countries,for instance, through the psychological associationsand human rights committees, is of importance inorder to provide support if situations of threats orreprisals arise.

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Wessells, M., Sveaass, N., Foster, D., & Dawes, A. (2017). Do noharm? How psychologists have supported torture and what todo about it. In M. Seedat, S. Suffla, & D. Christie (Eds.),Enlarging the scope of peace psychology: African and World-Regional Contributions (pp. 269–294). New York, NY: Springer.

HistoryReceived July 1, 2018Revision received November 16, 2018Accepted January 10, 2019Published online June 14, 2019

Nora SveaassDepartment of PsychologyUniversity of OsloP.O. Box 1094Blindern, 0317 [email protected]

Nora Sveaass is Professor at theDepartment of Psychology, Universityof Oslo. She is a clinical psychologist,especially engaged with refugees andtorture victims. She is a member ofUN Subcommittee for the Preventionof Torture and was chair of theCommittee for Human Rights at theNorwegian Psychological Associationfrom 1998 till February 2019. Her re-search mainly focuses on humanrights, transitional justice and familytherapy with refugees.



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Human Rights-Based Approachto Applied PsychologyNimisha Patel1,2,

1School of Psychology, University of East London, United Kingdom2International Centre for Health and Human Rights, United Kingdom

Abstract: This article addresses the nature and framework of human rights and its relevance to health care and to applied psychology. Itoutlines some of the limitations of human rights, but argues that human rights provide a tool for psychologists, one which can help defend thehuman rights of those we work with and support, and which can help promote the application of human rights principles in psychologicalpractice. A human rights-based approach (HRBA) is defined, particularly in relation to applied psychology and implications for adopting aHRBA in clinical practice, research, advocacy, and pedagogy are outlined. The professional stance of practitioner-activist is posited as apt forusing a HRBA in applied psychology.

Keywords: human rights, applied psychology, human rights principles, human rights-based approach, activism

Human rights and applied psychology share one key focus,among others: health and well-being. In this article, ahuman rights-based approach (HRBA) to psychology isexplored, by outlining the key features, principles, limita-tions, and the value of international human rights and byconsidering its relevance to psychological practice,research, advocacy, and pedagogy.

What Are Human Rights?

Human rights are international legal standards, conceivedand constructed following World Wars I and II, firstwith the establishment of the United Nations, an inter-governmental organization, then by the development andadoption of the Universal Declaration of Human Rights in1948 (UDHR). The UDHR, together with the InternationalCovenant on Civil and Political Rights (1966) with its twoOptional Protocols and the International Covenant onEconomic, Social, and Cultural Rights (1966) form the Inter-national Bill of Rights. The UDHR is the origin of the othernine international legal treaties, which together with variousregional conventions, declarations, principles of law, agree-ments, and judicial decisions, form international humanrights law. While the doctrine of human rights, as derivedfrom international human rights law, promotes humanrights as norms which share key features (Table 1), theyare perhaps more accurately to be understood as minimalmoral claims, encoded and established in legal language.

They are the outcome of a political enterprise of interna-tional consensus-building onmorality, on what governmentsshould and should not do to those under their jurisdiction.This political process has included the establishment ofhuman rights machinery, regional and international sys-tems, and peer review structures to ensure accountabilitybetween States within the international community.

Why Do We Need Human Rights?

One compelling justification for human rights is that theyseek to protect against threats to fundamental human inter-ests and that “an account of human rights requires reflec-tion both on what are the most basic human interests andon which political, social, and legal abuses are most danger-ous to those interests” (Nickel, 2004, p. 5). The notion ofbasic human interests is not new to psychology (e.g.,Maslow, 1943) and indeed central to psychological practice.Yet, in psychology, human rights have often been ignoredas peripheral: inequalities and injustices which happen“out there,” in “other” countries or by the “other,” ratherthan by us, and within our psychological practices and insti-tutions. When human rights are acknowledged in appliedpsychology, the focus is on the adverse psychological conse-quences resulting from grave human rights abuses, but noton the root causes. Violations, such as racial violence,slavery, and egregious crimes of torture, are psychologized(Patel, 2011) and the causes and the structural, political,


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and economic conditions which give rise to those violationsare airbrushed away. Further, the survivor is objectified asthe psychological impact (specifically, symptoms anddiagnoses) become the main focus for forensic scrutinyby psychologists, as if the impact is best understood whenstripped of its causes and context, thereby diminishingsurvivors’ own cultured, gendered, and politicized under-standings of their suffering. Similarly, when human rightsviolations (e.g., breach of the right to liberty) are high-lighted in the mental health field, psychologists are quickto step aside and point the finger at psychiatrists, withoutproper and equal scrutiny of how psychologists collude,and also may breach human rights. Unfortunately, whatpsychologists may easily forfeit are the low-hanging fruits– proactive and preventive activities within psychologicalpractice which respect, promote, and defend human rights.

What Is the Human RightsFramework Relevant to Psychology?

The term human rights framework refers broadly to humanrights responsibilities, commitments, and principles, whichare based in international human rights law.

Human Rights Responsibilities

Human rights responsibilities rest with the State which isobliged to protect the rights of its citizens. The responsibil-ities, relevant to health care and psychologists, include:

(1) The recognition that that every individual, by virtue ofbeing human, has human rights. This includes peoplewho use psychological/health services, their carers,and family members who are rights-bearers, and staffworking in State institutions or State-commissionedservices are both rights-bearers and duty-bearers.

(2) The State and public authorities, as duty-bearers, havea responsibility to respect, protect and fulfill humanrights of each individual. Duty-bearers include theState, policy-makers, hospital managers, and health

professionals (including psychologists) who workwithin State institutions, inspectors, regulatory bodies,and others. The term Public authority covers privateorganizations, including non-governmental or privateorganizations, which are commissioned to carry outa public function on behalf of the State.

(3) Accountability for human rights. This requires duty-bearers to provide mechanisms to ensure the socialdeterminants of health are known, understood, andaddressed; to monitor discrimination and disparitiesin access to health care and support; and to identifythe most vulnerable and marginalized. It enablesduty-bearers to explain their practices and to makenecessary changes. It also allows rights-bearers,including those who use services and their carers, tounderstand how service providers have fulfilled theirduties and to claim redress where rights are violated.

(4) Implementation of human rights. Human rights arelegally enforceable entitlements, which should be putinto practice. In health care, this means adhering tohuman rights commitments and principles in servicedesign and delivery, organizational strategies andpriority-setting, policies, procurement, commissioningand funding processes; in the organizational culture,clinical practices, and in all monitoring and evaluationactivities of health services.

Human Rights Commitments

Of the 30 basic human rights based on the UDHR, all mayhave implications for health and to psychological practice.Regional laws, such as the European Convention onHuman Rights and the Charter of Fundamental Rights, alsohave implications for health care. Additionally, domesticlaws contain rights relevant to health care (e.g., laws safe-guarding children, mental health, criminal justice, andanti-discrimination laws), and human rights have to be seentogether with other statutory and ethical obligations ofpsychologists.

The right to health, first established in the UnitedNations International Covenant on Economic, Social, andCultural Rights (ICESCR, article 12), is important for allhealth professionals. This is not a right to be healthy, butthe right to access health care providing equality of oppor-tunity for everyone to enjoy the highest attainable level ofphysical and mental health. Importantly, the right to healthincludes: (a) equal and timely access to basic health ser-vices, the provision of health-related education and infor-mation and services which are available, accessible,acceptable, and of good quality; (b) obligations for Statesto address the underlying determinants of health, whichinclude adequate nutrition and housing, healthy workingand environmental conditions, gender equality, and

Table 1. Human rights

Human rights are seen as:

� Minimal legal standards.� Universal.� Belonging to each individual, by virtue of being human; without

discrimination.� Inalienable and cannot be forfeited or eliminated permanently.� Not dependent for their existence on recognition or enactment by

States.


114 N. Patel, Human Rights-Based Approach to Applied Psychology

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health-related education and information; and (c) free-doms, such as the freedom from torture or other cruel,inhuman, or degrading treatment or punishment andfreedom from non-consensual medical treatment andexperimentation.

To understand how rightswork in practice, it is essential tounderstand that different types of rights set out in the Euro-pean Convention on Human Rights allow for different typesof lawful interference with them, under certain circum-stances. Absolute rights, such as the right to not be torturedor treated in a cruel, inhuman, or degrading way, addressesany treatment which causes severe pain or suffering, physi-cal, and/or mental. The consideration of whether treatmentamounts to torture or to cruel, inhuman, or degrading treat-ment depends on the particular circumstances of each case.As an absolute right, it cannot be limited or restricted in anyway or derogated fromunder any circumstance or situation –whether during war, emergency, health care, and so forth.An absolute right cannot be balanced against the needs ofanother individual or public interests, except where twoabsolute rights need to be balanced.

Limited rights, such as the right to liberty and security ofperson, protects against the deprivation of liberty througharrest and detention, being locked in a room, or in deten-tion setting, or to have movement restricted in any otherextreme way. The right to a fair trial and to not receivepunishment without law is also a limited right, and it appliesto both civil and criminal matters, detention under mentalhealth legislation, employment matters, and dismissal fromemployment and expulsion from a profession or withdrawalof license to practice a profession. Both rights can belimited in certain circumstances although any restrictionhas to be explicit, lawful, carefully justified by those respon-sible and finite.

Qualified rights are those which may need to be balancedagainst the rights of others and in the interests of the widercommunity, or public good, to achieve a fair outcome(as decided by courts). For example, the right to respectfor private and family life, home and correspondence,highly relevant to health care, is a qualified right. It includesprotecting an individual’s private life (e.g., lifestyle choices,choices of personal and sexual relationships, close personalrelationships, and individual sexuality); protecting (keepingconfidential) personal information, including medical,financial, and other personal records, including the storing,sharing, and dissemination of such information; and theright to access one’s own personal information (such ashealth records). It includes protection of personal autonomyand physical and psychological integrity (no one can inter-fere with an individual’s body, without consent); protectionagainst domestic or sexual abuse; respecting one’s estab-lished family life, including close family ties (e.g., carersor family members of clients); being able to maintain and

establish relationships with others (including family rela-tionships and relationships between unmarried and marriedpartners); being able to live with one’s family and wherethis is not possible, to have regular contact; respecting theright of each individual to influence decisions about theircare and contact with family; right to not have one’s homelife interfered with (e.g., by unlawful surveillance, unlawfulentry, and arbitrary evictions); and the right to confidential,uninterrupted, and uncensored communication with others(e.g., no surveillance of phone calls or email, not readingpersonal letters – including when in hospital or a mentalhealth setting). Qualified rights can be restricted, eitherpartly or completely, but with due consideration of the con-sequences for the individuals concerned. Where restrictionsare made on qualified rights, they must have a legitimateaim (as set out in the relevant article, e.g., national security,public safety, and prevention of crime); be necessary (noother actions or methods could achieve the same end);and proportionate (not excessive).

Human Rights Principles

Many of the principles underpinning human rights aresimilar to those embedded in ethical codes for psychologists(e.g., Meta-Code of Ethics of the European Federation ofPsychologists’ Associations, 2005; Universal Declaration ofEthical Principles for Psychologists), which are also providedas a universally applicable framework (Gauthier, Pettifor, &Ferrero, 2010). Of the numerous human rights principlesembedded in many international treaties and articles,12 principles are summarized to illustrate their relevanceto psychological practice and all health care (Table 2).

The interdependence, indivisibility, and inter-relatednessof rights, together, are an overarching human rights princi-ple (Vienna Declaration and Programme of Action, 1993),emphasizing the need to consider rights together, sincethe violation of one right can impair other rights. For exam-ple, the violation of the right to access to quality health carecan impair a person’s ability to engage in education oremployment, leading to poverty and social conditionswhich further impair their health, and the deprivation of lib-erty can also impinge on the right to private and family life –for the person with mental health difficulties and theirfamilies/carers.

Another cross-cutting human rights principle is the needfor gender and culture-appropriateness. In the context ofpatients’ rights, theWHO states that “everyone has the rightto have his or her moral and cultural values and religiousand philosophical convictions respected” (World HealthOrganization, WHO, 1994, article 1.5). The right to healthalso requires health facilities, goods, and services to be“culturally appropriate, that is, respectful of the culture of


N. Patel, Human Rights-Based Approach to Applied Psychology 115

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Table 2. Examples of human rights principles and their relevance to applied psychology and health care

Principle 1 Safety, securityand physical and mentalintegrity of person

The safety, security and physical and mental integrity of every individual person using services, carer/familymember and staff member is protected.

Services should do no harm: people who use services should be able to live as freely as possible and safe fromharm, including from any form of neglect, abuse, violence or exploitation.

Challenges:� How can we ensure that people who use services are not harmed in any way by services, by staff or by other

people who use services; or that their health and safety is not threatened by staff practices or by the environ-ment and conditions in which they are provided services?

� What are alternatives to compulsory treatment and restraint practices?� Which working conditions give rise to threats to staff health and safety?

Principle 2 Fairness Persons using services have access to fair, prompt and impartial processes and procedures for decision-makingabout their healthcare and treatment; and access to fair processes and procedures to provide feedback or makecomplaints about their healthcare and treatment.Decision-making processes to be based on the application of explicit criteria accessible to people who useservices, carers and staff.Staff access to fair processes and procedures to provide feedback or make complaints about employmentconditions and practices.

Challenges:� How can we ensure that all people who use services and their carers are informed of, and can readily access,

user-friendly complaints and feedback mechanisms?� How can we monitor clinical decision-making to ensure service criteria are fairly applied when accepting,

rejecting or sign-posting referrals; and that this decision-making is made transparent to those referred toour services?

Principle 3 Respect People who use services are valued and respected as individuals and are listened to; decisions about their careare respectfully effectively communicated to them; and what is important to them is viewed as important by theservice.Staff are valued and respected as individuals and what is important to them is viewed as important by theiremployer.

Challenges:� How can we seek and meaningfully integrate the views of people who use our services in our psychological

formulations and care?� How can we respectfully inform a person why they cannot be offered a service?

Principle 4 Dignity People who use services are always treated in a humane way –with compassion and in a way that values them ashuman beings and supports their self-respect, even if their wishes are not known at the time. Dignity is interlinkedwith the principles of respect and autonomy and includes the right to bodily integrity and to control one’s bodyand health, as well as the right to informed consent in the context of healthcare.Respect relies on gaining and acting on the views of the person; but all persons should be treated with dignityregardless of whether their views are known, whether unconscious, lacking mental or physical capacity, havingcommitted a crime, caused harm to another etc.Staff are treated in a humanitarian and compassionate way which values them as human beings and supportstheir self-respect.

Challenges:� How can we ensure the dignity of a person with cognitive decline, or someone lacking mental capacity, whilst

they are receiving care?� How can we prevent practices and healthcare conditions which could be considered degrading?� How can we ensure minimal and only lawful surveillance (e.g., cameras) when people are in hospital, care

homes etc.?

Principle 5 Autonomy People who use services can exercise the maximum amount of choice and control possible – in their individualhealthcare; in service development; in their relationships with others; and as citizens beyond the health and socialcare services that they are using.This includes the right to informed consent, ensuring information, encouragement and support to people who useservices and their carers to evaluate the possible benefits and harms of any choice or decision; and to be able tocontribute to decisions.

Challenges:� How can we best support people to freely choose or refuse a particular service or therapy on offer?� How can we respect the religious or other deeply-held beliefs (e.g., pacifism) of people who use services and of

carers?

(Continued on next page)



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Table 2. (Continued)

Principle 6 Participation andinclusion

Everyone has the right to participate in decisions and in the development of policy and practices which affectthem. Participation must be active, free, and meaningful.

A participatory approach seeks to uphold human dignity of every person by ensuring that each individual using aservice, and their family members/carers:(a) Are informed of and given opportunities to meaningfully participate in decisions that affect them.(b) Have equal opportunity to have their voice heard, including those who are already marginalised, excluded or

have limited influence in decision-making processes which affect them.(c) Are meaningfully involved in decision-making processes which affect them, and their needs and views are

properly considered.(d) Are given adequate, relevant and accessible information (considering age, gender, language, cultural and reli-

gious background); support and the means to making and having their views and complaints heard andaddressed.

(e) Are entitled to meaningful participation in the design, implementation and monitoring of interventions providedin services.

(f) Are given opportunities to meaningfully participate in decision-making at all levels of the organisation, e.g., inthe management board, service planning and development.

(g) Have freedom of association to meet with others in order to be able to participate in the above.

Challenges:� How can we ensure that service-user involvement mechanisms are not tokenistic and that they do not deter or

exclude those who are from marginalised backgrounds or others (e.g., women, young people)?

Principle 7 Indivisibility ofrights

Human rights are inter-related, indivisible and interdependent and need to be considered together, not inisolation. Violating one right can impair the enjoyment of other rights.

Challenges:� How can practitioners and teams keep in mind during decision-making that interfering with one right can

affect other rights of the individual, or others? For example, restricting the right to exchange information tosay or write what they like, may also interfere with the person’s right to private life; e.g., placing someonein seclusion in mental health setting restricts the right to liberty, but if it also prevents family visits, it caninterfere with the right to family life for the person and their family members.

Principle 8 Balancing ofrights

Each situation has its own unique context in which there should be a careful consideration of the rights of eachindividual.

There may be competing rights in some cases, and sometimes the rights of the person using the service may needto be considered alongside the rights of their carer, or the interests of the wider community. In these situations,there needs to be a balancing in reaching decisions.The classification and nature of the relevant human rights are considered in such balancing. Absolute rights (e.g.,freedom from torture or other cruel, inhumane or degrading treatment) would take precedence over limited rights(e.g., right to liberty). Absolute rights can never be balanced with qualified rights.

Challenge:� How are the views and the rights of children respected, whilst also considering the views and rights of their

parents/caregivers?� How can the safety of an individual, and the possible risk of harm to their family or the wider community, be

considered together?

Principle 9 Proportionality Restrictions placed on rights should be to the end that needs to be achieved; they should be lawful, legitimate andproportionate; and they should ensure a proper balance between the needs and rights of other people who useservices, carers/family members and staff.In other words, a proportionate action is one that is:(a) Appropriate to the situation, for a legitimate reason and not arbitrary or unfair.(b) In the given circumstances, as least restrictive on a person’s rights or freedoms as possible.(c) Not excessive (not “using a sledge hammer to crack a nut” when other means would suffice).(d) The infringement of a person’s human rights is kept to a minimum and reviewed regularly.

Challenges:� How services ensure that any actions and service policies (e.g., blanket bans on access to mobile phones when

detained on mental health grounds); and restrictions to an individual’s rights (e.g., preventing contact withfamily members, or seclusion practices), are not excessive, and not primarily for the convenience of staff?

Principle 10 Equality, non-discrimination and attentionto vulnerable groups

People who use or provide health services, and carers, do not experience discrimination on any prohibitedgrounds.

(Continued on next page)



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individuals, minorities, peoples and communities, sensitiveto gender and life-cycle requirements” (UN, 2000, para.12(c)). A gender-based approach recognizes “that biologicaland socio-cultural factors play a significant role in influenc-ing the health of men and women” and “where a genderperspective is integrated into health-related policies, plan-ning, programmes and research to promote better healthfor both women and men” (UN, 2000, para. 20).

Similarly, equality and non-discrimination are importanthuman rights principles, relevant to all health care (UN,2009a). States have an obligation to prohibit discriminationand a positive obligation to ensure equality of opportunityfor the enjoyment of the right to health by persons withmental health problems (ICESCR, article 2(2); UN,2009a, 2009b). States are also obliged to prohibit andeliminate discrimination on all grounds in access to healthservices and to address underlying social determinants andto prohibit and to eliminate racial discrimination and guar-antee the right of everyone to public health care (Interna-tional Covenant on the Elimination of all forms of RacialDiscrimination [ICERD], article 5). The principle of non-discrimination extends to those with mental health difficul-ties (UN, 2017a) and requires States parties to “recognizethat persons with disabilities [physical or mental] havethe right to the enjoyment of the highest attainable stan-dard of health without discrimination on the basis of dis-ability” (CRPD, article 25).

Statesmust also recognize and address the needs of speci-fic groups which face particular health challenges andwhichcan be considered vulnerable, particularly because vulnera-ble andmarginalized people are often less likely to enjoy theright to health (WHO, 2015). Vulnerable groups include, forexample, those who have suffered from social inequalities,discrimination, and stigma, and who face challenges in rela-tion to the right to health, including those who have beencontinuously discriminated against by State practices (UN,2009b). The reliance on the person’s ability to pay can beseen as discrimination against those without the adequatefinancial means to access equal quality of psychologicalhealth care. Yet, there are different quality of psychologicalcare provided to different social groups and to those fromsocially disadvantaged groups (e.g., low-income families,ethnic minority people, refugee people) and differentialaccess to psychological therapies, dependant on the nationalhealth structures and health-financing systems.

The Limitations and Valueof Human Rights

There are many obstacles to the implementation of humanrights globally, including geopolitical and economicnational interests, lack of political will, weak or absent civil

Table 2. (Continued)

All forms of discrimination must be prohibited, prevented and eliminated and those who are in situations wherethey can be considered vulnerable and less able to access their rights should be prioritised.

Challenges:� How can we prevent discrimination (based on sex, sexuality, race/ethnicity, disability, etc.) in our care/inter-

vention plans and in services?� How can we prevent discrimination against those who do not speak fluently, read or write in the main national

language?

Principle 11 Gender andcultural appropriateness

Decisions and practices towards people who use services, carers and staff should adhere to the human rightsprinciples of ensuring gender and cultural appropriateness, on a service-wide level and for each individualperson’s unique context.Challenges:� How can we systematically scrutinise our practices and services for gender- and cultural-appropriateness and

relevance; and promote good practice?

Principle 12 Monitoring bydisaggregation

Compliance with human rights obligations and potentially unfair disparities and discrimination in treatment andhealthcare practice should be monitored.

This includes monitoring of organisational practices related to staff, persons who use services and theirfamilies/carers (including disparities in access to services, types of services and practices). Such monitoringshould be disaggregated (e.g., by sex, gender, age, ethnicity, disability, sexuality) to assess organizationalpractices for non-discrimination, equality and fairness.Monitoring by disaggregation should be used to inform national, organisational and service policies, servicedesign, service development and practices within services.

Challenges:� How can services develop and implement appropriate mechanisms to routinely monitor their practices (e.g.,

according to sex, race/ethnicity, disability)?� How can the results of such monitoring be used to improve psychological practices and services?



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society, corruption, lack of an independent judiciary,harassment and intimidation of human rights defenders,lack of awareness and understanding of human rights, fearof threats, marginalization, persecution, detention, torture,and ill-treatment. The reasons are multiple, complex, andvariable, differing from country to country.

At the theoretical and philosophical levels, human rightsremain deeply contested (e.g., An-Nai’im, 2016; Ignatieff,2001; Panniker, 1982; Shachar, 2001). Human rights arearguably a substitute to traditional, institutionalized moral-ity. They are the legal codification of a certain set of moralprinciples, emerged from a process of consensus-buildingon norms and values, and fashioned by political interest,patriarchal, White, and economic privilege as well as bynational, regional, and global power struggles, within thespecific conditions and context of post-World War II.As such, human rights continue to draw criticisms fromsome States as being a neocolonialist enterprise of theWest. It is the nature of those moral principles, also thebedrocks of applied Western psychologies, that betraysthe Eurocentricity and individualism derivative of Westernmoral philosophies and culturally mediated understandingsof what it is to be human. For example, the principle ofautonomy, also rooted in liberal political philosophy, con-structs the human in human rights as an individual, anautonomous agent, whose entitlement to autonomy to exer-cise choice and control requires certain conditions and safe-guards. Such a construction of rights diminishes collectivesuffering and rights of those subjected to marginalization,persecution, and harm, as a group, for example, becauseof their ethnicity or beliefs. Similarly, the classification ofsome rights as absolute, and hence as conclusively valid,always, is also contested (Gewirth, 1981). Hence, whilehuman rights are posited as minimum moral guaranteesencompassing fundamental principles of humanity, theircontext-boundedness undermines claims to universalityacross contexts, cultures, ethnicities, religions, politicaland philosophical backgrounds, and history.

Yet, in defense of human rights, some have questionedwhat else could unify humanity (Tibi, 1994) in the absenceof international human rights. The search for a globallybinding, exhaustive, and acontextual set of morals or oneabsolute set of culturally-free norms is ambitious, and per-haps any such universalizing discourse is undesirable, sincecontext is inescapable. The particularist Western construc-tion of human rights (Cerna, 1994; Mutua, 2002; Panniker,1982) is unsurprising, since human rights were drawn upwithout the equal and full participation of all nations, somestill under colonial rule at the time. Nevertheless, humanrights continue to evolve and proliferate (e.g., in the AfricanCharter of Human and People’s Rights, the Cairo Declara-tion of Human Rights in Islam, 1990 and the Arab Charterof Human Rights, 1994), encompassing a wider set of

values, arguably consistent with “pluralist universalism”

(Parekh, 1999), or interpreting universalist values througha cultural lens, more akin to “relative universality” (e.g.,Donnelly, 2007). However, cultural rights arguments canalso be problematic in their propensity to reproduce patriar-chal domination (e.g., Shachar, 2001), both in the construc-tion and application of human rights, such that girls andwomen continue to be most at risk of harm and rightsviolations.

Notwithstanding the pervasive impresses and strugglesof power and ideologies in the codification and implemen-tation of human rights, they have been utilized in socialmovements and civil rights struggles in many contexts, bythose who are marginalized, discriminated against,oppressed, and subjected to persecution, violence, torture,genocide, and so forth. Ignatieff (2001) suggests, what isimportant is what human rights can do for people, anapproach which assumes that no one would want to contestthe view that all human beings deserve to be free ofviolence, poverty, insecurity, and that each of us shouldbe allowed to pursue a “good life” (however that is con-structed) with peace, freedom, and safety.

The recognition that every individual is worthy of respectand protection as a human being, and even more so when aperson is vulnerable to marginalization, exploitation, orharm, is one of the core values central to both human rightsand psychology. A pragmatic epistemological stance tohuman rights does not evade the shortcomings of humanrights, including the Eurocentric, gendered, ideological,ethical, political, and constructed nature of human rights.It would mean recognizing that a human rights framework,despite its limitations, offers psychologists a compass andimportant tools, in the service of change, to improve thelives of all human beings.

This does not resolve the dilemmas of using potentiallyoppressive discourses and tools, or the incompatibility ofsome values and cultural norms or competing claims forhuman rights (e.g., rights of the person and those of theircarer). Pragmatism, however, does not advocate that “any-thing goes,” nor is it a crude form of utilitarianism, withfluid principles and applications as situations and individualor institutional opinions and priorities dictate. Instead, prag-matism can enable ethical decision-making in psychologicalpractice, which draws on human rights to achieve particularends, for example, the prevention of harm toward, and theprotection and improvement of the health and well-beingof, individuals, families, and communities. A pragmaticand critical realist stance acknowledges the values andmoral arguments psychologists use in support of moralpositions on well-being, justice, humanity, and humanrights (Patel, 2011) and accepts that human rights are notfixed, complete, objective, and definitive truths, simply inneed of implementation. It is a stance which recognizes,



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as argued by Mutua (2002), that the human rights move-ment is young and hence provides scope for experimentaldevelopment and critique.

What Is a Human Rights-BasedApproach to Health Care?

The World Health Organization holds that a “humanrights-based approach [HRBA] to health provides strategiesand solutions to address and rectify inequalities, discrimina-tory practices and unjust power relations, which are often atthe heart of inequitable health outcomes” (WHO, 2015).The aims of HRBA are that States ensure that “all healthpolicies, strategies and programmes are designed with theobjective of progressively improving the enjoyment of allpeople to the right to health” (WHO, 2015). Globally, thereis increasing ownership at the level of policy-makersregarding the importance of HRBAs in framing servicesto benefit disadvantaged populations, and human rightsare being increasingly integrated into health policies andprograms in different countries (Hunt, Ely Yamin, & Bus-treo, 2015).

Inmental health, a HRBA is advocated by UN bodies. TheUN’s High Commissioner for Human Rights, noting thatstigma, discrimination, violations of human rights, and thedenial of autonomy and legal capacity are some of the chal-lenges faced by those who use mental health services, rec-ommended policy shifts to include systematic inclusionof human rights and the recognition of the individual’sautonomy, agency and dignity and attention to the underly-ing social determinants; elimination of stigma and non-discrimination; and the application of the principles ofparticipation, data collection/monitoring for accountabilityand free and informed consent for treatment (UN, 2017b).Both, this report and that of the Special Rapporteur onHealth (UN, 2017c), support a HRBA to improve mentalhealth service delivery and recommend an end to involun-tary treatment, arbitrary deprivation of liberty and institu-tionalization; the unconditional application of the principleof non-discrimination associated with the mental health“impairment”; and an adoption and integration of such aHRBA in mental health policy (UN, 2017b). However, notall UN bodies support an absolute ban on involuntary deten-tion and treatment (e.g., the Human Rights Committee andthe Subcommittee on the Prevention of Torture and otherCruel, Inhuman, or Degrading Treatment).

The implications of HRBA for practitioners have beenlargely neglected, partly due to the lack of agreed definitionsof a HRBA. In the UK, the FREDA principles of humanrights (fairness, respect, equality, dignity, and autonomy;

Curtice & Exworthy, 2010) and the PANEL principles(people’s right to participate in decisions that affect theirlives; accountability of duty-bearers; non-discriminationand prioritization of vulnerable groups; empowerment ofrights-holders; and legality; Dyer, 2015) are put forward aspart of a HRBA to health services. A HRBA to applied psy-chology andmental health can be described as the adoptionof human rights as a conceptual framework for all aspects ofhealth care, from policy, research, practice, and monitoring;an approach which places physical, psychological, and socialhealth firmly within the context of security, social justice,equality, and non-discrimination. Hence, a HRBA frameshealth not just as needs but as rights to safety, variousprotections, and freedoms, whereby every individual andcommunity can enjoy health and well-being. In practice, itrequires also a scrutiny of traditional notions of empower-ment – for example, where is privilege and power and howdoes operate –who has the authority, means, and legitimacyto empower and protect who, why, in whose interests? Forall psychologists and mental health professionals, the struc-tural reality and operations of power cannot be denied;power is embedded in our professional knowledge produc-tion, methods, practices, and professional, academic, andregulatory institutions. The dynamics of power between psy-chologists and those we seek to support are also inevitable.In some cases, the site of psychological assessment, formu-lation, therapy or other research, or other psychologicalactivities are the very source of disempowerment, subjuga-tion, and discrimination, raising human rights issues.

A HRBA to applied psychology requires a critical exami-nation of which human rights principles are privileged,which are subjugated or simply ignored, when and why;whose notion of health, rights, freedoms, dignity, and safetyprevail – and what is surrendered or made invisible in ourwork. This demands transparency in how and where poweroperates in our theories (e.g., scientific racism), our profes-sional roles, practices, and services (e.g., institutionalsexism, homophobia, and racism), and the adverse impactsof psychological models, practices, and institutions on eachindividual, their family/carers, and communities. A HRBAalso requires identification of the social determinants ofhealth, social inequalities, patterns of discrimination, andhuman rights violations which happen “out there” andwithin health services and practices. It requires an honestexamination and acknowledgment of how and when ourpractices and services lead to adverse consequences;collude with, condone, and perpetuate (directly or indi-rectly) human rights violations and social injustices; andhow they ignore or deny the right to redress for thoseharmed by our practices, research activities, and services.A HRBA has implications for psychological practice,research, advocacy, and pedagogy.



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HRBA and Psychological Practice

A HRBA implies that psychologists can promote humanrights principles and awareness in everyday professionalpractice with individuals, groups, and communities, indifferent settings and services.

HRBA and Psychological Research

With respect to HRBA to psychological research (Table 3),most research ethics governance structures and processes,where available, help ensure ethical risks are minimizedand breaches reported and addressed (Table 4). Yet, oftenresearch ethics governance fails to adequately addresshuman rights principles explicitly and inadequate monitor-ing and accountability processes can render such gover-nance toothless, where potential or actual breaches ofhuman rights in research pass unnoticed.

HRBA and Advocacy

A HRBA to psychology includes two levels of advocacy(Table 5): individual-level (specific to an individual

case – individual or family) and policy-level advocacy, bothconsistent with the role of psychologists as human rightsdefenders.

HRBA and Applied Psychology Trainingand Pedagogy

The adoption of a HRBA to psychology depends largely onthe commitment of diverse professional bodies and psychol-ogy training institutions to prioritize and meaningfullyengage with human rights. The broad components of anyhuman rights training would ideally include knowledge anda critical appraisal of human rights and its relevance to psy-chology; skills in applying human rights principles, alongsideethical principles, in clinical practice, services, research, andadvocacy. Human rights education is important for all healthprofessionals (UN, 20017a, para. 45) and ideally should beintegrated at every level of the curriculum pre-qualification,and post-qualification, it should be valued as a continuousprocess of learning and professional development.

A HRBA to pedagogy in applied psychology requires keycompetencies to be nurtured across the domains of aware-ness, knowledge, and skills (Table 6).

Table 3. Human rights in psychological practice

A human rights-based approach includes:

(1) Raising awareness of human rights and promoting a shared understanding of how human rights principles and legal standards may be at riskin a particular service (e.g., services for children and young people, older adults, refugees, those with learning difficulties) and which practiceshelp defend human rights, minimize the risk, or prevent human rights breaches.

(2) Respecting human rights principles, alongside ethical obligations, in all aspects of psychological practice, services, clinical supervision, andteam discussions.

(3) Recognizing and acknowledging the social, economic, and political causes of suffering and pain, including social injustices and experiences ofdiscrimination, inadequate housing, poverty, sexual exploitation, abuse and violence, torture, human trafficking, and other human rightsviolations.

(4) Adopting a stance of non-neutrality against human rights violations.(5) Recognizing and acknowledging the potential for, or actual discrimination, coercion, exploitation, harm, or other human rights breaches within

(a) psychological assessments, formulations, interventions, and evaluations; (b) team practices and team decision-making on individuals’care; and within (c) the design, delivery, policies, procedures, and practices of psychological services.

(6) Recognizing and acknowledging ethical and human rights breaches when they occur within clinical practice and services and addressing thisto ensure accountability and redress for clients.

Table 4. Human rights in psychological research

A HRBA to psychological research includes:

(1) Recognizing that research ethical principles and human rights principles are compatible and complementary and require integration through-out the research process.

(2) Respecting and protecting human rights principles in all aspects of psychological research and throughout the research process to ensureresearch does not entail, lead to, or promote discrimination, exploitation, abuse, harm, or other human rights violations, including unlawfulbreaches of confidentiality and absence of informed consent.

(3) Robust monitoring and accountability mechanisms to address human rights breaches in research.



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Applied Psychologists asPractitioner-Activists

In adopting a critical human rights-based approach to psy-chology, the role of applied psychologists can be conceptu-alized as practitioner-activists. The label of activism directlychallenges traditional psychological approaches whichfocus primarily on the psychological manifestations andconsequences of social adversity and rights violations. Inadopting a HRBA, it is important to recognize that everyaspect of psychological practice which is aimed at change

processes, whether individual, interpersonal, familial, com-munity, organizational, or societal, is activism – since suchpractices seek change to the status quo and the circum-stances, factors, and conditions which impact adverselyon psychological health and the well-being of individuals,families, and communities.

The practitioner-activist seeks to uphold and promote therights of all people to be treated as human beings with dig-nity. It is a stance which is value-laden, against humanrights violations and a role antithetical to being bystanders;a stance which seeks and values the views, experiences,and participation of survivors of human rights violations.

Table 5. Human rights-based approach to advocacy by psychologists

A human rights-based approach to advocacy by psychologists includes individual-level and policy-level advocacy:

Individual-level advocacy (working with individual cases – individual/family)

(1) Acknowledges the social, economic, and political threats, abuses, and human rights violations (e.g., poverty, inadequate housing, religiouspersecution, sexual violence, and torture) which cause psychological suffering and pain.

(2) Develops and implements psychological activities and interdisciplinary interventions, with others, which seek to protect and defend theperson’s/family’s social, economic, and cultural rights and basic needs for safety, security, adequate housing, food, and clothing.

(3) Develops and implements psychological activities and interventions which aim to protect the person/family from discriminatory abuse,violence or other physical, emotional, or sexual abuse or other forms of harm and exploitation, including economic and sexual exploitationand other human rights violations, in the wider society, public institutions and within psychological, health or social care services.

Policy-level advocacy

(1) Acknowledges and identifies the relationship between certain policies (service, local, national, or international), which may lead to humanrights breaches and their adverse psychological impacts.

(2) Raises awareness of human rights issues and the adverse psychological impacts of certain policies and practices of public institutions (e.g.,impact of national health policy, whistle-blowing within institutions, defending human rights of people using services and of staff).

(3) Develops and supports the implementation of interventions to influence, change, or help develop new policies (e.g., for gambling-regulation,refugees and immigration, social welfare, and housing) which can better protect human rights and promote psychological health.

(4) Ensures that professional bodies, their regulatory institutions and ethics committees, integrate a HRBA in their ethical codes and monitoringand accountability mechanisms.

Table 6. Competencies for human rights-based approach to applied psychology

Critical awareness and understanding of:

(1) The underpinning and shared values of human rights and professional ethics.(2) The relationship between human rights and psychology.(3) Human rights and the human rights framework relevant to psychology and health care; key limitations and critiques of human rights and the

implications for applied psychology.(4) One’s own values, experiences of social injustices, disadvantage, privilege, and experience of human rights (and their violations).

Ability to:

(5) Critique the role of psychologists in perpetrating, condoning, or supporting human rights violations.(6) Assess and formulate the impact of human rights violations on psychological health of individuals, families, and communities, addressing

context.(7) Use a range of interventions working with survivors of human rights violations, adopting a HRBA.(8) Apply a HRBA to psychological service design and delivery.(9) Apply a HRBA to conducting and evaluating psychological research.(10) Contribute to prevention activities including individual- and policy-levels of advocacy.



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As practitioner-activists, psychologists acknowledge andseek to understand and theorize the relationship betweensocial context, social injustices, and human rights violationsand health; they commit to a HRBA in psychological prac-tice, research, service design, and delivery. This in turndemands that practitioner-activists name, expose and seekto understand the dynamics of power as well as to addressthe root causes of suffering and the impact. A practitioner-activist works in collaboration with others, such as legal andadvocacy practitioners, to engage in advocacy-relatedactivities which seek to promote and defend human rightsand to help prevent human rights violations, enablingaccess to justice, redress, and health care. This requiresmore than human rights education; it demands changesin our theories, methods of knowledge production, ourprofessional training, and regulatory bodies, and in ourpractice so that human rights-based practice is a core, foun-dational competency.

Conclusion

Human rights set high international standards, yet thenumerous political, economic, cultural, and other obstaclesto the realization of human rights may mean that for theforeseeable future, human rights remain partially achiev-able and aspirational. For applied psychologists, often work-ing with those who are particularly vulnerable anddisadvantaged, a HRBA provides a framework andresources which complement our professional and ethicalobligations. At best, a HRBA enables psychologists to usetheir knowledge and skills, as practitioner-activists, to helprespect, promote, and defend human rights.

References

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Cerna, C. (1994). Universality of human rights and culturaldiversity: Implementation of human rights in different social-cultural contexts. Human Rights Quarterly, 16, 751–752.https://doi.org/10.2307/762567

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Gauthier, J., Pettifor, J., & Ferrero, A. (2010). The UniversalDeclaration of ethical principles for psychologists: A culture-sensitive model for creating and reviewing a code of ethics.Ethics & Behaviour, 20, 179–196. https://doi.org/10.1080/10508421003798885

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Ignatieff, M. (2001). Human rights as politics and idolatry. Prince-ton, NJ: Princeton University Press.

Maslow, A. (1943). A theory of human motivation. PsychologicalReview, 50, 370–396. https://doi.org/10.1073/h0054346

Mutua, M. (2002). Human rights: A political and cultural critique.Philadelphia, PA: Pennsylvania University Press.

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Panniker, R. (1982). Is the notion of human rights a westernconcept? Diogenes, 120, 75–102. https://doi.org/10.1177/039219218203012005

Parekh, B. (1999). Non-ethnocentric universalism. In T. Dunne & N.J. Wheeler (Eds.), Human rights in global politics (pp. 128–159).Cambridge, UK: Cambridge University Press.

Patel, N. (2011). The psychologisation of torture. In M. Rapley,J. Moncrieff, & J. Dillon (Eds.), De-Medicalising Misery: Psychi-atry, psychology and the human condition (pp. 239–255).London, UK: Palgrave Macmillan.

Shachar, A. (2001). Multicultural jurisdictions: Cultural differencesand women’s rights. Cambridge, UK: Cambridge UniversityPress.

Tibi, B. (1994). Islamic/Shari’a law, Human rights, universalmorality and international relations. Human Rights Quarterly,16, 277–299. https://doi.org/10.2307/762448

United Nations (UN). (2000). General Comment no. 14: The right tothe highest attainable standard of health. E/C.12/2000/4,reprinted HRI/GEN/1/Rev.6 at 85 (2003). http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=4slQ6QSmlBEDzFEovL-CuW1AVC1NkPsgUedPlF1vfPMJ2c7ey6PAz2qaojTzDJmC0y%2B9t%2BsAtGDNzdEqA6SuP2r0w%2F6sVBGTpvTSCbiOr4XVFTqhQY65auTFbQRPWNDxL

United Nations (UN). (2009a). General Comment no. 20: Non-discrimination in economic, social and cultural rights. E/C.12/GC/20. Retrieved from https://tbinternet.ohchr.org/_layouts/treatybodyexternal/Download.aspx?symbolno=E%2FC.12%2FGC%2F20&Lang=en

United Nations (UN). (2009b). Report of Special Rapporteur onright to health. A/64/272. Retrieved from https://www.ohchr.org/en/hrbodies/sp/pages/ga64session.aspx

United Nations (UN). (2017a). Human rights council resolution onmental health and human rights. A/HRC/36/L.25. Retrievedfrom https://www.ohchr.org/EN/HRBodies/HRC/RegularSes-sions/Session36/Pages/ResDecStat.aspx

United Nations (UN). (2017b). Mental health and human rights.Report of the United Nations High Commissioner for HumanRights. Human Rights Council, A/HRC/34/32. https://digitalli-brary.un.org/record/861008

United Nations (UN). (2017c). Report of the Special Rapporteur onthe right of everyone to the enjoyment of the highest attainablestandard of physical and mental health. A/HRC/35/21. Retrievedfrom https://www.ohchr.org/en/issues/health/pages/annualre-ports.aspx

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World Health Organization (WHO). (1994). Declaration on thepromotion of patients’ rights in Europe Retrieved from https://www.who.int/genomics/public/eu_declaration1994.pdf.Geneva, Switzerland: WHO

World Health Organization (WHO). (2015). Health and HumanRights, Factsheet no. 323 Retrieved from https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health.Geneva, Switzerland: WHO

HistoryReceived June 4, 2018Revision received October 28, 2018Accepted January 24, 2019Published online June 14, 2019

ORCIDNimisha Patel

https://orcid.org/0000-0001-7909-2785

Nimisha PatelSchool of PsychologyUniversity of East LondonArthur Edwards BuildingThe Green Water LaneStratford E15 4LZUnited [email protected]

Nimisha Patel is a UK-based Con-sultant Clinical Psychologist; theExecutive Director of the Interna-tional Centre for Health and HumanRights, an NGO; and Professor ofClinical Psychology at the Universityof East London, UK. She has exten-sive experience working with anddeveloping services for survivors oftorture and of other human rightviolations, and in conducting inter-disciplinary human rights researchand policy work in this field interna-tionally.



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Taking Ethics SeriouslyToward Comprehensive Education in Ethics and HumanRights for Psychologists

Duška Franeta

Faculty of Law and Business Studies “dr Lazar Vrkatić”, University Union, Novi Sad, Serbia

Abstract: Education in ethics and professional regulation are not alternatives; education in ethics for psychologists should not be framedmerely as instruction regarding current professional regulation, or “ethical training.” This would reduce ethics to essentially a legal perspective,diminish professional responsibility, debase professional ethics, and downplay its primary purpose – the continuous critical reflection ofprofessional identity and professional role. This paper discusses the meaning and function of education in ethics for psychologists andarticulates the reasons why comprehensive education in ethics for psychologists should not be substituted by instruction in professionalcodes. Likewise, human rights education for psychologists should not be downgraded to mere instruction in existing legal norms. Human rightsdiscourse represents an important segment of the comprehensive education in ethics for psychologists. Education in ethics should expose andexamine substantial ethical ideas that serve as the framework for the law of human rights as well as the interpretative, multifaceted, evolving,even manipulable character of the human rights narrative. The typically proclaimed duty of psychologists to protect and promote human rightsrequires a deepening and expounding of the human rights legal framework through elaborate scrutiny of its ethical meaning. The idea ofaffirming and restoring human dignity – the concept often designated as the legal and ethical basis, essence, and purpose of human rights –

represents one approach to framing this duty by which the goals of psychology on the professional and ethical levels become unified.

Keywords: ethics for psychologists, professional identity, code of ethics, human dignity, human rights

Recent decades have witnessed substantial development inthe professional ethics field. The amount of literature in therealm of medical ethics, legal ethics, media ethics, and soforth, has grown considerably. Since this millennium began,ethics has stood as a separate subject in the curriculum ofmedical schools in the EU (Claudot, Alla, Ducrocq, & Cou-dane, 2007), also becoming a mandatory course in lawschools in significant jurisdictions worldwide, such as inthe US and Canada (Economides & Parker, 2011).

In the field of psychology, a similar trend has been occur-ring. Not so long ago only scant literature addressing topicsregarding the ethics for psychologists existed (Bobbitt, 1952;Pettifor & Sinclair, 2011; Sinclair, 2017). In several previousdecades, however, the amount of attention paid to this areaof knowledge has grown extensively (Sinclair, 2017; List ofAPA books on Ethics, https://www.apa.org/pubs/books/browse?query=subject:Ethics&sort=DateAsc). Furthermore,nearly all surveyed American Psychological Association(APA) accredited PhD programs in the US maintain ethicsas a required course (Domenech Rodriguez et al., 2014).Contrastingly, in European institutions for higher learningof psychology, separate ethics courses are not necessarilystandard, nor is there a consensus that they should be,

despite research supporting this option regarding researchethics (Antes et al., 2009) and the growing awareness ofrelevance of ethics for psychologists. Indeed, there are rec-ommendations on the European and national levels thatethics should be integrated in all psychology programs(European Federation of Psychologists’ Associations[EFPA], 2017; British Psychological Society [BPS], 2017)or specifically through seminars in educational models thatqualify for practice in particular areas (EFPA, 2017).

Although the “osmosis approach” as critically labeled byHandelsman (1986, p. 371) – the idea that spontaneous andinformal ethical training during supervision on its own isthe right educational choice – is apparently under retreat,the current situation in Europe, regardless of how muchthe instruction is being based upon a more formalized prac-tice tutorials, still does not fully foster comprehensive edu-cation in ethics for psychologists. This paper discusses themeaning and function of education in ethics for psycholo-gists, articulates the reasons for why it should not bereduced to instruction in professional codes, and elaborateson a comprehensive approach to addressing essential ethi-cal topics, such as human dignity (hereafter: dignity) andhuman rights.


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Codes’ Limitations and Educationin Ethics for Psychologists

Recent Developments

Ethical codes entered the psychology arena in the 1950swith the New York State Psychological Association stan-dards (Harris, 1952) and the APA’s first provisional andlater final standards (1953, 1959; Sinclair, 2017). These dec-ades also characterized a considerable increase in numberof articles on ethics for psychologists, professionalizationof psychology, development of Nuremberg code (1949),first ethics committees in the realm of psychology, adoptingof ethical standards by APA (1959) and developing of codesfor psychologists in other countries, first courses in ethics,and so forth (Sinclair, 2017). However, already at that timethe opinions on the purpose and contents of psychologists’codes differed from clear skepticism of their benefits (Hall,1952) to optimistic standpoints (Bobbitt, 1952; Miller, 1952),from views that they should be maximalist (Macfarlane,1952) to those preferring minimalistic ones (Hunt, 1952),from those favoring abstract codes (Pratt, 1952) to thoserequiring specific ones (Cook, 1952). During these early dis-cussions important questions were raised:

“Will the adoption of a code give us inflexiblestandards in a world permanently changing? Will acode result in our leaning so heavily on institutionalcontrol that we stifle individuality and establish acheap surrogate for individual conscience? Is offi-cially codified morality a move toward undesirableand undemocratic centralization of authority anddepersonalization of life?” (Bobbitt, 1952, p. 425)

The following decades would be marked by the codificationof ethics for psychologists. Did this mean that the earlyquestions, worries, and uncertainties were simply resolvedor suspended? The next few paragraphs will examine howsome of the troubling issues were addressed or integratedby some of the codes themselves.

The first APA code was created on the basis of empiricalresearch of ethically troubling incidents psychologists faced(Pope & Vetter, 1992). Its function was to replace morecentralistic, undemocratic, and unrealistic procedures, butfrom a contemporary perspective the research mutedclients’, students’, citizens,’ and the general public voice.Certain inadequacies of this code – such as legalism, ethno-centrism, lack of moral foundation, and so forth (Pettifor,2004, p. 268) – led to its revision as well as to codes in othercountries attempting to tackle the early worries and skepti-cism alternatively, such as the Canadian Code of Ethics forPsychologists (Canadian code, first adopted in 1986; fourth

edition, 2017) or the Meta-Code of Ethics (EFPA, 1995/2005) which was designed as a general framework forcodes of EFPA member associations. The Canadian codehas been imagined as a “social contract” (Canadian Psy-chological Association [CPA], 2017, Preamble) – althoughits empirical basis also covered only psychologists’ voices,as both constituting the ethical maximum and minimum,as including a place for individual moral reasoning (Sinclair,1998). Like the somewhat later EFPA Meta-code (EFPA,1995/2005), it has been developed as an umbrella docu-ment for other codes and guidelines. Characteristic to thesetwo and some later codes are also a series of recognitionsthat deserve mentioning.

The Canadian code recognizes that ethical principles andvalues may conflict, that ethical principles sometimes areby themselves insufficient for making decisions, that someissues are difficult to resolve in only one way, that there aresignificant differences in the understanding of moral rights,that psychologists’ own values and experiences influencetheir actions and choices (CPA, 2017). The EFPA Meta-code distinguishes knowledge of ethics and knowledge ofcode, recognizes possible tensions between different ethicalduties, acknowledges the presence of ethical dilemmas andemphasizes what psychologists should be aware of insteadof directly regulating the matter (EFPA, 1995/2005). Thelatter strategy has been also employed by the UniversalDeclaration of Ethical Principles for Psychologists(UDEPP), a document developed by an international work-ing group chaired by Janel Gauthier and modeled as aframework for psychology organizations’s codes worldwide.The UDEPP requires awareness of acting in a larger socialcontext, of differences in cultures, of influences of self-knowledge upon one’s work, of the need to balance open-ness and other duties and puts an emphasis on valuesand principles rather than on binary rules, and so forth(International Union of Psychological Science, 2008).Emphasizing the issue further, the Model Code of Ethics,another EFPA’s umbrella document for member associa-tions which was adopted in order to complement theEFPA’s Meta-code and to model future professional legisla-tion and codes, highlights that it is not possible to regulateeverything nor does the code “provide answers to everyethical dilemma” (EFPA, 2015, p. 8). BPS’s Code of Ethicsand Conduct (BPS code) acknowledges that “no code canreplace the need for psychologists to use their own profes-sional and ethical judgment” (BPS, 2018, 1.5), the Order ofPortuguese Psychologists Code of Ethics (2011) emphasizesthat the enumerated principles are not exhaustive and thatdifficult conflicts of individual and social interests appear,while the Czech-Moravian Psychological Society (CMPS)code indicates that psychologists are aware that theiractions develop amidst “political and power circumstances”(CMPS, 2017, I.3).


126 D. Franeta, Taking Ethics Seriously

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All these recognitions are testament to an awareness ofthe limitations of codes expressed in codes themselves;the awareness that codes are not self-sufficient instruments.Naturally, these limitations cannot be healed by codes.Certainly, huge differences exist between ethical codes attheir best and worst, but even the most successful codesare, regarding the aims of ethics education and meaningof professional ethics, limited educational tools. Instructionmerely in codes of ethics cannot substitute for professionalethics education.

The latter claim raises two more questions. The firstrelates to the meaning and role of professional ethics.The second concerns why mere instruction in codes is adowngraded type of ethics education. Yet, before examin-ing these issues in detail, brief overview of views and trendsregarding education in ethics for psychologists is required.

The general deficiency in literature on education in ethicsfor psychologists has recently been observed (Self, Wise,Beauvais, & Molinari, 2018) and finding the best way toteach ethics identified as an important contemporarychallenge (Sinclair, 2017). Indeed, certain attempts havebeen made to evaluate teaching methods in ethics forpsychologists or research ethics (e.g., Antes et al., 2009;Pettifor, Estay, & Paquet, 2002; Watts et al., 2017). Also,some steps have been taken to distinguish and recommendpossible approaches to the matter. Most noteworthy are amore general principles-based approach (Kitchener, 1984),Rest’s model based on four objectives of moral education(Rest, 1982),1 which was adapted to BPS’s Guidance onTeaching and Assessment of Ethical Competence inPsychology Education (Guidance) (2015) and to EFPA’sRecommendations, a model differentiating between “over-riding principle” and “moral dilemma” approaches (O’Neill,1998, p. 194) and the one contrasting “positive” and “floor”approaches (Knapp, Gottlieb, & Handelsman, 2018, p. 1).Worthy of mention is also a model differentiating among“traditional, empowering, postmodern and emancipatory-communitarian” (Prilleltensky, 1997, p. 525) approaches,which respectively relate to more general psychology ethosand standpoints than specifically to educational context, anda model of ethical acculturation, viewing ethics as part ofdeveloping professional identity instead of focusing on rulesand cases (Bashe, Anderson, Handelsman, & Klevansky,2007).

These approaches reflect examples of the growing aware-ness that ethics for psychologists should be broadened,deepened, and further developed. This same sentiment isfound in certain claims observing the limitations of codes,ethics education, or psychology in general: that “the fullestunderstanding of codes” is not enough for ethics (Lindsay,

Koene, Øvreeide, & Lang, 2008, p. 153), that codes aremade “with little input from the public,” and “primarily pro-tect the interests of professionals and offer a narrow andsometimes legalistic interpretation of ethics” (Prilleltensky,1997, p. 518), that codes sometimes dissimulate existingconflicts between moral values (Kitchener, 1984; Ricoeur,2007), that ethics education literature still lacks non-ethnocentric models (Pettifor, Sinclair, & Falender, 2014),considerations of virtue (Pettifor, 1996; Pettifor et al.,2014) and social justice issues (Louis, Mavor, LaMacchia,& Amiot, 2014; Sinclair, 2017), and fails to recognizepsychology having political agendas (Pettifor, 1996). Addedto this, BPS’s Guidance and updated EFPA’s Recommenda-tions (2017) do recognize the need to escape “narrow ethicsapproaches” (p. 1) by virtue of connecting ethics “withbroader human encounters” (p. 1), “developing ethicalidentity” (BPS, 2015, p. 14), the inclusion of “basic ethicaltheories and their relation to practice” (EFPA, 2017, p. 6),and so forth.

Although the mentioned papers and requests presentsome valuable critiques, ideas, and directions regardingfuture of ethics for psychologists, there is a need for expan-sion. Education in ethics for psychologists is in a developingphase and thus faces, beyond a deficiency in literature oneducation in ethics for psychologists, a lack in literature thatthoroughly elaborates and integrates ethical narratives withthe role and identity of the psychology profession. The briefgeneral sketches of different views of ethics which someprofessional ethics books offer (e.g., Lindsay et al., 2008;Pence, 2015) cannot compensate for this.

Since ethical codes and their standards are not self-generated and self-evident, taking them as if they weresuch fails to fulfill the ultimate purpose of ethics education.The following sections will examine the limitations of codesand codes-focused ethics education and support emergingtendencies to escape narrow definitions of ethics education.Consequently, they will pave a path toward elaboratingupon the meaning and function of education in ethics forpsychologists.

Code Instruction as Downgraded Ethics

Although ethical codes have a place in teaching ethics forpsychologists, they must not acquire the status of its basis,center, or purpose. Without sufficient studies on practicedapproaches to ethics for psychologists in academia inEurope, how codes are being implemented contemporarilyin teaching remains unclear. Yet, as already suggested, thecurrent lack of literature elaborating and integrating ethicalnarratives does not seem to contribute to adequate

1 Education in ethics has to differentiate, focus on, and influence different processes internal to morality: Interpretation of the situation, moralreasoning and formulating of moral ideals, the way one decides what to do and implementing of intentions (Rest, 1982).


D. Franeta, Taking Ethics Seriously 127

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handling of codes. Analyzing approaches to teaching inother professional ethics fields, certain authors have indi-cated the “pragmatic” approach that accentuates “rulesand procedures defined by regulatory bodies” (Illingworth,2004, p. 9), while others have noted professional ethicscourses focused explicitly on codes (Haws, 2001). Addedto this, some mention courses in ethics for psychologistsproviding only information on standards, codes, and exam-ples (LoCicero et al., 2016). Furthermore, some profes-sional ethics teachers spoke of a tendency to treat ethics(for psychologists) as a set of rules (Knapp et al., 2018),some even arguing that “moral theory is always a wasteof time in professional-ethics course.” (Davis, 2011, p. 51)

Consequently, the place of codes in teaching ethics forpsychologists deserves an articulate stance. Indeed, equat-ing ethics education and code instruction (hereafter called“code perspective”) is an intentionally exaggerated, Webe-rian ideal-typic and distopic picture of certain tendencies tonarrow ethics education by overly prioritizing codes – anddisregarding ethical narratives – thus misinterpreting theirnature. However, why any form of overemphasis on codes,let alone code perspective, leads to downgraded type ofethics education must be understood.

In its pure form in reality unlikely present, code perspec-tive is an approach which recognizes codes as the core andbasis of professional ethics education. Professional ethics isconceived as a collection of standards, principles, and rulesthat are to be applied to concrete situations. These stan-dards would be approached as demonstrated; as aboveexisting axiological, that is, value and social, narratives,and discourses.

The basic problem with code perspective is that it mis-conceives the epistemological nature of ethics and conse-quently downplays basic ethical functions of exposing andchallenging in favor of applying established ethical codes.There are at least three specific ways in which such anapproach belittles ethical concerns (to an extent similarlyagainst narrowing of psychiatrist ethics, see Radden, 2002).

The first relates to the fact that matters of professionalresponsibility cannot be restrained to the framework ofany code. Either a code would be uselessly or dangerouslyabstract or certain significant issues and perspectives wouldbe disregarded. Some of the examples for the latter case arethe Nuremberg code (1949) which failed to address envi-ronmental concerns and conflicts of interests, a previousAPA code that lacked “specific rights of clients in a counsel-ing relationship” (Kitchener, 1984, p. 45), nowadays BPScode lacking specified ethics of payment or most Europeancodes lacking specific standards on incompatibility withother vocations and on bioethical issues such as euthanasiaand abortion. Indeed, some of the mentioned issues may beregulated by higher legal acts what leads us to the issue ofthe relation of law and morality, which is evidently being

viewed in very different ways (e.g., Kelsen, 2000 viewedlaw as independent of morality). However, as a lower act,code depends on regulations inherent in all higher actsand cannot contradict them, but this should not removelegally unregulated or legally regulated issues from consid-eration from the profession and individual professionals orone could, for example, arrive at the absurd position ofchanging views about human dignity when crossing theborder. In any case, constant revisions of codes (e.g., APAcode revisions) also testify the upper alternative. Further-more, these problems have also been recognized in litera-ture (Lindsay & Colley, 1995; Pettifor, 1996; Welfel &Kitchener, 1992) and noted in some codes themselves(e.g., BPS, 2018).

Even worse, reducing professional responsibility to only acode implies conflating law and morality, assimilating theiroverlap into their identity at the expense of morality.Scheler long ago warned that ethical is not just what canbe commanded and imposed (Scheler, 1966).

Complete codification means contextualizing somethingaccording to rules, procedures, and sanctions. Therefore,it is not possible to codify ethics without adding to it attri-butes of law. Such a perspective cannot fully correspondto the ethical viewpoint – the final aim of education in pro-fessional ethics – which transcends the law and does notrely on the authority of existing legal institutions.

Thus, a second danger of the code perspective is codesbeing read in a specific juristic manner, the manner ofthe “crooked operator” (Hall, 1952, p. 430), as it was oncetermed: everything not forbidden is allowed (e.g., the noto-rious Stanford Prison experiment case, or more recentGuantanamo Bay case, that included harsh interrogations– not adequately addressed in previous versions of APAcode, Lindsay, 2011 – in which psychologists participatedand “that amounted to torture”, LoCicero et al., 2016,p. 345); therefore everything not precisely coded or ambigu-ously codified is ethical. Take this one step further and notonly that which has not been precisely regulated becomesethical, but also that which is not being enforced. From thisperspective, if a disciplinary procedure or lawsuit is avoid-able, the ethical status of the issue is already resolved.Such defensive ethics, which may also relate to risk man-agement framework, as some authors warned (Koocher &Keith-Spiegel, 1998, p. 4), culminates in the ideal of per-sonal self-defense and not of professional responsibility.Whether codes or risk-based or both, this perspective couldlegitimate ethical relativism in matters not strictly definedby codes, diminish professional responsibility, and harmthe idea of integrity, since a legally possible way of escapinga dilemma or resolving an issue must not always be the eth-ically best solution. If viewed only from a risk-managementperspective and upgraded to the level of a professionalassociation, professional ethics risks becoming an elitist



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and potentially oppressive endeavor (how elitist profes-sional ethics feeds on ethical relativism, see Veatch, 1999).

A third serious concern regarding the downgrading of pro-fessional ethics to a specific code is that the reversed rank-ing of ethics and codes disables one from critically reflectingon the code itself. If a code is understood as the alpha andomega of professional ethics, it becomes impossible to thinkprofessionally beyond it, what negatively affects identity ofthe profession. Remembering that codes are typically andinherently time-limited and lacking, or too abstract andtherefore prone to different application, or even “imposedby elites” (Louis et al., 2014, p. 17), without critical perspec-tive toward the codes in education, professional ethics riskstransformation into an instrument of those in power in pro-fessional organizations or in professional relationships.

It must be reiterated that ethical codes are neither redun-dant nor needless; they are useful, but insufficient tools forpromoting responsibility and raising ethical awarenessamong psychologists. Education and regulation are notalternatives, nor should education in ethics be just instruc-tion regarding current regulations. Psychologists need anethics education that is more than familiarity with enactedprinciples, rules, procedures, and case law. Instruction incodes and rules is no substitute for a comprehensive, elab-orate, and critical approach to one’s professional role, toidentity, and to values. Without such a thorough approachto the role and identity of the profession, ethical problemsand values beyond the contents of codes are likely to be dis-missed, professional responsibility reduced, codes dogmat-ically applied, and ethics downgraded to a system ofgoverning and disciplining; a manual for avoiding lawsuitsand discipline procedures.

Ethics as Inquiry, Values,and Professional Identity

Ethics as Inquiry

As stated previously, equating ethics with a set of rules orprinciples is a misinterpretation of its epistemological nat-ure. The following paragraphs will focus more closely onthe nature of ethics as a prelude to examining the meaningand role of ethics for psychologists.

Ethics and professional ethics are not a collection offacts, nor are facts their goals. Situating ethical questions,such as “Is this act just?” within a perspective looking forethics as a collection of definite facts (and codes), negatesa proper ethical or, more broadly speaking, philosophicalinquiry – a discourse on constructing and deconstructingmeaning (der Sinn, ger.). Instead, only statistical informa-tion regarding the current convictions about good and justare generated.

As ethics is focused on ideas and interpretations ratherthan facts, it is as much about asking questions as yieldinganswers. Questions and answers have at least equal impor-tance in ethics, as in any other form of philosophicalinquiry. Gadamer explained how questioning could evenbe understood as epistemologically superior to answeringsince it leads to the weighing of different opinions as speci-fic communications of meaning instead of channelingmonologic and dogmatic expositions (Gadamer, 2006).Questioning enables contextualization along a horizon,the understanding of every text or speech as an answer tosome other question. Invaluable ethical questions aim atwhat has not been thought of, indicating the limits ofconceptual frameworks, highlighting suppressed ways ofunderstanding and the price of such choices. Ethics is apursuit of both constructing and deconstructing meaning,a process of integrating values and knowledge and reflect-ing their integration in theory and in the “lifeworld” (dieLebenswelt, ger.).

Regarding ethics for psychologists as a particular subtypeof professional ethics, the aims, attitudes, behaviors, iden-tity, and practices of psychologists – whether practitionersin any of the fields, educators or scientists, trainees orsupervisors – are situated within the larger frameworks ofthe good and the just. Indeed, there are numerous individ-ual and social factors shaping the former, but there are alsounderlying ethical ideas to be tracked and scrutinized.Ethical reflection on conceptions of psychologists’ rolesshould run the gambit: from the phenomenology of themundane contact of psychologists and their clients throughthe (de)construction of the profiles and nets of these basicconcepts (such as health, well-being, justice, or freedom),which these relations embody. Exposing the ethical mean-ing of prevailing lines of action and thought, and whennecessary challenging them, should stand as the primarytask of education in professional ethics.

The complexity of ethical inquiry means its claims anddiscourses cannot be refuted straightforwardly; they maybe challenged as illogical, eclectic, hypertrophic, or reduc-tive and therefore confusing, manipulative, hegemonic, oruseless. Similarly, an ethical claim or standpoint cannotbe true, but rather could be evaluated as more comprehen-sive, more logical, more grasping of existing phenomena, ormore sensitive to subtleties of reality, and, therefore assuperior.

Professional Identity, Values,and Ethics as Inquiry

An education in ethics for psychologists can contributeto psychologists’ knowledge in distinct and crucial ways,but its fundamental objective is to enable individuals to



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continuously and critically reflect on their professional roleand identity.

Dahrendorf (1965) typically understood one’s social roleas an aggregate of requests or expectations directed at theholder of a specific social status. The professional role is aspecific type of social role attributed to representatives of acertain profession in a society. Indeed, the role of mother,pupil, artist, and of course psychologist, in a particular con-temporary society can be grasped in many fashions, fromrelaxed to fixed. Furthermore, there are more establishedroles and such recent additions as motivational speakersor bloggers. Culture itself is a dynamic and heterogeneous,diversified structure, which changes over time, gatheringversatile ideas and worldviews, which then manifest inthe distribution and definition of social and professionalroles themselves.

What comprises a professional role is tied to the conceptof professional identity. Drawing from Ricoeur’s (1994)seminal work, identity, for humans, is not a mere sameness,but a narrative preserved over time. Identity is simultane-ously a definite fact and task; a chain novel whose previ-ously written chapters influence future writings, yet thenewest paragraphs themselves transform and give meaningto those preceding (Dworkin, 1986). At the core of suchidentities lie certain values, specific worldviews, conceptualframeworks, or their elements.

To reconstruct the ethical elements of a group’s profes-sional identity, one must consider the mutual constitutionof identity and culture (Markus & Kitayama, 1991)displayed among other in its characteristic language andcustoms, the respective legal and ethical rules pertainingto its identity, the foundations of professional authority,existing in-group and out-group comparisons (Tajfel &Turner, 2004), its symbolic self-completion (Wicklund &Gollwitzer, 1981), and, finally, perspectives regarding itsbasic concepts, values, and dichotomies (healthy-unhealthy,normal-pathological, useful-useless, etc.) that define it. Thisis the aforementioned task of exposing the existing ethicaldiscourse.

Yet, professional identity is not an elemental social truththat exerts a gravity-like force, though social pressures canindeed result in it being experienced and interpreted thusly,or pushed in this direction. Some professional identities arestill in their early, developmental phases. For instance,some years ago, concerns were raised regarding the identityof industrial-organizational (I-O) psychologists (Lefkowitz,2005; 2011). The essence of this is captured in the followingstatement: psychologists are not, and should not be, thepassive recipients of their professional identities. Their partin this respect is ultimately connected with their ethicalawareness and responsibility. Nadal (2017) has recentlyeven claimed being an activist is psychologists’ ethicalresponsibility.

Professional identity is discovered, reflected upon, andreconstructed constantly. The perpetual result of thisenduring intellectual pursuit means that in times of socialcrisis and transformations, professional identity or someof its aspects may be defended, certain professional profilesrejected, behaviors regarded as illegitimate, or the existingnarrative or its elements redefined.

Ethical exposing and challenging depends upon situatingacts and thoughts in an ethical narrative. An education inethics introduces these narratives. A specific code couldbe an amalgam of distilled elements of an ethical narrative,but usually it contains elements from various ethical narra-tives. Education in professional ethics should bring profes-sional identity into connection with these narratives. Thefoundation metaphor – seeking some eternal basis for moralclaims – could be substituted for the framework or the lensmetaphor, as has already been suggested (Sherwin, 1999),but the task of exposing the strength and the deficienciesof prevailing ethical discourses still remains.

Introducing differing narratives enables the exposingor challenging of certain aspects of professional identity,while also facilitates various ethical questions related to aspecific problem that could be posed: for instance, fromthe Kantian perspective, the legitimacy of psychologists tomake decisions on behalf of their clients could be raised;utilitarian approaches might highlight the questioning ofthe broader social consequences of a selected solution;post-Marxist and feminist standpoints would likelyemphasize issues regarding the needs of all those takingpart in the caring relationships being appropriately metand whether a solution is oppressive toward the mostvulnerable (Sherwin, 1999).

This process of exposing and justifying, challenging, andeventually narrowing or widening the dominant discourse isnecessary for an individual to be able to justify one’s owndiscrimination of relevant and irrelevant social expecta-tions. It critically enables one to reflect upon one’sprofessional role; the ever-changing collection of socialexpectations pressing upon an individual.

Such (value) inquiry cannot be separated from the powerrelations inquiry. As a specific type of social role, the profes-sional role is allocated a certain amount of power – derivedfrom the professional authority, a monopoly on services, orthe social status of the profession – power continuouslyexerted upon individuals, groups, or the general society.To discriminate between the use and abuse of power, onemust recognize that prevailing discourses themselves areoften raised amidst power relations or get pulled into situa-tions involving them. The Foucauldian perspective, forexample, challenges us to perceive institutional settingsand bureaucratized systems of a hospital, school, or work-place as ethical issues themselves, to gain awareness ofthe larger abuse of knowledge supporting stigmas and



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“spoiled identities,” to grasp inherent gender or ideologicalbias in psychological theories, to recognize practices pathol-ogizing different forms of disobedience, to reveal themedicalization of social control (excessive widening of therealm of medical with the effects of disciplining, governing,ordering etc.) as existing ethical problems, and so forth.Building upon this viewpoint and other contemporaryapproaches, we are nowadays urged to consider how dis-courses of dignity regard children, the incapacitated, stran-gers, the unborn, and even non-human animals (Singer,1999), or how the discourse on normality bears the ambiva-lence of “normal” as meaning, potentially, statistically aver-age or ideal, and how this discourse is being reflected in our“hiding from humanity” (Nussbaum, 2004, book title).

Such critical reflection of one’s professional role is a con-tinuous task that cannot be accomplished in some definite,prescribed way, since there are always new paths of apply-ing knowledge (as observed in Lefkowitz, 2005; Lindsay &Colley, 1995; Lindsay, 1996, 2011; Sinclair, 1998), new envi-ronments – such as digital, multicultural, or transitional(Corey, 2009; Nicholson, 2011; Pettifor & Sinclair, 2011),and new modes of ethical awareness (e.g., respecting allliving beings and future generations) that must be consid-ered or ethically examined.

Finally, a significant segment of professional ethics liter-ature (e.g., Day, 2006; Koocher & Keith-Spiegel, 1998;Lindsay et al, 2008; Pence, 2015; Wendel, 2007) empha-sizes strong consideration of case studies and commentary.Situated in the context of the real, case studies provoke andstimulate thought and represent invaluable part of profes-sional ethics, but if tied to a code perspective and notaccompanied by a comprehensive ethics education, theyrisk encouraging the misplacing of emphasis on subordina-tion to existing rules and practice rather than focusing onthe ethical discourse and fostering continuous reflection.With this risk inherently comes a serious threat; that educa-tion is turned into training for hierarchy, as was warnedmore than thirty years ago (Kennedy, 1982).

Human Rights and Human Dignity inEthics for Psychologists Education

The human rights narrative has both ethical and legalaspects. Human rights emerged as an ethical idea, and havesince been elaborated both ethically and legally. Theseaspects developed as closely connected and are in somerespects unified.

The protection and promotion of human rights is nowa-days typically regarded as an ethical duty of psychologists(EFPA, 1995/2005, 2.1; CPA, 2017, p. 4). A prerequisiteof this task is an awareness of the existing rules and an

ability to ethically approach human rights issues; to ethi-cally trace and frame current human rights norms.

The ethical duty of protecting and promoting humanrights requires one to situate them in ethical discourse.One should be able to perceive human rights as a narrativeso as to interpret its existing chapters coherently and,eventually, take part in writing new ones.

Yet, it is obvious that the narrative in question is multi-faceted, versatile, and constantly developing. Differentgroups of rights – sometimes dubbed generations – havebeen raised by different ethical discourses, some examplesbeing German idealism, expressing the idea of everyonebeing a subject (das Subjekt, ger.), Marxist, expressing theidea of human sociality, and existentialist, expressinghuman singularity and authenticity (Maihofer, 1968).

One particularly influential way of approaching humanrights – some or all of them – is based on the idea of dignity.This approach is now upheld by both moral and legal argu-ments. Regarding legal perspectives, dignity has beendesignated – internationally and nationally, particularly inEurope – as the inviolable and inalienable core or foundationof human rights. It is present in most contemporary Euro-pean constitutions and has acquired a place of distinctionin certain ones, as well as in the Charter of FundamentalRights of EU (EU Charter) and other important legal docu-ments. It has been designated as the basis of human rightsin major international legal documents (Preambles to Inter-national Covenant on Civil and Political Rights and Interna-tional Covenant on Economic, Social and Cultural Rights),as a fundamental legal value (Const. S. Africa, 1996, art.1), untouchable (unantastbar, ger.) (Const. Germany, 1949,art. 1; Const. Andorra, 1993, art. 4; Const. Serbia, 2006,art. 23), as a sacred value (Const. Czech R., 1993, preamble),as an unamendable constitutional guarantee (Const.Germany, 1949, art. 79), as inviolable (EU Charter, art. 1;Const. Finland, 1999, art. 1; Const. Poland, 1997, art. 30),as an indivisible and universal value (EU Charter,preamble), and so forth (see Constitutions worldwide,http://www.verfassungen.de/). Moreover, certain legalproceedings of the European Court of Human Rights haveregarded it as the essence of the European Convention onHuman Rights (ECHR: S. W. v UK, 1995; Christine Goodwinv. UK, 2002).

Conceived as legal instruments, human rights mayenable certain vital conditions of dignity and freedom, butthey cannot exhaust them. Dignity as a specific conditionof a human being in the world goes beyond the law(Maihofer, 1968). Kant described this way of being as beinga person, while Hegel explained that it is possible to be aperson only through other persons. In short, there is moreto dignity, freedom, and being a person than a legal frame-work can command and enforce. Kant (1977) assertedrationality (die Vernünftigkeit, ger.) and autonomy as the



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core of dignity, while Ricoeur (2007) placed self-esteem atits roots. From this perspective, the ethical duty of protect-ing and promoting human rights goes well beyond the legaland reaches toward the basic ideas, values, and purposes ofhuman rights. The request for dignity and human rights tobe respected in psychologist-client relations and in everyother role psychologists perform – researchers, practition-ers, or educators, is aimed not only at abiding by currentlegal rules guaranteeing rights to physical and mentalintegrity, the right to privacy, or the right to fair workingconditions, but also entails being aware of, revealing, andrespecting different existing forms of human fragility, theeffects of individual, cultural, environmental, and othertypes of deprivations, and various types of systemic andinterpersonal macro- and micro-aggressions, while at thesame time emphasizes the restoring and reaffirming ofself-esteem and the autonomy of individuals and groupsin manners that the law may still not address or can hardlymandate. In restoring and reaffirming dignity, the goals ofpsychology as a profession and the respective ethics ofthe profession coalesce.

Differing, in some respects even conflicting, discourses onhuman rights and dignity do, however, exist. Human rightshave typically been approached from naturalistic, utilitarian,and contractualistic standpoints. In recent decades, theyhave also been framed as legal trumps (Dworkin, 1984),as products of history (“rights from wrongs”, Dershowitz,2005, title), as rights pertaining to the development ofcentral human capabilities (Nussbaum, 1997; Sen, 2005),and so forth. Centuries earlier, as well in recent times,dignity has been interpreted as the value of being person(Kant, 1977), as the essence of human rights (Dürig, 1956),as a value and the right to identity (Tiedemann, 2006), asa nexus of principles of self-respect and authenticity(Dworkin, 2013), as a right to rights (Enders, 1997), as theuniversal legal status of human beings (Waldron, 2009),as a request for the balanced development and exercise ofdifferent groups of human rights (Habermas, 2011), as theopposite of humiliation, degradation, and dehumanization(Kaufmann, Hannes, Neuhäuser, & Webster, 2011), and soforth. This discursive and dynamic nature of the humanrights narrative and the interpretative variations of dignitymust be considered and reflected upon, rather than humanrights and dignity regarded as some static idea, some purelegal or ethical axiom. Furthermore, from previous throughto contemporary times, the outcomes of this innate dynamicnature of ethical debate have presented serious challengesto the human rights narrative, often criticized as incoherentand evenmanipulable; yet the development of human rightsdepends upon such critique. A comprehensive education inethics for psychologists should integrate its interpretativenature, and reiterate the limits and challenges to thisnarrative. By doing so, idolization of the existing set of rules

is prevented, while protecting human rights and dignity israised to the status of an ethical duty; moreover, the individ-ual is encouraged to enrich and improve them in one’s ownresearch and practice.

Conclusion

Professional ethics is a discursive inquiry into questions ofgood and responsibility in the professional context andtherefore the education in ethics for psychologists shouldnot be framed as mere training. Restricting professionalethics and human rights education for psychologists intoinstruction based only on existing ethical codes, legalstandards, rules, procedures, and their application debasesprofessional ethics and human rights discourse and dimin-ishes the realm of professional responsibility. It confinesethical reflection to a given horizon, distorting its purposefrom one of taking responsibility into one of acknowledgingauthority. Moreover, it mystifies the idea of human rights,replacing it with the existing set of rules and overshadowingtheir ethical, discursive, evolving, and interpretative nature –thus risking manipulative expositions and applications ofrights.

Although often encountering urgent and complexdilemmas which require decisive action, education in ethicsand human rights for psychologists is to be understood as apart of a broader ethical inquiry which itself generatesresponsibility. In this sense, an education in ethics andhuman rights of psychologists and the regulation of profes-sional behavior of psychologists cannot be conflated. Whenthis distinction becomes blurred and professional ethics,idea of human rights and responsibility are uprooted fromtheir genuine niche, then the inquisitory, apologetic, defen-sive, and even manipulable traits of professional ethics andhuman rights discourse become promoted at the expenseof the vital elements of responsiveness, demystification,and emancipation.

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HistoryReceived April 17, 2018Revision received March 5, 2019Accepted May 3, 2019Published online June 14, 2019

Duška FranetaFaculty of Law and Business Studies “dr Lazar Vrkatić”University UnionBulevar oslobođenja 7621000 Novi [email protected]

Duška Franeta is a Professor forPhilosophy of Law, Legal Ethics andEthics for Psychologists at UniversityUnion, Serbia. Her primary researchinterests include legal axiology, witha particular focus on human dignity,philosophical and legal hermeneu-tics, and professional ethics.



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Critical Reflexivity andIntersectionality in Human RightsToward Relational and Process-Based Conceptualizationsand Practices in Psychology

Marco Gemignani and Yolanda Hernández-Albújar

Department of Psychology, Universidad Loyola Andalucía, Sevilla, Spain

Abstract: Within traditional social, community, and clinical psychologies, the human rights framework has typically been interpreted andadopted from a person- or patient-based perspective. While useful and well meaning, ideological values concerning empowerment, agency,and resiliency have often framed human rights interventions or programs within psychology. We propose in this manuscript a theoretical shiftfor psychology to decentralize the role of the individual human being while at the same time avoiding forms of social behaviorism that tend toportray the person as passive or as reacting to external stimuli. Following this first shift from the individual to the collective, we suggestadopting anti-essentialist discourses about the parties, agents, and issues involved in human rights. To this goal, the philosophical frameworkof process or relational ontology may be especially useful. Based on critical theory, critical feminism, social constructionist, and post-humanviews of knowledge and reality, process ontology considers reality as complex, fluid, discursive, and dialogical. The separations between thepersonal and the political are questioned to underscore the entanglement and inseparability of dimensions of possibility and actions, whichare continuous reconstructions. To conclude, we reflect on the ways in which these two movements toward anti-individualism and relationalontology might inform specific practices and reflections within human rights frameworks in psychology.

Keywords: critical community psychology, process ontologies, post-humanism, reflexivity, relationality, participation

There is little doubt about the notional importance of theInternational Declaration of Human Rights as a milestoneof civilization principles and as a post-WWII statementabout the basics of human life and dignity. Yet, as it usuallyhappens, the devil is in the details: It is at the interpreta-tions of the specific content of human rights (HR) policiesand how they should be applied where issues start emerg-ing (Andreopoulos & Arat, 2014). No one questions, forexample, the importance of the right to education for every-one (Art. 26 of the Universal Declaration of Human Rights),but concerns and challenges emerge about educationalmodels, criteria for evaluation and excellence, and thenational and international standards that may allow for atitle to be recognized by and transferred to another country.Beyond the universality of the principle, this becomes amajor issue for immigrants and refugees, whose schoolaccreditations are seldom recognized internationally.

The promotion of HR within a society is not done in theabstract but can only occur in the here and now and the“muddy waters” of everyday reality. As Gregg argues, theuniversality of HR is always a “local fabrication” (2011,p. 2) whose goodness should not be assumed a priori

without a serious analysis of the modes and means throughwhich they can be achieved or, better, constructed throughthe participation and commitment of the local community.The promise is that, when HR are “grown” locally, “if pos-sible by the addressees themselves,” “they would carry anexceptional motivating power, for theirs would be a validitythat is indigenous rather than imposed from without orcoerced from within” (Gregg, 2011, p. 3).

To be able to manage the pitfalls of concrete doing inspecific situations, a theoretical reflection is needed espe-cially in a field such as psychology, which is deeply interestedin the “human” and, at the same time, is characterized by anarray of subdisciplines and agendas that rarely talk to eachother. A reflection on ideological assumptions is in order toavoid taking for granted assumptions about knowledgesand practices of psychology that are ideological and not nec-essarily universal (Kirmayer, 2007, 2012).

To guide our reflections about the construction and prac-tice of a HR framework within psychology, we will focus ontwo main theoretical moves that we deem central to thepurpose: the shift from the personal to the collective insocial, community, and clinical psychology and a critical


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approach to knowledge and reality that is based on processor relational ontologies and on participation.

From the Personal to the Collective:The Critique of Individualism inPsychology

Even within psychological frameworks that underscore theimportance of relational, social, and cultural aspects anddynamics, the focus on personal experiences, cognitions,and functioning remains often central. In the case of HRabuses, for instance, psychology is typically concerned withthe effects of abuse on a person’s well-being and function-ing. As Tim Ingold (2015, p. 12) observes, “even today, theforces that would reduce minds to built-in, interactive mod-ules continue to command the mainstream, in disciplinesranging from psychology to economics.”While the personalrepercussions of HR abuses are extremely important, “theparallel neglect of wider sociopolitical and historical factorsand the economic, social, and psychological consequencesfor whole communities puts into question the ethics ofthe continued symbiotic relationship between psychologyand the social order” (Patel, 2003, p. 20). Focusing onlyon personal suffering not only promotes a view of psychol-ogy as an individualistic discipline, but also distorts itsattention from other readings of that suffering that maylocate it socially and culturally. For instance, social recon-structions of traumatic memories may not necessarily passthrough individual debriefing and may greatly benefit frompsychological practices that are based on collective and cul-tural rememberings of the past (Gemignani, 2011b; Kevers,Rober, Derluyn, & De Haene, 2016).

When it comes to psychological experiences, the socialand political circumstances that surround an issue are offoremost importance. In the case of refugees, for instance,despite their universal legal definition, the political condi-tions that led to their fleeing are unique of every situationand will deeply affect the experiences lived by these collec-tives. Still, clinical psychologists are rarely concerned withanalyzing the ways in which the political causes of a forcedmigration may lead to different constructions and experi-ences of what only superficially seems to fall in the samediagnostic categories (Dudley, Silove, & Gale, 2012). Asan alternative, critical analyses of discourses on traumaand its historical evolution to become a cultural focus ofour times (Meskell, 2006; Summerfield, 1999) offer inter-pretative frameworks on what would otherwise appear assimply present or self-evident. Such critical process can helpthe community or clinical psychologist to collaborate withclients to contextualize and understand their concerns associal constructions and purposeful, political narratives,

instead of mere problems to be solved (Worthen, Veale,McKay, & Wessells, 2010). This collaborative and criticalprocess may also help to counter dangerous affirmationsof dominant discourses, which normalize social categoriza-tions of refugees’ psychological experiences and tend toerase within-group diversity (Malkki, 1995).

For instance, healing as based on “talk therapy” mayassert a view of the person as a separate and independentbeing, who can change in isolation from the social contextof his or her life. Giving the responsibility for change to thepatient and the doctor, leaves the social order relativelyunaffected and affirms a depoliticized view of psychologicalissues as personal rather than cultural or ideological mat-ters (Gemignani, 2011b). By adopting an individualized orindividual-based understanding of social process and psy-chopathology, “psychologists continue to focus on effects,not the root causes of distress” (Patel, 2003, p. 31), there-fore engaging in damage control instead of bravely tacklingthe larger picture that links issues to social and culturalorders and settings (Foucault, 1963). Interpretations ofsocial or clinical concerns that are merely cognitive tendto naïvely support the society’s indifference toward formsof human suffering that it has itself contributed to cause,such as the effects of colonialism and globalization on thecontemporary migration crisis in Europe. The risk is that,“psychologists and their associated academic and profes-sional networks stand accused of acting as ‘servants ofpower’, with their work more often sustaining rather thanchallenging the interests of the dominant classes in unjustsocieties” (Campbell & Cornish, 2014, p. 5).

A reflection on the ideological values that are implicit inthe work of the HR psychologist may help to develop criti-cal considerations on what may otherwise appear as a trans-parent and benign effort to help others to “be human” andenjoy a “dignified life.” This does not mean that individual-ism is wrong, as Caranti (2012, p. 96) provocatively asks,

“If rights in general and human rights in particularare intrinsically biased in favor of individualism,why should we abandon this perspective [. . .] whenand where such bias would be most beneficial,namely where the need of defending individuals fromall possible forms of a majority’s oppression is partic-ularly urgent?”

Rather, HR psychologists need to be aware that “individual-istic conceptions of the good life may preclude shared com-munity values that are central to one’s identity” (May, 2012,p. 313) and may distort the psychologists’ focus away fromcritical considerations on social dynamics and ideologicalorders that are likely to be part of a HR framework.

The invitation is to move beyond the individual-societyantinomy. For this, it is crucial to understand that the


M. Gemignani & Y. Hernández-Albújar, Critical Reflexivity and Intersectionality 137

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presumed universality of HR is necessarily and uniquelylocated within a specific social context. Keeping a con-text-specific sensibility is instrumental to avoid forms ofcultural imperialism and to connect with the participantsin ways that help them develop a shared sense of author-ship and belonging in their assertions of and strivings fora system of rights. As Habermas wrote, “a correctly under-stood theory of rights requires a politics of recognition thatprotects the individual in the life contexts in which his orher identity is formed” (Habermas, 1994, p. 113).

Relational/Process Ontology

Especially for the delicate balance in the HR frameworkbetween universal values and their local interpretationsand applications, a non-essentialist view of reality mayresult particularly useful to increase the chances of successfor practices based on HR. Processes ontology found inspi-ration on the works of Spinoza, Whitehead, Deleuze, and,more recently, Barad and Braidotti, to underscore the fluidinterconnectedness of all things, against the tendency toreify social and human process and reduce them to self-standing realities (Helin, Hernes, Hjorth, & Holt, 2014).

Although a thorough description of this philosophy isbeyond the scope of this article, Karen Barad’s (2007) con-cept of “intra-action” best describes this critical positioningtoward what is considered to exist. “Intra-action” refers tothe entanglements of realities, concerns, and people whichcome to exist in their necessary relation to each other. Forinstance, the freedom and dignity of the first principle ofthe Universal Declaration of Human Rights cannot beconsidered as absolute, independent, and self-containedentities or constructions. They do not preexist their interac-tions with other relevant processes, such as cultural inter-pretations or political milieus, which in their turn are notisolated and decontextualized realities. In other words,everything exists in connection with everything else in anongoing web of intersecting constructions.

As Karen Barad writes (2007, p. ix), the emergence ofrealities, rights, or concerns does not happen “once andfor all, as an event or as a process that takes place accordingto some external measure of space and of time”. Rather,“time and space, like matter and meaning, come into exis-tence, are iteratively reconfigured through each intra-action,thereby making it impossible to differentiate in any absolutesense between creation and renewal, beginning and return-ing, continuity and discontinuity, here and there, past andfuture.” For example, freedom and dignity become typifiedaccording to other relevant “intra-actions”, such as gender,religion, economic power, and social roles, which, instead ofbeing essential variables, dimensions, or structures, arelocalized relations and discursive constructions.

In contrast to thinking of the world through the meta-phors of “the building block, the chain and the container”which underscore the interaction of independent realitiesor lifeless “pre-cut pieces” (Ingold, 2015, pp. 14–15), intra-actions are agentic processes of reality construction. Theyare dynamic assemblages that constantly define and rede-fine the boundaries of what is allowed and not allowedwithin their entangled realities, such as cultures, identities,and rights. Although HR are discursively constructed asexisting, it is only through intra-action that realities becomephenomenologically present, actions become meaningful,and events become experiences (Scott, 1991). As JohnShotter puts it, “we inhabit circumstances in which almosteverything seems to merge into everything else; we donot and cannot observe this flow of activity as if from theoutside” (Shotter, 2015, p. 62). In the moment in whichwe, as researchers or observers, take part in a HR frame-work, we are contributing to its own constitution. At thesame time, we also become “intra-agents” to the possibilityof constructing and reconstructing these rights in relation tothe realities that articulate the participants’ life contexts.

Even the term “human” is an intra-action: “whatevercounts as ‘human’ is not so much ‘born’ as ‘made’” (Baxi,2009, p. 208). From this perspective, HR are relationalpractices which evolve in their doing. As such, HR are notsimply given or granted out by someone with enough powerto do so, such as governments or institutions. As we willfurther elaborate in the section about “participation,” theadoption of a position that is radically collaborative andreflexive toward the rights of others is instrumental tosuccessful constructions and implementations of HR. Par-ticipating others become constitutive partners of ontologies,beyond individual free will and before determinants ofsocial justice and well-intended practices of “othering.”

Relational Ontology, Knowledge,and Methodology

Process ontology underscores the ever-shifting fluidity ofsocial and psychological realities, which escape any formof stable representation (Gemignani & Peña, 2008). Thisdoes not trivialize representations, but binds them tospecific contexts and performances that are partially co-constructed by the observers and themethods of observationand representation (Gergen, 2014).

In a perspective about epistemology and ontology thatgoes beyond essentialism and universalism, being humancannot be reduced to descriptors or variables that arealways expected to be about something specific and stable,as pieces of a jig-saw puzzle. In the context of a HR frame-work, the making of knowledge moves beyond mererepresentations and descriptions of abuse to include the


138 M. Gemignani & Y. Hernández-Albújar, Critical Reflexivity and Intersectionality

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observational and interpretative acts as part of the veryprocess that allows for specific realities to become morepresent. Representations, in other words, contribute to theconstruction of what is observed. Or, said otherwise, episte-mologies are not separate from ontologies.

As Sara Harding evocatively puts it, realist conceptualiza-tions in science have progressively adopted and imposed“unique ideals of objectivity, rationality, and good method,and [. . .] ontologies that conceptualize nature as isolated bitsof dead matter in motion” (Harding, 1998, p. 157. Italicsadded). Similar to Barad’s arguments against the “logic ofsameness” that helps to maintain the status quo, Hardinginvites us to engage in a radical form of reflexivity thatmay allow for alternative systems of knowledge-makingthat extend beyond the scientific rationality of positivismand empiricism. In postcolonial and indigenous settings,for instance, the epistemology of modern science becomes“predatory” “while also destroying all other knowledgesystems” (Harding, 1998, p. 157; Tuhiwai Smith, 1999).In this context, methods need to be qualitative and post-qualitative to be able to engage in critical reflections onthe ongoing interplay of creation, construction, and actionand the inevitable connections between power and knowl-edge (Foucault, 1980) within which interpretations andpractices of HR are situated.

Knowledge about abuses should of course be reported,but at the same time, it is important to realize the entangle-ments among the discursive reality that is being described,the researcher’s constructions of it, the victims’ complexinterpretations, the psychosocial contexts of its occurring,the interventions that have already been tried out and thosethat are expected from future agendas, and the future-forming consequences of such knowledge-making. Knowl-edge develops, in other words, always in the place betweenthe researched and the researcher (Gemignani, 2011a) isitself located within other relations, contexts, and dis-courses. Similar to what happens in psychotherapy, theserelationships are the sites in which realities and construc-tions can be creatively explored and alternative possibilitiesconsidered (Anderson, 1997; Kelly, 1955). In the process oflearning or developing knowledge about HR, “we imprintthe provisional world we experience in and on our bodiesand make it part of the coming to be. There is little distinc-tion to be made between researcher and researched in arelationship that belongs to the world” (Helin et al., 2014,p. 11). This emphasis on the relational becoming of realitiesand knowledge well-fits participatory models of HR inter-ventions that have long been advocated by liberation andcritical psychologists (Martín-Baró, 1996; Parker, 2015;Watkins & Shulman, 2008).

When considered from the critical perspective ofprocess or relational ontology, participation becomes a

game-changing praxis for psychology (Fals-Borda, 1979).Experience, for instance, has always been a central interestfor the discipline. Yet, what counts as experience is notstraightforward. It has to fit within various systems ofmeaning that culturally, locally, and individually recognizesomething as worth-noticing and interpreting. As in anomadic wandering, experience is not exempt from power,politics, and the limits and possibilities offered by existingframeworks of interpretation. Experience “is at once alwaysalready an interpretation and something that needs to beinterpreted. [. . .] it is always contested, and always there-fore political. [. . .] Experience is, in this approach, not theorigin of our explanation, but that which we want toexplain” (Scott, 1991, p. 797). The identification of (an)experience needs to pass through both master plans of ide-ological positions, which may be considered universal anduntouchable (such as the sacrality of life and the body; orthe rejection of imposed violence), and horizontal practicesof participation and (de)territorialization, in which the par-ticipants point out experiences that they – and perhaps onlythem – deem dignifying of a life that is worthy “human.”

In the view of HR psychology that we suggest here,humanism needs a post-humanism that critically questionsthe possibility of a unique standard or model of “human-ness” (Braidotti, 2013) and asserts the constant becomingof the meanings, understandings, and conditions of human-ity. The interplay of humanism and post-humanism isneeded to underscore that interpretations and practicesentail both the authoritarian, vertical presence of “trees”(e.g., legal systems, cultural norms, and nation-state appara-tuses) and rootlike “rhizomes,” which horizontally spreadwith “no beginning or end; always in the middle, betweenthings, interbeing, intermezzo” (Deleuze & Guattari, 1987,p. 25). The rhizome simultaneously represents and consti-tutes an agentic and anarchic relationship to space and sub-jectivity that counters structural impositions. As resistanceto any vertical imposition, the rhizome does not simplyrepresent the individual or the community that strugglesfor empowerment and rights. Rather, it situates powerlocally to engage human capabilities and critically analyzesocietal distributions of power.

The weaving of vertical and horizontal lines underminescommonsense distinctions between the personal and thesocial. It follows that psychologists concerned with HR,power, and empowerment should be engaging with bothmicro- and the macro-levels of analysis and practice: Thework with individuals and their agency needs to be pairedto critical reflections and actions on the ways in which“societal hierarchies are set up and maintained throughwealth, class, labor market position, ethnic dominance(majority/minority status), gender, etc., and the way soci-etal structures impact on people” (Fryer, 2008, p. 242).



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From this perspective, the work of critical psychologists canbe instrumental to pinpoint that practices of subjectivation(the Foucaultian formation of subjectivities) may act astechnologies to maintain the status quo. For example, theinternalization of discrimination by victims (Jones, 2000)or the a-critical adoption by children and adolescents of lifemodels that associate freedom with consumerism (Aitken,Lund, & Trine Kjørholt, 2007) are likely to counter thedevelopment of human capabilities in vulnerable and disen-franchised groups. In these examples, the HR psychologistcollaborates with victims and children to critically analyzetheir relational environment and the power games thatare active within it.

The intersection of trees and rhizomes debunks the naïveimages of the hero and savior. Rather than positioningagency and structure as polarities (Fryer, 2008), a moreconstructive inquiry and practice for psychologists maycome from understanding and engaging their interplay.Both subjectivities and social structures are constructionswhose ontological status depends on their function: It isat this level that a psychologist may, for instance, collabo-rate with participants to elaborate models of developmentand “good life” that, instead of being presented as politi-cally and ideologically neutral, are localized and purposeful(Aitken et al., 2007).

Intersectionality Theory

As seen above, relational and non-essentialist positioningsand understandings are not linear. The borders of eachdescription are fluid and muddy; processes of constructingconstructions and narrating narratives continuously frameexperiences and social phenomena. Reflections on suchframing within interactive systems are at the core of inter-sectionality theory, which is another important source ofconceptualizations in relational views of HR (Crenshaw,1991; Hancock, 2013; Hill Collins, 1990). For instance,gender, power, race, culture, and class cannot be consid-ered or used as separate analytic dimensions of HR thatindependently exist and contribute to the formation of theidentity and sense of agency of, for instance, African-American women. Rather, they can only be understoodand analyzed in their mutual relations of constructionsand de-constructions:

First, identities and the differences that are attributedto them are not fundamentally disagreeable. There issomething about being a woman of color that cannotbe decomposed empirically into a “race” part and a“sex” part. Second, the shift from a margin centermetaphor to one of intersections reshapes the wayin which scholars conceptualize power distributions(Hancock, 2013, p. 262).

In intersectionality as well as in relational ontologies, theattention centers on the discourses and politics that allowfor specific issues to become visible and present and forspecific (im)possibilities to become dominant in an histori-cal period. In other words, the focus moves from the real tothe politics of reality. Translated into practice, this meansthat psychology cannot see HR and their affirmation andabuse as internal matters to the person or as social practicesthat linearly go from a perpetrator to a victim, in the sameway as power (resistance) and responsibility and agencycannot be implemented without the interpretation andparticipation of local people and communities.

A Non-Individualized andProcessual Model of Human Rightsas “Intra-Actions”: Capabilities,Power, Liberation, and Participation

Human Capabilities

The vast majority of models that form a HR frameworkcreatively and very often usefully put together variouscombinations of the relation between power and responsi-bility. Yet, in focusing on the “interaction of power dynam-ics in psychological and political domains” (Nelson &Prilleltensky, 2005, p. 131), we need to be careful to avoidseeing these dimensions or foci as discrete from each other.We suggest, instead, interpreting Prillenltensky’s idea of the“psychopolitical” not as a component or realm of humanfunctioning, but as an inseparable intra-action amongdiscursive constructions of HR.

HR are not just concerned with the right to operate in thesocial context and to influence it. Rather, they are concernedwith the building of human capabilities, which refer to whatpeople can do and be, not simply as result of personalagency but also of socioeconomic arrangements and possi-bilities for change (Sen, 2005). It is neither a matter ofsaving nor of empowering others, as if agents were inpositions of autonomy and followed the rationality of self-interest, as in liberalism. Rather, the concept of humancapabilities underscores the need for fellowship (Nussbaum,2006). By working at micro-, meso-, and macro-levels, theHR psychologist is therefore concerned with helping othersto develop complex forms of agency and see themselves asconstructed and constructing intersections. This reflection iscrucial to analyze the context in which the interplay of“realities” and interpretative frameworks may operate, notas a sort of background against which personal and commu-nity agency emerge, but as a constitutive dimension topower, responsibility, knowledges, and ontologies.



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A critical focus on human capabilities, for instance,blends the positioning of the player or community who isstruggling for HR and sees itself as (dis)empowered and(un)responsible with the constructions of the social andpolitical (im)possibilities that condition its agency. Fromthis viewpoint, HR become constitutive constructions andnarratives. Going beyond a view of the totality as madeup from individual parts, HR are “always weaving, alwaysin process and never finished.” The territory they presentand their (dis-)”harmonies reside in the way in which eachstrand, as it issues forth, coils around the others and iscoiled in its turn” (Ingold, 2015, p. 11).

As such, for instance, power is not something that peoplehave inmore or less quantity but is a relational narrative that“only exists within relationships” (Angelique, 2008, p. 249).For this reason, to the term “power”, Foucault preferred “re-lations of power” to avoid locating it in specific institutionsand political structures. Instead of being crystalized inessential locations, Foucault invited us to see power rela-tions as strategies that “are mobile, they can be modified,they are not fixed once and for all” (Foucault, 1984, p.292). As for Ingold’s idea of “humaning”, here as well weshould talk of “powering” to underscore the constant rela-tional and therefore situated becoming of power, as a mate-rial performance that feeds and (re-)/(de-)territorializesitself. For instance, in a participatory project conducted withAfrican young mothers formerly associated with armedgroups, Worthen and her colleagues (2010) worked on thedevelopment of human capabilities through complex under-standings of empowerment and the participants’ ongoingand critical dialoguing about freedoms and realities. Beyondthe specific results, the reflexive process in itself allowed forlocalized constructions and developments of HR and for re-territorializations of relational spaces through the creation ofcommunities of mothers with shared experiences.

The Limits of Empowerment

While the idea of empowerment is foundational in commu-nity psychology and is part of virtually any HR framework,it is crucial to explore the limits to this concept to avoidreducing it to a matter of personal responsibility and action.To this respect, Andreopoulos and Arat (2014) question thelegitimacy of advocating under the overly broad and some-times totalizing framework of HR. For these authors, powerdynamics between the provider of humanitarian help andits beneficiary are always at play and will influence the waysHR violations are inferred and understood.

Without reflections on the complex intersection of intra-actions or, as we wrote above, of trees and rhizomes, unidi-rectional identifications and interpretations of abuse runthe risk of becoming yet another way through which ethno-centric views of the Global North on human interactions

are exported and imposed on the Global South. This isparticularly dangerous in those circumstances in whichsuch interpretations are decontextualized and do not takeinto consideration the impact that interventions in thename of HR may have in the long term, or the impact thatthey may have on groups other than the direct beneficia-ries. This was the case of the Child Labor Deterrence Act:It intended to ban the import to the European Union ofgoods produced through child labor and, according to theUNICEF, caused around 50,000 children in Bangladeshto lose their jobs in the textile industry. Without their jobsand other means to sustain themselves, but also withouteducation and social support, many of these children wereforced into worse forms of exploitation, such as prostitutionor stone-crushing (Andreopoulos & Arat, 2014).

HR violations are complex events, whose multiple layersof interpretation and experience intersect at various levels.As such, they cannot be solved by intervening only on asingle aspect or manifest issue. Even if the fight againstchild labor is legitimate and necessary, the Child LaborDeterrence Act threatened economic sanctions towardsome of the poorest countries of the world without reallychanging the social orders that contributed to the issue ofchild exploitation. At the psychological level, a similar logicmight happen if the HR framework acted only on individu-als and communities without understanding and eventuallyaddressing the social and political dynamics through whichrealities and experiences evolved.

Liberation and Collaborative Psychology:HR as Process, Not as Result

Reflecting on his work and advocacy with oppressed indige-nous populations of El Salvador, liberation psychologistMartín-Baró claimed that it was an historical mistake tomove in the direction of understanding the psychology ofsocieties and groups as a combination of individual featuresand personalities without considering the power ofmacrosocial structures of control and power (Martín-Baró,1983). Rather, the role of the community psychologistentails fostering critical reflection and awareness amongall members of a society, about their and others’ HR. Inother words, it is “through increasing critical consciousnessof the world that one becomes aware of the myth thatoppression and dehumanization are natural” (Landsman,2014, p. 346). Through his grassroot work, Martín-Barórealized that mental-health improvement needs to passthrough the transformation of society to transcend its his-torical limitations and overcome its forms of oppression.He argued that community psychologists need to be “onthe streets”, in close contact with the people with whomthey work. They participate, become political, and often



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in practices of social advocacy that go beyond safe profes-sional roles and positions.

The same critical reflection on the boundaries and normsof disciplinary practices applies to HR as well. As Foucaultargued, “one must guard against hegemonic thought on thepretext of presenting human rights theory or policy. Afterall, Leninism was presented as a human rights policy. . .”

(Foucault, 1982, p. 472). Psychologists might unwillinglyimplement an hegemonic logic in the moment in whichthey uncritically refuse local knowledges and “opportunitiesto make use of culturally consonant forms of assessmentand treatment” and to reflect on “cultural assumptions builtinto different systems of help and healing” (Kirmayer, 2012,p. 109).

Participation

Liberation psychology, social constructionism, and criticalforms of inquiry share a view of psychology as based onthe participation of local agents. “Participation” is here akeyword which underscores the importance of localized col-laborations with individuals who are active parts and bene-ficiaries of the knowledge which psychologists contribute todevelop (Fals-Borda, 1979) and of which they are part too.In addition to re-position the researcher, the praxis of“participation” radically moves the individuals with whompsychologists work from the position of passive subjects tothose of agents of the change that they wish to see.

In practice as well as in research, to collaborate withothers starts from recognizing their expertise (Anderson &Goolishian, 1992) and embedment in a cultural world(Bhatia & Ram, 2009). It then continues through engagingwith them to build conditions of trust and empowerment(Revsbæk, 2016). Throughout this process, it is crucial toacknowledge central and marginal constructions of identi-ties and social contexts. To achieve genuine participation,power needs to be seen and negotiated not as somethingpresent, but as an “intra-action” that constantly weaves“subjective manifestations of societal distributions” (Fryer,2008, p. 242). In this sense, the involved parties collaboratecritically and reflexively to question the status quo of socialroles, the absolute goodness of HR agendas or programs,the identification of issues or abuses, and the effectivenessof proposed solutions or interventions. Rather than thinkingof power as something to subvert or invert, analyzing thepractices in which the individual-society relation developsoffers a more pluralized account of ways in which powergames may collide in the everyday.

Participatory Action Research (PAR) and Community-Based Participatory Research (CBPR) are methodologiesthat champion radical ways of collaborating with the partic-ipants in all of the phases of an inquiry or practice. Thepersons and communities “become part” of the project,

without feeling pressured to follow ideological or disci-plinary values imposed from above or from the experts.The aim of the inquiry is not necessarily to create harmonyor solutions, but to “probe the desirability of the direction oftravel” and to “hold in tension the many ambiguities andcontradictions” (Nolas, 2013, p. 133). This ongoing negotia-tion of power is often challenging: The participants mightnot be used to this level of collaboration with externals;people in power might be reluctant to give it up; andexisting social orders are likely to play a normalizing pres-sure on power relations. The traditional role of the psychol-ogist as external helper or researcher is deeply questionedin participatory models of psychology, as the figures ofthe observer, therapist, and community activist blendtogether to give rise to an entanglement of roles and exper-tises, the most important of which are the promotion ofdialogue and the openness to recognize and capitalize onexisting resources and knowledge.

From this perspective and in line with process/relationalontologies, research is not done on the other and neither forthe other, but with the other (Parker, 2004). In addition tosearching for solutions or the denouncing of abuses, partic-ipation based on relational ontologies analyzes the differentways through which realities can be configured and throughwhich discourses promote specific realities, views of theworld, and knowledges. In this sense, “the techne or craftof doing research becomes more like following, a goingwith things, rather than attempting to capture and fix them”

(Helin et al., 2014, p. 10). While the approach is deeplybottom-up, the presence of the psychologist or theresearcher is by itself constitutive of what is to be observed,analyzed, and reported (Gemignani, 2011a). Radical formsof reflexivity about ontologies and social positions are thenin order to critical reflect on the constructive processes andagents of any inquiry (Gemignani, 2017).

Conclusions: Toward an EthicalPsychology of Human Rights

“As a helping professional, one may accept the status quo,or engage critically with institutions, disciplines, communi-ties, colleagues, and clients for emancipatory purposes”(Dudley et al., 2012, p. 650). Yet, neither the status quonor the problems from which to become emancipated orthe parties involved are crystalized entities and identities,which operate in isolation from their contexts and fromeach other. The view of HR that we proposed in this manu-script underscores the ongoing process of co-constructionsof constructions, in a web of meanings and realities thatconstantly re-constitutes itself through its performativeand intersecting “intra-actions” (Barad, 2007). Moving



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beyond arguments and conceptualizations that see thepractices of psychology and the HR framework as value-free and universal, we invite adopting a relational view ofreality and a critical approach to knowledge (Gergen,2009; Gemignani, 2017). The result of such critical thinkingis an openness toward radical forms of collaboration andparticipation, toward a view of psychology as deeplyembedded in constructed contexts, and toward the devel-opment of critical awareness on ideological and culturalassumptions in psychology, such as the individualizationof sufferance and traumatic memories or the promotionof empowerment and agency as internal processes linkedto personal will (Kevers et al., 2016).

In this perspective, ethics moves from what is right andnormal to an ethical care of the self. Far from being an invi-tation to personal care or the celebration of the individual,here “caring for the self” concerns the politics, practices,and technologies that allow specific “selves,” realities, orissues to become true to some people in some historicaland cultural circumstances. The Foucaultian concept of“care of the self” is here seen as the reflexive psychologist’seffort to participate in processes that both analyze specificproblems and understand the intersecting social dynamicsthat contribute to their existence and experiencing. Thismove encourages the HR psychologist to rediscover the dis-cipline’s roots and basic foci, starting from a sensibility toecologically understand the situated others and the phe-nomena that concern them in complex, not-reductive, andmeaning-laden ways and continuing with an openness to aplurality of knowledges beyond what might otherwiseappear true and inevitable.

Inviting HR psychologists to work critically means toacknowledge the entanglement of power, responsibility,subjectivities, and social dynamics (Fryer, 2008). Thisacknowledgment “entails understanding how helping pro-fessions may hinder people, engaging with service users’concerns and pain, and promoting citizenship that involvesadvocacy and genuine partnerships across social divides”(Dudley et al., 2012, p. 650). Of course, this warning doesnot want to dissuade psychologists from helping others orresearching psychosocial issues. Rather, it underscores thatpsychologists working for and with HR will benefit fromengaging people and concerns as processes of becomings.Instead of being based on stable building blocks, territories,allegiances, solutions, or harmonies, HR become intersect-ing “lines of flight” that simultaneously connect and swirl inthe in-between, through multiple paths of differentiation(Deleuze & Guattari, 1987; Ingold, 2015). Through ongoingcritical reflections, a HR framework develops its potentialsto become a complex material process which is shapedthrough the “intra-actions” of ongoing inquiries and dia-logues, rather than through the imposition and moralityof single narratives and interpretations.

While we understand that embracing critical reflexivityand relational ontologies represent a major move fromthe post-positivist and neoliberal logics that has so fardominated Western psychology, especially in the academia,taking this theoretical step becomes a way to looking at thelarger pictures, “to avoid playing small ball [. . .]. To dootherwise will limit our future ability to transform the soci-ety we sought to change by becoming change-orientedscholars in the first place” (Hancock, 2013, p. 296).

HR are not merely practices of making people morehuman, as in universalist frameworks. Neither they aretruths or givens to be applied. Rather, rights are intersectingintra-actions through which “human” becomes an actionand a differentiation. When we acknowledge the processof becoming in the making, HR rights are always not yet.They are a process of aspiration. Or, as Ingold poeticallywrites about “humaning” (i.e., human as a verb), “Whereasother creatures must be what they are in order to do whatthey do, for humans it is the other way around. They mustdo what they do to be what they are” (Ingold, 2015, p. 118).It is not simply a matter of applying a HR framework thatmakes people more human: People’s becoming “human”continually overtakes their being.

HR practitioners and clients (need to) engage in ongoingprocesses of critical reflexivity and radical participation toendlessly challenge the status quo of existing orders andsimultaneously construct themselves in the doing. Westarted this manuscript by saying that “the devil is in thedetails.” We conclude hoping that both the devil and thedetails can now be seen as intersecting and relational pro-cesses that co-construct each other in their necessary, situ-ated, and yet always unfinished practices of becominghuman.

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HistoryReceived May 14, 2018Revision received October 23, 2018Accepted January 10, 2019Published online June 14, 2019

ORCIDMarco Gemignani

https://orcid.org/0000-0003-1765-111X

Marco GemignaniDepartment of PsychologyUniversidad Loyola Andalucíac. Energía Solar 141014 [email protected]

Marco Gemignani is associate pro-fessor of psychology at the Universi-dad Loyola Andalucía, Seville, Spain.He specializes in qualitative method-ologies and his research concerns theacculturation of refugees and irregu-lar migrants from cultural studies,constructionist, and critical perspec-tives. Through forms of participatoryand community-based research, Dr.Gemignani inquires about social pro-cesses and practices that createspecific possibilities, subjectivities,and ontologies for migrants andminorities.

Yolanda Hernández-Albújar is anassistant professor in the departmentof Humanities and Philosophy at theUniversidad Loyola Andalucía, whereshe teaches courses in CulturalAnthropology and Migrations. Shegraduated from the University ofPittsburgh with a PhD in Sociologyand her main areas of research con-cern the interplay of identity, gender,and migration.



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The Human Right to Make One’sOwn Choices – Implications forSupported Decision-Making inPersons With DementiaA Systematic Review

Theresa S. Wied1, Maren Knebel2, Valentina A. Tesky1, and Julia Haberstroh1,2

1Geriatric Medicine, Institute of General Practice, Goethe University, Frankfurt am Main, Germany2Interdisciplinary Ageing Research, Faculty of Educational Sciences, Goethe University, Frankfurt am Main, Germany

Abstract: Autonomy is a human right and implies the “freedom to make one’s own choices.” The UN Convention on the Rights of Persons withDisabilities (UN-CRPD) is a human rights treaty granting persons with disabilities, such as persons with dementia (PwD), legal capacityregardless of their impairments. State parties and healthcare practitioners (HCP) are obliged to enable PwD to make decisions with legaleffect. The UN-CRPD does not specify the nature of support, thus, the implementation of supported decision-making (SDM) remains unclear.The objective of this review is to compile empirical support strategies for decision-making in dementia and address the specific needs of PwD.Using search terms related to “dementia,” “decision-making,” and “support,” we conducted a systematic review (following PRISMA guidelines)and searched MEDLINE and PsycINFO for empirical studies. References were cross-referenced. Information on support strategies wasextracted, summarized, and thematically categorized to provide an overview of international literature on SDM in dementia. Initially, we found2,348 articles. Thirty-five full-text articles were screened for eligibility (criteria followed PICOS model), 11 of which met the inclusion criteria.Strategies to support decision-making in PwD were categorized according to approach. Support began either with the individual and his/herspecific abilities or with the social, spatial, and procedure-oriented environment. As the first systematic review on SDM for PwD, this articlecontributes to the implementation of SDM in practice. Despite heterogeneous evidence, the findings have crucial implications for HCP on howto enable PwD to exercise their human right to make decisions with legal effect.

Keywords: supported decision-making, dementia, human rights, autonomy, informed consent

In recent years, the importance of autonomy in health andsocial care contexts has been increasingly reflected in anemphasis on user involvement in decision-making (DM)(Wilkinson, 2001). The right to make self-determineddecisions is an integral part of autonomy. As dementia isa mental disorder involving progressive decline in cognitivefunctions, the decision-making abilities of PwD are fre-quently mistrusted (Marson, Ingram, Cody, & Harrell, 1995).

Legal Framework

Human rights laws do not question the right to make auton-omous decisions, regardless of a person’s impairments. Thefirst human rights treaty this century, the UN Conventionon the Rights of Persons with Disabilities (UN-CRPD,2006), uses a broad definition of the term disability (Article

1) that includes persons with dementia. Individual auton-omy is demanded in Article 3, including “the freedom tomake one’s own choices” (UN-CRPD, Article 3 (1)). Fur-thermore, the UN-CRPD grants people with disabilitieslegal capacity and recognizes them as persons before thelaw (UN-CRPD, Article 12).

State parties are requested to help persons with disabili-ties to exercise their legal capacity (Article 12, UN-CRPD),meaning PwD need to be enabled to make decisions withlegal effect.

“Article 12, paragraph 3, does not specify what form thesupport should take. ‘Support’ is a broad term thatencompasses both informal and formal support arrange-ments, of varying types and intensity” (Committee onthe Rights of Persons with Disabilities, 2014, p. 4).


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However, the nature of support remains unclear.For ratifying countries, the UN-CRPD will have major

implications for the implementation of SDM. Country-specific laws may require redefinition in line with changesin the legal standing of PwD while SDM should replaceconcepts like guardianship (Kohn & Blumenthal, 2014).

Practical Implementation

The UN-CRPD and its emphasis on SDM have extensiveimplications for practice and healthcare professionals(HCP). HCP have a legal and moral obligation to supportPwD and encourage them to participate in decision-makingto the best of their ability (Black, Wechsler, & Fogarty,2013; Groen van de Ven, Smits, Oldewarris, et al., 2017;Moore & Hollett, 2003). Support strategies within the ICprocess are called enhanced consent procedures (ECP)(Mittal et al., 2007) and aim to facilitate autonomousdecision-making (Eyler & Jeste, 2006).

The crucial question is how to balance autonomy andprotection against harm (non-maleficence) in the deci-sion-making of PwD (Beauchamp & Childress, 2013; Webb& Dening, 2016; Wilkinson, 2001) and whether SDM canhelp achieve this desirable balance. Based on theirdiagnoses, PwD should neither be excluded fromdecision-making, nor considered incompetent (Kim, Kar-lawish, & Caine, 2002; Marson, Schmitt, Ingram, & Harrell,1994).

A paradigm shift from negating the perspective of PwDin research to actively incorporating their experience, views,and perceptions as experts in their disease (e.g., De Boeret al., 2007; Moore & Hollett, 2003; Von Kutzleben,Schmid, Halek, Holle, & Bartholomeyczik, 2012) hasresulted in a variety of studies and findings on decision-making in dementia.

Several studies concerning decision-making capacity(mental capacity) focus on assessing deficits and resourcesof PwD (e.g., Kim et al., 2002; Marson et al., 1995; Moyeet al., 2006; Palmer et al., 2005).

A growing body of literature examines if, how, and towhat extent PwD take part in decision-making (Blacket al., 2013; Boyle, 2013; Feinberg & Whitlatch, 2002;Hamann et al., 2011; Hirschman, Joyce, James, Xie, & Kar-lawish, 2005; Menne & Whitlatch, 2007), and howinformed consent is provided (Black, Kass, Fogarty, &Rabins, 2007). Further research focuses on decision topicsand the influence of key events (Bronner, Perneczky,McCabe, Kurz, & Hamann, 2016; Horton-Deutsch, Twigg,& Evans, 2007; Groen van de Ven, Smits, Oldewarris,et al., 2017), while another concentrates on the controver-sial role of caregivers and proxy consent (Black et al.,2013; Hirschman et al., 2005; Horton-Deutsch et al.,2007; Karlawish et al., 2008).

An almost unaddressed area of interest is SDM in demen-tia and relevant evidence is scarce (Fetherstonhaugh,Tarzia, Bauer, Nay, & Beattie, 2016). Studies that focusmore on assessing mental capacity than explicitly on SDMhave developed certain recommendations. Firstly, supportcan address the decision-making environment, for example,by creating a calm and undisturbed atmosphere for theinformed consent process (Eyler & Jeste, 2006; Moyeet al., 2006). Secondly, support may address the resourcesand deficits of PwD. On a deficit-based level, it is possibleto consider someone’s individual cognitive profile (Eyler &Jeste, 2006). Depending on individual impairments, forexample, verbal retrieval, support can deal with aspects ofunderstanding by varying information delivery methods(Haberstroh et al., 2014; Moye et al., 2006). Moreover,the consideration of cognitive fluctuations in PwD duringassessments is important. In this case, the underlying causeshould be diminished, the time of the “best cognitivemoments” exploited, and additional support can aim atsimplifying and summarizing relevant information(Trachsel, Hermann, & Biller-Andorno, 2015). On a moreresource-based level, individual communicative behaviorof PwD can be considered. Support may, for example,include non-verbal content aspects (e.g., pictograms) andrelational aspects (e.g., emotions) (Knebel, Haberstroh,Kuemmel, Pantel, & Schröder, 2015; Kuemmel, Haberstroh,& Pantel, 2014).

The aim of this systematic review is to compile a compre-hensive overview of current international evidence onpossible support for PwD in decision-making and tocontribute to the urgently needed clarification of Article12 (3) of the UN-CRPD. Thus, the main research questionsin this review are:

Research Question 1 (RQ1): What decision-making sup-port strategies exist for PwD? To what extent haveexisting support strategies been empiricallyevaluated?

Research Question 2 (RQ2): What support needs anddemands do PwD have, and how do they think thedecision-making process could be improved?

To our best knowledge, no systematic review of SDM orECPs exists that focuses specifically on PwD.

Methods

Search Strategy

The authors followed the systematic approach of thePreferred Reporting Items for Systematic Reviews and


T. S. Wied et al., Supported Decision-Making in Dementia 147

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Meta-Analysis (PRISMA). Both PRISMA components wereused, these being a 27-item checklist and a four-phase flowdiagram (Figure 1) (Moher, Liberati, Tetzlaff, Altman, &The PRISMA Group, 2009). As this systematic reviewwas not registered, we cannot provide a registrationnumber. A review protocol was not prepared.

The international literature search was conducted in twoscientific databases: Medline via PubMed and PsycINFO.These databases are the most suitable for the area ofinterest and include millions of records. The search wasconducted in December 2017.

The search strategy was developed by establishing threemain categories of content-related relevance. Subsequently,related terms and synonyms were formulated for eachcategory and were used for both databases (see Table 1).We used controlled vocabulary, medical subject headings(MeSH), thesaurus (descriptors), and free-text terms.

The main Boolean Search Operators were used in thesearch process. We linked all terms of one main categoryusing OR (or-relations) and afterward linked the terms

within the three main content categories using AND(and-relations). The search strategy and the imposed limita-tions are presented in Table 1.

We ensured a comprehensive search by “snowballing”references of relevant articles. After duplicates wereremoved, two reviewers (Julia Haberstroh and TheresaWied) conducted three independent screenings. Firstly,the titles were screened, and then the abstracts of theremaining articles. The third screening consisted mainlyof one reviewer reading full-text articles.

Selection Criteria

A number of systematic overviews and reviews of relatedresearch areas (e.g., SDM for general target groups likevulnerable persons) enabled the authors to gain a roughidea of the current literature (Dunn & Jeste, 2001; Eyler& Jeste, 2006; Fields & Calvert, 2015; Flory & Emanuel,2004; Kim et al., 2002). These studies provided informa-tion on the scarcity of current existing evidence, for which

Figure 1. Flowchart displaying study selection according to PRISMA.


148 T. S. Wied et al., Supported Decision-Making in Dementia

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the inclusion criteria were defined widely to identify asmany suitable articles as possible. Beyond formal eligibilitycriteria (imposed limitations), criteria on a more content-and methodology-related level followed the PICOS model(participants, interventions, comparisons, outcomes, andstudy design):

(P) PwD functioning as decision-makers, regardless ofthe decision; all decisions were included.

(I) Support interventions and strategies for PwD;demands and needs of PwD relating to support indecision-making process.

(C) No, or an alternative support intervention, no involve-ment of PwD in decision-making process.

(O) Benefits for PwD, that is, improved understanding,higher satisfaction, and increased involvement.

(S) Empirical studies (qualitative, quantitative, and casestudies; reviews).

Articles addressing other target groups, for example,persons with schizophrenia, other decision-makers, suchas surrogates, other decision-making concepts, such asadvance care planning, were excluded.

Disagreement on whether to include an article wasresolved by discussion or incorporating a further reviewer.

Data Collection Process

Theresa Wied extracted most data, and a second reviewerchecked for completeness by examining random samples.We used an individualized data extraction form to extractdata and summarize information (simplified version seeTable 2). The development of the data extraction formwas based on examples from the Joanna Briggs InstituteReviewer’s Manual (Aromataris & Munn, 2017).

Data Analysis

For a systematic overview of existing support, we analyzedthe provided details and assigned them to thematic cate-gories. One reviewer categorized the passages of the arti-cles that described strategies to support decision-makingin PwD. The reviewer returned to the primary studies tocheck indicated reasons for support (underlying needs ofPwD or concrete targeted outcomes) when the supportcategory was unclear. The wide variety of support was sum-marized in general and subcategories. To reach consensus,the research group subsequently discussed categorization.

Results

The database search revealed 2348 articles. Eight furtherarticles were identified by cross-referencing the referencelists. After removing duplicates, two reviewers conductedthe initial screening of 1,926 records. After the secondscreening of abstracts, 35 articles remained. Thirty-threefull texts were assessed for eligibility as the full texts oftwo articles were not accessible. A total of 11 articles wereultimately included in the systematic review. The stepwisestudy selection process is displayed in a flow diagraminspired by PRISMA (Figure 1).

Six of the 11 included studies focused specifically onSDM, while the remaining five dealt more with the mean-ing of decision-making for PwD, their decision-makingneeds, and their involvement in the decision-making pro-cess. Summarized information from the 11 included articlesis shown in Table 2. We found four intervention studies:two quantitative studies, one qualitative study, and onemixed-methods study (Mittal et al., 2007; Murphy & Oliver,2013; Rubright et al., 2010; Span et al., 2015). The otherseven are predominantly qualitative interview studies thatdescribe support strategies based on experiences andperceptions of PwD or caregivers and practitioners thatwork with or care for PwD. We therefore subdivided ourfindings into the major categories “interventions” and“strategies.”

Table 1. Search terms and database search strategy

No. Search terms and relations Category ofsearch terms

#1 Dementia [MeSH]/[DE] Dementia

#2 Alzheimer* [TA]

#3 “cognitively impaired” [TA]

#4 “cognitive impairment” [TA]

#5 #1 OR #2 OR #3 OR #4

#6 Decision making [MeSH]/[DE] Decision-makingcapacity

#7 Capacity [TA]

#8 Competence* [TA]

#9 Consent [TA]

#10 “Mental capacity” [TA]

#11 “Capacity to consent” [TA]

#12 #6 OR #7 OR #8 OR #9 OR #10 OR #11

#13 Support [TA] Support

#14 Enhance* [TA]

#15 Assist* [TA]

#16 Facilitat* [TA]

#17 #13 OR #14 OR # 15 OR #16

#18 #5 AND #12 AND #17

#19 Limit: English and German

#20 Limit: humans

#21 Limit: abstract

Note. MeSH = medical subject headings; DE = descriptors; TA = title/abstract.



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Tab

le2.

Su

mm

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form

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spec

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orks

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Pw

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form

alca

regi

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pro

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alca

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(201

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care

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dad

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(200

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pro

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un

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g(M

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AT

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y(2

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18d

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s-

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din

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un

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Tab

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Thre

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mily

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dp

rofe

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nal

care

give

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015)

Dem

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aca

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etw

orks

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Within these two major categories and despite theirheterogeneous nature, support strategies and interventionscould be categorized with respect to overall approach. Thepossible support approaches focused on “person” or “envi-ronment.” Environment-related support aims to influenceexternal factors that are not obviously linked to the impair-ments or abilities of PwD. It may address (1) the “technical”process of decision-making by including supportive materi-als or considering time constraints, (2) the space design andits optimization, and (3) the person-centeredness and rela-tionships initiated during the decision-making process. Incontrast, support that takes a person-oriented approachfocuses on individual abilities. This kind of support mightaddress understanding, appreciation, reasoning, andexpression of a choice, whereby these subcategories areselected in accordance with Grisso and Applebaum’s(1998) definition of decision-making abilities. All categoriesand subcategories of support are shown in Figure 2.

While the qualitative studies presenting strategiesdescribed underlying needs of PwD and formulated aimsof the support, the intervention studies sometimes namedconcrete outcomes (see Table 2).

Strategies

The strategies were either developed jointly by practitionersand PwD, or derived from expressed or interpreted needsand demands of PwD. The identified strategies wereapplied in decision-making processes with and by PwD,but not empirically evaluated.

Environment – ProcedureAs the underlying need of PwD was to contribute to thedecision-making process, feelings of productiveness andusefulness were encouraged by working within frameworks,for example, writing task lists to facilitate the choice what todo and when (Fetherstonhaugh, Tarzia, & Nay, 2013). Theinclusion of further material in the process appeared tomake sense. According to Lord, Livingston, Robertson,and Cooper (2016), PwD appreciated decision aids andexpressed specific wishes regarding delivery and contentof such aids, for example, aids should not be provided atthe point of diagnosis, but during the interaction with theHCP.

The consideration of time appeared to be important.Several authors described the need to adapt the decision-making process to the pace of PwD, and to provide timeto recognize the need to decide, reflect on alternativesand the final decision. Furthermore, decision topicsshould be introduced slowly and pressure or haste avoided(Fetherstonhaugh et al., 2013, 2016; Groen van de Ven,Smits, Elwyn, et al., 2017; Smebye, Kirkevold, & Engedal,2012; Tyrrell, Genin, & Myslinski, 2006). Tyrrell and

colleagues (2006) mentioned that PwD felt they had insuf-ficient time for reflection and needed time to think throughoptions and let them ripen.

Environment – SpaceSmebye and colleagues (2012) described the simplificationof the spatial environment with the aim of clarifying choicesfor PwD. This goal could be achieved by “[. . .] keepingthings tidy, removing irrelevant objects and keeping orderby labelling drawers” (Smebye et al., 2012, p. 5). Accordingto Fetherstonhaugh and colleagues (2016), noisy or dis-tracting environments, including numerous attendantpersons, should be avoided during the decision-makingprocess.

Environment – RelationshipTo establish appreciative and trusting relationships and aperson-centered attitude meant support should be offeredsubtly and disempowerment and taking-over avoided(Fetherstonhaugh et al., 2013). PwD appreciated supportas “backup” and corrective feedback when decisionsseemed inappropriate. An environment was perceived assupportive when it encouraged the development of confi-dence and self-esteem and gave PwD the feeling somethingwas expected of them (Fetherstonhaugh et al., 2013). Thatmight mean making suggestions, establishing a plan, form-ing strategies together, enabling a dialog to develop ratherthan simply providing information, and checking PwD feltcomfortable with the decision-making process (Fetherston-haugh et al., 2013; Smebye et al., 2012; Tyrrell et al., 2006).

PwD should be encouraged to express views, wishes, andpreferences actively, perhaps by using a conversationalinterview style, or proposing compromises, and givinglevels of choice that fostered participation in decision-making (Fetherstonhaugh et al., 2016; Smebye et al.,2012; Tyrrell et al., 2006). PwD frequently mentioned

Figure 2. Categories and subcategories of support approachesdeveloped in this review.



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having no chance to express themselves and felt unheard(Tyrrell et al., 2006).

According to Fetherstonhaugh and colleagues (2013), itwas important to treat PwD as adults and talk with ratherthan about them. PwD mentioned a strong need to play acentral role in decision-making, which was sometimesimpeded by being ignored and marginalized.

To support decision-making, information should be tai-lored to the wishes and preferences of PwD or to what theythink it is important to know (Tyrrell et al., 2006). BotheringPwDwith options they have no interest in may lead to angerand agitation. Knowledge about them and the developmentof trust encouraged them to relax and feel comfortableduring the decision-making process (Fetherstonhaughet al., 2016). PwD perceived a lack of satisfying information,which could result in a reduced ability to make decisions(Tyrrell et al., 2006).

PwD wanted to make the final decision and complainedwhen they saw no chance to revoke or modify decisions.Where possible, the final decision should be left to PwDand it should be emphasized that decisions could alwaysbe revoked or modified (Fetherstonhaugh et al., 2013;Tyrrell et al., 2006).

Person – UnderstandingSupport strategies focusing on individual abilities andimpairments aimed predominantly to help PwD under-stand. Smebye et al. (2012) described the need for abalanced approach. “On the one hand they [caregivers]needed to explain matters thoroughly but on the other handgiving excessive information overwhelmed and confusedthe person” (Smebye et al., 2012, p. 8).

To avoid miscommunication and indicate the need for adecision, it was also important to highlight the start of thedecision-making process by raising and defining a decisiontopic and discussing goals (Groen van de Ven, Smits, Elwyn,et al., 2017).

As PwD mentioned they were dissatisfied with the pro-vided information, rethinking the presentation of informa-tion is necessary (Tyrrell et al., 2006). Studies showedthat using simple and clear language, focusing on consis-tency of expression, and employing additional non-verbalcommunication fostered understanding (Fetherstonhaughet al., 2016; Smebye et al., 2012; Tyrrell et al., 2006).

Visual illustrations, aids, and props, such as pictures,could help compensate for impaired memory and supportunderstanding (Fetherstonhaugh et al., 2016; Smebyeet al., 2012).

The use of reminders, such as alarms or calendars, couldhelp PwD reflect on the past and future and encouragethem make timely decisions (Fetherstonhaugh et al., 2013).

In view of limited powers of concentration and delibera-tion, several authors recommended presenting fewer

options to avoid confusion, being side-tracked, and losingfocus (Fetherstonhaugh et al., 2013, 2016; Samsi &Manthorpe, 2013; Smebye et al., 2012).

Appraising the level of PwD engagement during theprocess and asking questions accordingly could also reducecognitive overload (Samsi & Manthorpe, 2013).

Verifying that PwD understood information by (inter alia)using a question–answer pattern, waiting for answers, andchecking understanding (Smebye et al., 2012; Tyrrellet al., 2006) were essential.

Person – AppreciationAssisting in overseeing what is relevant to the PwD’ssituation and focusing on each individual’s situation whenchecking understanding could foster appreciation of theperson (Groen van de Ven, Smits, Elwyn, et al., 2017;Smebye et al., 2012).

Person – ReasoningWhen no standard alternative existed, alternatives shouldbe clarified (Smebye et al., 2012) by jointly recognizingand developing them, weighing pros and cons, and deliber-ating on them. As deliberation was sometimes difficult forPwD, trying out alternatives may be a suitable support strat-egy (Groen van de Ven, Smits, Elwyn, et al., 2017).

Interventions

Interventions in the remaining four studies were evaluatedempirically. Details on design, methods, and outcomes areshown in Table 2.

Environment – ProcedureThe DecideGuide is an interactive web tool, introduced tosupport decision-making. According to Span and colleagues(2015), the aim of the aid was to enable communication(chat function: messages), encourage joint decision-making(deciding together function: assist stepwise in decision-making), and allow individual views and opinions (individ-ual option function: questionnaires) to be expressed.Despite little overall usage and rare use of the decidingtogether function, participants valued the tool positively.PwD in particular mentioned no perceived improvementin decision-making, but appreciated easier communicationand information sharing. Technical failure was mentionedas an important barrier to the tool’s use (Span et al., 2015).

Murphy and Oliver (2013) aimed to support PwD in com-munication and decision-making processes with carers viathe implementation of the Talking Mats Framework (TM).Within the framework, picture symbols for a (decision-)topic were placed below a visual scale (“managing,”“needing assistance,” and “not managing”). Topics wereconverted into comprehensible and highly visible symbols.



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Furthermore, PwD were assisted in demonstrating theirfeelings and views about options. One of TM’s aims is tohelp PwD stay focused and organize thoughts. Findingsshowed that PwD felt significantly more involved andsatisfied with the overall discussion. TM helped PwD toremember the issue, relevant words, and to express theirviews. According to Murphy and Oliver (2013), TM helpedviews to be expressed, engaged PwD in decision-making,and improved relationships.

Person – UnderstandingBased on PwD’s cognitive deficits, Mittal and colleagues(2007) developed two enhanced consent procedures to sup-port PwD’s understanding in IC. As part of an enhancedwritten consent procedure, understanding should be sup-ported via a written consent form that included highlightedkey elements and a bigger font. Study coordinators pro-vided verbal information, checked understanding, anddirected the attention of PwD to critical elements.

To promote understanding, a PowerPoint slideshowpresentation consisting of graphics, a video of the proposedtreatment, and voice narrations, replaced written consentforms. Key elements were summarized, and the study coor-dinator gave verbal information and highlighted importantissues. Following a simulated IC procedure (trial 1), bothECPs were used in a second trial. Both intervention groupsshowed significant improvement in understanding afterre-explanation (trial 2), but there were no significant differ-ences in scores between the ECPs. Mittal et al. (2007)concluded it was premature to draw final conclusions onthe value of ECPs and particularly of PowerPoint slideshowpresentations.

Rubrightandcolleagues (2010) strived to support recogni-tion memory and executive functions by comparing two dif-ferent ways of assessing decision-making capacity. Duringthe standard assessment, PwD received and retained a con-sent form written in the standard style and format, includ-ing mandated content. The interviewer transferred theinformation entirely, asked PwD to read aloud sections ofthe consent form and summarize them step-by-step. PwDwere encouraged to use the consent form when summariz-ing, and the interviewer corrected the errors.

The enhanced assessment was similar to the standardprocedure, except that a memory and organizational aidwas provided to support PwD. The aid presented informa-tion using the same sequence and header titles as theconsent form, summarized key elements, and simplifiedimportant points at sixth grade reading level. After summa-rizing each section’s content, interviewers directed PwD’sattention to the relevant section of the aid and asked themto read it aloud again.

Findings showed that with the aid’s support, PwD weremore likely to be judged capable and had higher scores in

understanding, but not in appreciation, reasoning, andexpressing a choice. According to Rubright and colleagues(2010), the findings showed that when tailored to thecognitive patterns of PwD, support could improve abilityto provide IC.

Discussion

The main aim of this review was to summarize empiricalstudies on needs/demands and support strategies for deci-sion-making in PwD. The findings show that support gener-ally focuses on the person’s understanding, relationalenvironment, and on procedure-oriented environmentalaspects. This may reflect concrete indications on how tosupport decision-making that have been generated bythorough empirical and theoretical examinations of cogni-tive impairments in PwD. As the whole decision-makingprocess is based on understanding information and alterna-tives, it appears plausible to focus on understanding inSDM. Support to the relational environment may beprovided by emphasizing person-centered care (Kitwood,Herrmann, & Müller-Hergl, 2008), particularly in the caresettings under review in most included studies.

Many support strategies presented here are described byseveral authors (expert-consensus). We believe they havedemonstrated their practical value and can positively influ-ence PwD. Based on practical knowledge, these strategieshave important implications for the implementation ofSDM and further research. Moreover, agreement betweendeveloped strategies and both applied interventions andexperts’ recommendations underline the value of derivingrecommendations from these strategies.

The following recommendations were derived.

Person – Understanding

In IC procedures, re-explanations of information (Mittalet al., 2007; Rubright et al., 2010), summaries of keyelements, and simplifications of written information(Rubright et al., 2010) resulted in increased understanding.As the interventions did not improve appreciation and rea-soning, it is uncertain whether understanding reallyincreased, or PwD simply answered questions by readingfrom the aid. The consideration of language in the deci-sion-making process and the use of clear, simple, verbaland non-verbal communication, and consistent expressionpatterns was recommended several times (Fetherstonhaughet al., 2016; Smebye et al., 2012; Tyrrell et al., 2006). Thisindicates that HCP require further communication trainingduring their formal education. To prevent PwD from losingfocus due to cognitive overload, various authors mentioned



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reducing the number of options (Fetherstonhaugh et al.,2013, 2016; Samsi & Manthorpe, 2013; Smebye et al.,2012). This strategy needs to be handled with care, as itsapplication may lead to unwanted results. Verification ofPwD’s understanding certainly appears to be an importantsupport strategy (Groen van de Ven, Smits, Elwyn, et al.,2017; Smebye et al., 2012; Tyrrell et al., 2006). This couldbe achieved by, for example, using a question–answer inter-view technique (Smebye et al., 2012).

Environment – Relationship

Enabling PwD to contribute to decision-making byempowering them via subtle support may promote indepen-dence and satisfaction with the decision-making process(Fetherstonhaugh et al., 2013). Such support could takevarious forms, for example, by encouragingdialog anddevel-oping strategies together (Fetherstonhaugh et al., 2013; Sme-bye et al., 2012; Tyrrell et al., 2006). PwD needed to beencouraged to express their views, wishes, and preferencesrather than be passed over (Fetherstonhaugh et al., 2013,2016; Smebye et al., 2012; Tyrrell et al., 2006). The resultsof actively attained knowledge about wishes andpreferences should then be integrated into the decision-making process, for example, when providing information(Tyrrell et al., 2006).

Many strategies exist within this category but can besummarized as the development and application of a per-son-centered approach during the decision-making process,whereby PwD need to be understood as equal partners. Ourfindings indicate that especially in decision-making onmedical treatment and research participation, which arestrongly influenced by dependence, power, expert opinion,and resulting paternalism, HCP should improve awarenessof their own attitudes and roles during decision-makingprocesses. In addition to communication trainings, HCPshould learn about person-centered behavior.

Environment – Procedure

Environmental interventions focus on decision-making pro-cedures and the application of tools to support decision-making. PwD mentioned several barriers and concerns aboutthe usability of the DecideGuide, but no improvementsregarding decision-making. Nevertheless, they regardedthe tool favorably (Span et al., 2015). This may be becausethey valued increased communication and attention fromresearchers, caregivers, and HCP during research.

Talking Mats is recommended as a framework that facil-itates communication (Murphy & Oliver, 2013). Accordingto Murphy and Oliver (2013), it improved satisfaction withand involvement in discussions and supports PwD’s

memory, concentration, and expression of views. Thisfinding served as a successful example of the strategies“working in frameworks” and “inclusion of furthermaterial” such as decision aids (Fetherstonhaugh et al.,2013; Lord et al., 2016). As both tools were applied in thecontext of daily living, transferability to and appropriatenessfor more complex decision contexts need furtherinvestigation.

Almost half the studies indicated the consideration oftime as crucial. PwD should be given time to reflect anddecide at their own pace (Fetherstonhaugh et al., 2013,2016; Groen van de Ven, Smits, Elwyn, et al., 2017; Smebyeet al., 2012; Tyrrell et al., 2006).

The findings in this review indicate that support in theremaining four categories is either relatively abstract ordoes not exist (Person – Expressing a Choice).

Ethical considerations result in different balancesbetween support and outcomes. While language simplifica-tion may help PwD understand, they may also feel they arenot taken seriously. Besides positive effects, knowledgeabout PwD and the development of trusting relationshipsmay lead to over-confidence regarding wishes and prefer-ences (Fetherstonhaugh et al., 2016) and the exclusion ormanipulation of PwD. Presenting fewer options to preventcognitive overload and PwD being side-tracked may leadto the oversimplification of complex decisions and inten-tional omission of important information. Most of theseethical concerns are not addressed in the included studies.The assumption that support always leads to positive out-comes for PwD needs to be viewed critically, as supportcan also overshoot its target.

Limitations of Included Studies

The methods applied in the few included studies vary con-siderably. Very few support interventions have yet beenexamined in terms of effectiveness. Conducting a meta-analysis was therefore impossible, and we chose to performa narrative systematic review to summarize diverse infor-mation on SDM in dementia. It remains unclear what kindof support is suitable for which severity level or type ofdementia, as few of the predominantly qualitative studiesdifferentiated between support strategies for particularseverity levels, or even specified the type of dementia, orthe degree of severity of participants.

In the absence of a clear theoretical SDM framework,few studies based their choice of approach and outcomemeasures in theory. The inclusion of mainly qualitativestudies shows that authors rarely name specific outcomes.Qualitative studies generally describe underlying needsof PwD and formulate the aims of their support mea-sures. The categorization of outcomes was therefore notfeasible.



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Limitations of this Review

This study has some limitations. First, our inclusion criteriadid not differentiate between stages or types of dementia,so we could not classify our findings accordingly. As partic-ipants in most of the included studies were able to expressthemselves verbally, it is likely their disease was mild tomoderate. Second, time constraints meant we could notprepare and provide a review protocol. Third, althoughsome support strategies applied in care and everyday lifecontexts would probably be of little use in other decision-making contexts, we did not focus on specific decisions ordecision-making contexts due to scarcity of evidence.Fourth, the choice of more specific search terms may haveresulted in fewer non-relevant papers. Nevertheless, weidentified only eight additional articles using other sources.Finally, the detected support strategies were categorized toprovide a systematic overview. We would like to emphasizethat this categorization is just one possibility and othercategorizations would also have been appropriate. AsSDM can be conceptualized as person-relationship inter-linkage, we conclude that strategies and interventions couldsometimes have been allocated to several categories. Inmost instances, a clear assignment of findings to a singlecategory was feasible.

Conclusion

Overall, the findings of this systematic review show thatresearch on SDM is scarce, particularly in dementia, andit is generally performed on other target groups, for exam-ple, vulnerable groups or at-risk populations. Furthermore,developed support strategies and interventions are not care-fully adapted for PwD. Even the studies included in thisreview do not all explicitly deal with SDM but with aspectsof SDM under the umbrella of different concepts such asparticipation or involvement. To fulfill the legal and politicalobjectives of the UN-CRPD, it is important, on a theoreticaland conceptual level, to find out how concepts of participa-tion, involvement, and empowerment are linked with SDMand to clarify overlap and clear distinctions between them.Although the UN-CRPD provides practitioners with noclear recommendations how to support PwD in the exerciseof their legal capacity, our findings show HCP consider theneed to support PwD in decision-making in terms of care oreveryday life within care networks or dyads. This meansHCP are partly aware of their influence and do not reck-lessly deny PwD the right to make their own decisions(Fetherstonhaugh et al., 2016; Groen-van de Ven, Smits,Oldewarris, et al., 2017). In contrast, SDM in dementia israrely discussed in the contexts of medical treatment and

research participation. For politicians and practitioners,the derived recommendations of this systematic reviewcan serve as a first clarification of Article 12 (3) of theUN-CRPD, in particular on how to redefine and supportthe legal standing of PwD in line with human rights law.

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HistoryReceived April 27, 2018Revision received August 28, 2018Accepted January 19, 2019Published online June 14, 2019

AcknowledgmentsThe authors would like to thank Frank Oswald, Johannes Pantel,and the whole ENSURE project team for useful remarks andhelpful advice. Furthermore, the authors would like to thankPhillip Elliott for proofreading the document.

Conflict of InterestThe authors declare that no conflicts of interest exist.

FundingThis work was funded by the Network of European Funding forNeuroscience Research (ERA-NET NEURON), the German FederalMinistry of Education and Research (Grant Number 01GP1623A),and the Volkswagen Foundation.

Theresa S. WiedGoethe University FrankfurtFrankfurt Forum for Interdisciplinary Ageing ResearchTheodor-W.-Adorno-Platz 660629 Frankfurt am [email protected]

Theresa S. Wied (M.Sc.) is a researchassistant and PhD candidate at theInstitute of General Practice and theFrankfurt Forum for InterdisciplinaryAgeing Research of the GoetheUniversity Frankfurt (Germany). Herwork focuses on supported decision-making in persons with dementia, inparticular on the development,implementation, and evaluation ofsupport tools to enhance informedconsent processes in dementia.

When starting this review, MarenKnebel (PhD) was a postdoctoral re-searcher in the Geriatric Psychiatryof Heidelberg University and in theFrankfurt Forum for InterdisciplinaryAgeing Research at Goethe Univer-sity Frankfurt (Germany). She is nowworking as a psychologist in a familycounseling service. Her researchinterests are communication,informed consent and enhancedconsent procedures in dementia.

Valentina A. Tesky (PhD) is a psy-chologist working as a researchassistant at the Goethe UniversityFrankfurt (Germany). Since 2018, sheis deputy head of the working areaGeriatric Medicine at the Institute ofGeneral Practice of the GoetheUniversity. Her work focuses onpsychogeriatrics and clinical geron-tology, for example, mental capacityand enhanced consent procedures.

Julia Haberstroh (PhD) is a psychol-ogist working as an independent re-search group leader and coordinatorof the research projects EmMa andENSURE at the Goethe UniversityFrankfurt (Germany). In 2015, shefinished her cumulative habilitation.Her research interests are thecapacity to provide consent tomedical treatment and researchparticipation and enhanced consentprocedures in cases of dementia.



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Human Rights, Dementia,and IdentitySarah Butchard1 and Peter Kinderman2

1Mersey Care NHS Foundation Trust, Liverpool, United Kingdom2Department of Psychological Sciences, University of Liverpool, United Kingdom

Abstract: Human rights are integral to the work of applied psychologists, particularly when supporting people who may be experiencing someform of vulnerability. As dementia progresses, potential vulnerability increases and the need to protect and promote the fundamental humanrights of people living with dementia becomes even more important. However, we also need to translate complicated human rights law intopractical strategies which facilitate upholding people’s rights on a day-to-day basis. The FREDA principles (of Fairness, Respect, Equality,Dignity, and Autonomy) provide a framework to make this translation. Recent research has highlighted the applicability of the FREDA principlesto dementia but also added an important new element – identity – to this rubric. This paper explores the links between identity and humanrights and the ways in which preserving identity can enhance human rights-based approaches. The similarity between human rights-basedapproaches to care and the more traditionally cited model of person-centered care are noted, and it is suggested that the legal underpinningof human rights-based approaches affords them weight that is sometimes lacking in other care frameworks. It concludes that no one singleframework is sufficient to ensure optimum care but that recognizing a person’s right to maintain and express their identity, as well as the otherFREDA principles, allows us to understand more fully the individual and her or his needs and in turn allows us to better apply the law and guideprofessionals in delivering care that is of the highest possible standards.

Keywords: human rights, dementia, identity, FREDA, personhood

Human Rights and Psychology

Applied psychologists are acutely aware that human rightsabuses feature prominently in the lives of the people theysupport. Many clients of clinical, educational, and forensicpsychologists report egregious abuses, clearly related tothe circumstances that led them to need the help of profes-sionals. Although not true for all our clients, we know thatmuch of our mental health is dependent on the same socialand economic pressures (and especially inequalities) asthose which are associated with wider issues of abuse anddiscrimination. We also know that crises such as divorce,family difficulties, unemployment, stresses at work, finan-cial difficulties, illnesses in family members, crime (bothas a victim and as a perpetrator, when caught up in thecriminal justice system), assaults, bullying, and childhoodabuse are all powerful direct causes of mental health prob-lems (Kinderman, 2014). Psychologists are therefore neces-sarily closely involved in understanding and caring forpeople whose human rights have been infringed. Clinicalpsychologists work every day with people receiving mentalhealth care under compulsion, as well as with people whocannot care for or make decisions for themselves. Forensic

psychologists work in the Prison Service and in the Immi-gration Service, and educational psychologists work in edu-cation and in social services. And, sadly, within mentalhealth and other services, psychologists work with peoplewho continue to be socially excluded, discriminatedagainst, and even abused and assaulted.

Psychologists also have a distinctive perspective onhuman rights (Kinderman, 2004). The underlying assump-tion of applied psychological practice and human rights-based approaches is highly congruent (Butchard & Green-hill, 2015). Maslow (1954) suggested that we all have needs– from basic physiological needs such as food, water, andsleep, through to needs such as safety and security to highersocial needs such as love, self-esteem, and respect fromothers. He argued that these basic needs must be metbefore we can achieve our full potential in life. Doyal(2001) and others have extended this perspective to humanrights, arguing that what we define as rights reflect basichuman needs.

Moreover, these needs and rights are expressed andnegotiated in social relationships. This means that, for psy-chologists, human rights also reflect formalized systemsdesigned to ensure that these basic needs can be achieved


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(Fitzgerald, 1977; Gallatin, 1976; O’Neill, 1994). From thisperspective, human rights are normative social representa-tions embedded in institutional juridical definitions (Doise,2003). In 2004, the UK’s most senior Government lawofficer (quaintly and historically called the Lord Chancellor)said: “The big human rights questions . . . are aboutbalancing one person’s interests against another. . .valueswe can all share, and practical respect for each other’sdignity” (Department for Constitutional Affairs, 2004).For psychologists, perhaps human rights might beexplained as formal codifications of how we collectivelyunderstand our relationships and obligations to each other(Kinderman, 2004).

Human Rights and Dementia

Discussions around dementia and the difficulties it causesto individuals have historically been dominated by a medi-calized narrative of the condition, in which there is no cureand nothing can be done other than watch the persondecline (Guleria & Curtice, 2016). As a result, there oftenexists a sense of hopelessness about the opportunities forpeople living with dementia to maintain a good quality oflife and fear of developing dementia is endemic in our soci-ety (Alzheimer’s Society & Saga Home Care, 2012). A studycarried out by the Alzheimer’s Society highlighted that overtwo-thirds of people believed that if they were diagnosedwith dementia, their lives would be over (Alzheimer’sSociety, 2017). Associated with this was the perceived,and feared, loss of ability and loss of identity, with 68%of people thinking that they would no longer be the sameperson if they were diagnosed with dementia. Conse-quently, the ultimate aim for most researchers is to find acure for all forms of dementia. But, even if we were to finda cure tomorrow, we have an urgent and moral case toimprove the care for those currently living with dementia.And this, essentially, includes protecting and promotingfundamental human rights.

It is, of course, a reality that as dementia progresses, aperson’s needs and reliance on others to provide supportincrease. This can result in people being placed in circum-stances where their fundamental rights are under evengreater threat, as they become reliant on others to providecare that upholds dignity, is respectful and as far as possiblepromotes autonomy. It is comforting to believe that thehuman rights of the most vulnerable people in our societyare routinely upheld and promoted by those tasked withcaring for them. Unfortunately, the sad truth is that this isnot always the case. The Care Quality Commission(CQC) routinely uncovers practices that threaten thehuman rights of people living with dementia. For example,

in one care home, inspectors noted that many residentsstayed in bed all day for no apparent reason. When theinspectors questioned staff about this practice, they weretold, “One side [of the house] we get up Monday, Wednes-day and Friday. The other side we get up Tuesday, Thurs-day, Saturday” (Merrifield, 2016). This is obviouslyunacceptable and in direct conflict with the principles ofthe Human Rights Act (Her Majesty’s Stationery Office,1998). Similarly, a recent UNISON report (2017) found thatfewer than 20% of care home staff who responded to theirquestionnaire felt that they had enough time to provide carethat upheld the dignity and individuality of residents. Thisled to residents not receiving treatment such as assistanceto go to the toilet, efficient monitoring of their condition,and meeting of personal care needs, and 88% of workersreported that they did not have time for a conversation withtheir residents. Laird (2010) has provided examples of howfundamental human rights can be violated in healthcaresettings: Situations cited by British Institute of HumanRights include failure to change soiled bed sheets, neglectleading to pressure ulcer development, not helping peopleto eat when they are too frail to eat themselves, excessiveforce used to restrain people and washing or dressing peo-ple without regard to dignity.

Quality care is distinguished by being both person-cen-tered and respectful of an individual’s human rights (BritishInstitute of Human Rights, 2013). Too often, substandardcare is accepted and unquestioned. It is expected that qual-ity of life will be low when people are living with dementiaand that little else is aimed for. This can lead to care that istask orientated and driven by goals and objectives ratherthan being person orientated and reflecting our unique indi-viduality. Culture has been defined as “the basic assump-tions, values and norms shared by and influencing howmembers of an organization behave and interact” (Sehein,1985). Given this definition, it is clear that in order to pro-vide high-quality care, there must be an appropriate culturein which to provide this care. The Francis report (2013),arising from the lack of care provided at Mid-StaffordshireNHS Foundation Trust, highlighted the importance of cre-ating the “right culture of care.” The law – whether weare talking about assault or about the Human Rights Act(Her Majesty’s Stationery Office, 1998) or the UnitedNations Convention on the Rights of Persons with Disabil-ities (United Nations, 2007) – should protect us. But theselegal protections are also underpinned and supported bothby good practice on the part of the caring professions andon the attitudes and values of the general public.

More recent social movements to recognize dementia asa disability have opened up opportunities to framedementia within a rights-based approach (Mental HealthFoundation, 2015). It has been suggested that this has anumber of benefits, including greater legal protection,


160 S. Butchard & P. Kinderman, Human Rights, Dementia, and Identity

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entitlement to services, and a positive cultural shift in theway that dementia is perceived and understood (includingby people with dementia themselves). This shift in empha-sis has not happened in isolation but is rather against thebackdrop of more active service user involvement indementia services, changes in the language used todescribe dementia and a shift in national legislation.

In recent years, there has been an increase of interest inthe links between human rights and dementia, with thepublication of a number of documents and policies focusingon this issue (World Health Organization, 2015). There hashowever been a tendency for this work to focus primarilyon policy rather than on the practical application of theprinciples of human rights in supporting people living withdementia. In 2016, Dementia Alliance Internationallaunched “The Human Rights of People Living withDementia: From Rhetoric to Reality.” Although this was amove to ensure that people living with dementia are awareof their rights, it stopped short of outlining the specificapplications of human rights-based approaches. Similarly,the Dementia Engagement and Empowerment Project(DEEP) has worked alongside people living with dementiato produce “Our Dementia, Our Rights” (Hare, 2016).Although this was a positive move to raise the issue ofrights in the collective minds of society and to produce adocument in an accessible format, it did not evaluate theimpact that the practical application of human rights lawcould have on the day-to-day lives of people living withdementia.

Without a thorough understanding of the ways thathuman rights can practically influence the lives of peopleliving with dementia, there is a danger that rights-basedapproaches fall short of having the impact that theypotentially could and should have. Part of this must inevita-bly involve understandingmore fully the experience of rightsfrom the point of view of people living with dementia.Similarly, while the Human Rights Act provides the legalframework to apply human rights principles, there is aneed to translate law into principles which can informday-to-day life.

FREDA Principles

Clearly, human rights have most commonly (and perhapsmost powerfully) been operationalized from a legal perspec-tive – rights to be enshrined in law and prosecuted throughthe judiciary. But laws (and perhaps especially human rightslaws) are also based on principles. The rights enshrined inthe European Convention on Fundamental Rights (Councilof Europe, 1952) have been argued to be based on theprinciples of fairness, respect, equality, and dignity (the

“FRED” principles; Butler, 2005; Kinderman & Butler,2006), further amended to include the principle of auton-omy (Equality and Human Rights Commission, 2009).These principals or core human rights values are notreplacements for statutory provisions (which remainenshrined in law), but are rather intended to be practicallyuseful, for example, as “flags” that help people recognizewhen human rights may have been violated, or as“prompts” when solutions or suggestions to human rightsissues are needed.

There is no inherent incompatibility between under-standing our rights from a legal perspective and appreciat-ing the principles underpinning the law. Indeed, it has beenargued that these principles are fundamental to the provi-sion of high-quality public services. Human rights principlesare intended to transform the way in which public servicesare delivered so that users are always treated fairly, equally,and with dignity and respect. This has been described asthe “human rights-based approach,” and it has been arguedthat if public authorities adopted such an approach to theprovision of public services, the risk of violations occurringwould be reduced and overall standards should rise, leadingto improved services for all (Butler, 2005; Kinderman &Butler, 2006). Human rights-based approaches thereforerefer to the process of applying human rights to a specificissue or practice (Gready, 2008). They not only helpconceptualize how we work with individuals and systemsseeking help but also help us shape organizations that aremore ethical (British Institute of Human Rights, 2013).

FRED, FREDA, and FREIDA

A recent randomized control trial conducted by the authorsand funded by the UK’s National Institute for HealthResearch (NIHR) developed a research program to investi-gate the effectiveness of training in human rights for front-line care staff (Kinderman et al., 2018). The first draft of thetraining package was based around the FREDA principlesof human rights in practice – of Fairness, Respect, Equality,Dignity, and Autonomy. An integral part of the study how-ever was the systematic collection of data with people livingwith dementia and carers to explore the meaning of “fun-damental human rights” in that particular context. A seriesof focus groups involving both people living with dementiaand carers were held during the study, with the aim of elic-iting information about the relevance of human rights topeople living with dementia. In total, 79 people attendedthese groups from a formal service user and carer forumin Liverpool, UK (SURF) and other relevant groups withinMersey Care NHS Foundation Trust; some continued aspart of the public and patient involvement (PPI) reference


S. Butchard & P. Kinderman, Human Rights, Dementia, and Identity 161

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group, while others attended just one or more focus groups.No existing human rights models were initially presented tothe groups; instead, they were asked to reflect on, andexplore, elements of their experiences that had had a posi-tive and negative impact on their sense of well-being asindividuals living with dementia. Thematic analysis of thediscussions identified strong support for the FREDA princi-ples in that participants felt strongly that these principlesreflected, summarized, and described the reality of humanrights in their lives. However, in addition to these FREDAprinciples, participants indicated that “identity” should alsobe regarded as a particular and important aspect of humanrights in dementia. Specifically, the importance of preserv-ing identity in the face of changing abilities experienced indementia. These themes were then shared with the PPIreference group and translated into statements, directlyrelevant to dementia care, which reflected the rights ofpeople living with dementia. These statements are pre-sented in Table 1.

Those living with dementia asserted that, as theyadjusted to living with dementia, it was important to themthat their identities, choices, personality, lifestyles, and pref-erences were protected and respected. It was recognizedthat as dementia progressed people may need help withmany aspects of their lives including memories, mobility,the activities of daily living, reading and writing, and evenrecognizing loved ones but those involved with the researchstressed how important it was to them to be confident thattheir essential identity, and how other people treat them,must be protected, even as they need the help of others.As one person put it; “as the disease progresses, my needsmight change, but that doesn’t change who I am.” Indescribing, in human and practical terms, therefore, theapplication of the principles of human rights to the careof people living with dementia, the research would indicatethat we need to adhere to the principles of: Fairness (ensur-ing that our decisions are made fairly and on the basis ofrobust and transparent processes), Respect (e.g., ensuringthat we respect people’s private and family life), Equality(ensuring that people are not discriminated against particu-larly in relation to their dementia diagnosis), Dignity (and,particularly in the context of care for people living withdementia, this may well involve protection againstinhumane or degrading treatment), and Autonomy (againwith particular relevance to people living with dementia,ensuring that people are supported in making decisionsthemselves in respect to their care), but we also need toapply the principle of “Identity.”

The research participants also thought that it was ofupmost importance that the abstract principles of humanrights were translated into practical examples that wererelatable to those living with dementia. In response to this,a series of films were produced called “These Rights Are

Our Rights” (SURF Liverpool, 2018) which highlightedthe FREIDA principles by showcasing times when humanrights had been undermined in everyday situations.

Basic Psychology of Identity

Sharma and Sharma (2010) discuss how a sense of identity– both in an individualistic and in a social sense – is key toour relationships with other people and to our health andwell-being. The concept of “identity” is central to psychol-ogy, but is often an implicit element of psychological the-ory. There is perhaps relatively limited discussion ofidentity per se. Across psychology, identity – or identities,as we tend to integrate multiple, shifting, and dynamicidentities (Maalouf, 2000) – is an umbrella term used todescribe our understanding of ourselves as discrete,separate, entities (Stryker, 1980). This refers to those

Table 1. Statements reflecting the practical application of the FREIDAprinciples in dementia

FREIDA Principle Statements developed

Fairness Do not make assumptions about me

Give me time and space

Do not exclude me because of my dementia

Respect Listen to me

Find out who’s important to me

Make a positive effort to get to know me

Speak to me

Look at me when you speak to me

Equality Give me input into the care I receive

Respect my culture, race, and religion

I have the right to intimate relationships

I have the right to vote

Identity Respect my intelligence

Recognise my skills and talents

Respect my choices about how I want to live mylifeLet me live my life

Dignity Do not embarrass me

Ask my opinion

Do not patronise me

If you are helping me, explain what you are doingto me

Autonomy Allow me to express my views

Respect my personal freedom

Give me the freedom to do what I want, whichmayinclude taking risksProvide assistance to make decisions for myself

Provide assistance to make decisions for myself

Take my significant others into account

Give me advice but do not try to control me



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idiosyncratic things that make each person unique and themeaning they hold. Identity then appears as a basis forsocial role and group membership (Tajfel & Turner,1979). We relate to others from the starting point of whowe are. In cognitive psychology, the term “identity” refersto capacity for self-regulationand the awareness of self, func-tions that obviously develop in early childhood. As childrenand young people age, there is a change in key elements ofthe content of their self-concept. Very young childrendescribe themselves in physical terms, using descriptors ofappearance. Slightly older children refer to abilities or activ-ities, and these elements of self-concept become graduallymore abstract as the young person ages. Group membershipand friendship circles become significant, and, as youngpeople enter adulthood, ideas of principles, values, andbeliefs become important as self-descriptors. Beyond theseevolutions of content, however, the sense of identity self-sameness and self-continuity despite changes and growthis a key psychological concept (Sharma & Sharma, 2010).This is significant in the context of dementia, as inevitablechanges in ability affect our sense of what we can do, butnot necessarily who we are.

From many psychological perspectives, a positive senseof identity is seen as important for well-being (Sharma &Sharma, 2010). Our sense of self, our social identity, ourconcepts of who we are, what we believe, and what wedo all contribute to psychological well-being, but also affectour ability to deal with stress and solve problems that wouldotherwise threaten our mental health. As we grow older, wecontemplate our accomplishments and review our lives –

with good fortune, able to see ourselves as having led,and continuing to lead, a successful life. Erikson (1959)believed if we see our lives as unproductive, feel guilt aboutour past, or feel that we did not accomplish our life goals,we become dissatisfied with life and develop despair, oftenleading to depression and hopelessness. The World HealthOrganization (WHO) definition of health includes not onlyphysical but mental (psychological), social, and spiritualwell-being, linking self and identity intimately with physicalas well as mental health (Contrada & Ashmore, 1999).

Human Rights and Identity

In retrospect, we should not have been surprised that theprinciple of “identity” is related to human rights. There isclearly considerable overlap between ideas of dignity andrespect and identity, but it is also clear that the history ofhuman rights abuses includes a history of striping peopleof their personhood and identity. Indeed, psychologicalresearch examining the processes of abuse (e.g., the infa-mous “Stanford Prison studies” or the historical record ofgenocides and war crimes; Haney, Banks, & Zimbardo,

1973) indicates how abusers take planned steps to removeor disguise the identity of their victims. Persons abusedare no longer referred to by name, are stripped (physically)of their personal identifiers (dressed, e.g., in institutional-ized clothing), and are referred to in the third person oractively identified as non-humans. In the field of healthcare, and more specifically the care of people living withdementia, this process of dehumanization, contributing toand facilitating abuses of various kinds, has been high-lighted in a number of reports and research projects (Corn-well, 2012; Featherstone et al., 2018).

Dementia, Identity, and HumanRights

The centrality of identity as an important factor inmaintain-ing well-being and delivering high-quality care in dementiais obviously not a novel idea. The concept of a continued selfand identity in the face of changing cognitive abilities asso-ciated with dementia has been a longstanding debate. Whilesome researchers have contested that the self diminisheswhen living with dementia, “until nothing is left” (Davis,2004) a more widely held, and supported, view within theliterature is that the self remains intact throughout thecourse of dementia (Caddell & Clare, 2010; Fazio &Mitchell, 2009). One contributing factor to the uncertaintysurrounding this issue is the lack of a clear and consistentview of what constitutes a sense of self. Martin Conway(2005) drew on the classical work of William James, whichemphasizes that memory is an important feature of yourself.It would appear intuitively correct that your idea aboutyourself is based on your recollections of memories aboutyourself. If this definition were adopted above all others, itis obvious that issues may arise when the cognitive changesassociated with dementia progress. Similarly, a number ofstudies have tried to identify different components of the selfand quantify these abilities as dementia progresses. Thesehave focused on areas such as role identity (e.g., Cohen-Mansfield, Golander, & Arnheim, 2000), self-knowledge(e.g., Klein et al., 2003), and self-recognition (e.g., Biringer& Anderson, 1992). Evidence collected in this way seemsto suggest that some components underpinning our senseof self do deteriorate in dementia; however, there are alsoquestions over the ability of people living with dementia tocomplete some complex measures designed to assess therespective components, which may show effects other thana deterioration of the sense of self. More qualitatively basedstudies have tended to show that a sense of self persistsacross the course of the condition (Caddell & Clare, 2010).

Caddell and Clare (2011) have however proposed thatfor people living with dementia, there exists a complex



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interaction between continuity and change in the sense ofidentity simultaneously. In this explanation, people livingwith dementia are in a state of flux as they maintain anoverall sense of their identity being preserved whileacknowledging that there are aspects of them that are dif-ferent following the dementia diagnosis. While the empha-sis appeared to be on continuity, all participants were ableto describe changes that had occurred. The changes how-ever were related to more specific difficulties as opposedto a more general deterioration in their sense of self. Itwas interesting to note that a prominent feature for manypeople was the uncertainty about the impact future changeswould have on identity. While no participants explicitly sta-ted that they expected their identity to change in the future,the possibility of this happening was not ruled out.

A social constructionist model of self-identity indementia (Sabat & Harre, 1992) would posit that the inter-actions between the person living with dementia and otherindividuals are key in upholding the self-identity of the per-son living with dementia. This idea of our identities beingdependent on the behaviors and actions of others is a widelyheld concept. The Zulu phrase “Umuntu ngumuntu nga-bantu” translates literally to “a person is a person throughothers.” Receiving a diagnosis of dementia can in itself leadto a change of perceived identity with others around you, asSabat, Napolitano, and Fath (2004, p. 178) report:

“When healthy persons refrain from engaging inmalignant positioning of the person with Alzheimer’sdisease in the early stages of the disease, the degreeto which the person with Alzheimer’s disease experi-ences a loss of control, humiliation, embarrassment,and other losses can be ameliorated. As a result,the person’s remaining intact cognitive abilities maybe sustained for a longer period of time than mightotherwise be the case.”

This conveys the idea that our interactions can promote orinhibit our own sense of self and identity. As a result, it hasbeen suggested that efforts should be made toward encour-aging a person with dementia to maintain meaningful rela-tionships and interactions with others in order to promotepsychological well-being and a clear sense of self (Sabat,2005).

This has huge implications for the way in which we sup-port, and relate more generally to, people living withdementia. The language we use to describe dementia hasa role to play here in conceptualizing dementia in wayswhich either uphold or undermine a person’s sense of self.Recent co-produced guidance from the Dementia Engage-ment and Empowerment Project (DEEP, 2014) highlightsthe impact use of language has on people living withdementia. In an emotively titled paper, “The living dead?

The construction of people with Alzheimer’s disease aszombies,” Behuniak (2011) suggests that people living withdementia face a particular form of stigma, one which fea-tures “dehumanisation based on disgust and terror.” In thisaccount, it is suggested that the attribution of characteris-tics associated with “living death” construe people withdementia as “animated corpses and their disease as a terri-fying threat to social order” and therefore positioned as“other” with the emotional responses of disgust and terror(Scholl & Sabat, 2008). In this way, people living withdementia are dehumanized and less worthy of empathyand compassion than others. The implications for careand support related to this are staggering.

In his seminal work, Kitwood (1997) outlined the psycho-logical needs of people living with dementia and empha-sized the importance of identity in preserving personhood.These psychological needs are illustrated by the “Kitwoodflower” in Figure 1. In this context, personhood was definedas “a standing or a status that is bestowed on one humanbeing, by another in the context of relationship and socialbeing” (Kitwood, 1997, p. 8). The development of this posi-tion was influenced heavily by the earlier work of Buberand Smith (1937) who encouraged viewing relationshipsas “I-Thou,” thereby engaging on a human-to-human levelwith the people we provide care and support for, as opposedto “I-It,” which adopts a detached task-orientated approachwhereby people are viewed as jobs to be done and tasks tobe completed. It has been suggested that, in many caresettings, “the gap between the rhetoric and the realityremains uncomfortably wide” (Mathers & Paynton, 2016)when we are considering models of person-centered care.

It is not a coincidence that many of the human rightsviolations reported in the media and therefore in the pub-lic’s attention (e.g., Department of Health & Social Care,2012; Equality & Human Rights Commission, 2011) occurin populations where there is a level of cognitive impair-ment. Society places emphasis on the value of intact cogni-tion above all else in our understanding of humanity.

Figure 1. The Psychological Needs of People living with Dementia –

Kitwood (1997).



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Bar-Tal defines delegitimatization as, “categorization ofgroups into extreme negative social categories which areexcluded from human groups” (1989, p. 170). Althoughpeople can often agree that human rights apply to allequally the stripping of humanity in this way makes behav-ing in ways that undermine and disregard human rightseasier. People’s actions are attributed to their dementiadiagnosis as opposed to their wishes and desires.

Kitwood (1997) highlighted ways that people can inten-tionally or unintentionally undermine the personhood ofpeople living with dementia. He termed these practices“malignant social psychology”; treachery, disempower-ment, infantilization, intimidation, labeling, stigmatization,outpacing, invalidation, banishment, objectification,ignoring, imposition, withholding, accusation, disruption,disparagement, and mockery. It is clear that many of thesepractices would directly undermine the identity of a personliving with dementia.

There are high levels of congruence between the funda-mental principles of person-centered care and a humanrights-based approach, such as empowerment and inclu-sion. A human rights-based approach gives backbone anda legal framework to person-centered principles (Butchard& Greenhill, 2015) potentially making them clearer to oper-ationalize and more accessible to rigorous research. Thereis no obligation to carry out person-centered care other thanknowing that it is the right thing to do. With their statutoryweight, human rights approaches can strengthen person-centered approaches (Mansell & Beadle-Brown, 2004)and maximize the chances that they will be adopted as itframes particular actions as legal infringement of rights asopposed to poor practice.

Given the centrality of identity and the promotion of thisconcept in upholding personhood within dementia care, it isnot a huge leap to assert that if we seek to truly promote thehuman rights of people with dementia then identity mustplay a clear role in this. Failure to positively promote theidentity of those living with dementia and a dismissal ofthe importance of continuity of perceived identity can easilyresult in care practices which may undermine the abilitiesand decrease the quality of life of people living with demen-tia. Examples mentioned by participants in our researchwhich, often inadvertently, threaten a sense of continuedidentity include all preferences being disregarded howeverminor, decisions being made on their behalf with no consul-tation, being excluded from society because of the diagno-sis, lack of appreciation of people’s sexual needs, and pastachievements being underplayed. Many participants men-tioned how, after a diagnosis, previous identities as spouses,parents, members of the community, and successful profes-sionals seems to be sublimated into a generic identity of“person with dementia.” As commented earlier, the linkageof identity with preserved personhood in dementia is not

new. However, the fact that people living with dementiaand their carers linked identity so closely to human rightsis not only consistent with this tradition, but also givescredence to the idea that a legal, human rights, frameworkcould help protect this key element of psychological well-being.

Conclusions

No one single framework is sufficient to ensure optimumcare. The very well-established “bio-psycho-social” model(Engel, 1977) offers one route to integrating differentperspectives on mental health, with the implicit assumptionthat no one of the component elements is individuallysufficient. But we have also seen many frameworks of dif-ferent kinds. “Person Centred Care” (Brooker, 2003) is awell-known framework, especially in the field of dementiacare. Both psychiatrists (Royal College of Psychiatrists,2017) and clinical psychologists (British PsychologicalSociety, 2011) offer “formulation” (or more specifically,“co-produced formulations”) as a core element of their pro-fession, but also as a key element of care. The list couldcontinue, but the over-riding point is that none of these“frameworks” renders the other approaches unnecessary.

Such “frameworks” are ways of informing professionalpractice. Like the ethical principles widely used in medicine– beneficence, non-maleficence, justice, and autonomy –

the principles of applied science (Shapiro, 1967), and clini-cal guidelines such as those produced by the UK’s NationalInstitute for Health and Care Excellence (NICE), thesevarious recommendations complement and support eachother. Similarly, conceptual models of the principles under-pinning rights-based care (FREIDA, Fairness, Respect,Equity, Identity, Dignity, and Autonomy) are entirely con-sistent with quasi-legal Charters of Fundamental Rightsand, ultimately, the statute legislation of sovereign nation-states. It is fair to say that legislation has (by definition)greater legal weight than clinical guidelines, which aremore influential than the professional practice guidelines,which in turn have more weight than academic papers.But these ideas all dovetail.

Our research supported the widespread idea that theprinciples supporting legal charters of human rights canoffer helpful frameworks of understanding these complexbut clinically important issues in dementia care. In addition,however, our research highlighted the importance ofprotecting our identity and sense of continuing identity,as we begin to receive support in living with dementia.

We therefore recommend that the concept of “identity”should join other key principles in our understanding offundamental human rights. Our sense of identity has obvi-ous links to the concept of “personhood,” a central tenet



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of psychologically informed person-centered care. An appre-ciation of our sense of identity makes sense of our relation-ships and our concept of meaning and purpose in life, keyelements of personal well-being. This emphasizes care as arelational, rather than instrumental, process and personal-izes decision-making in difficult circumstances.

Frameworks or professional practice guidelines willalways be necessary to complement and contextualize legalcharters. Making decisions that concern people’s health careand quality of life involve complex ethical dilemmas, wherestaff and carers have to choose among alternatives. Whenthe individual’s own capacity is compromised, thosedecisions are even more complex (and stressful) with inevi-table challenges to our human rights. Recognizing a person’sright to maintain and express their identity, as well as theother FREDA principles, allows us to understand more fullythe individual and her or his needs. This allows us better toapply the law – the various Charters of Fundamental Rightsand local legislative instruments. The rights themselves areinviolate, and the laws are, by definition, enforceable, buttheymust also reflect individual circumstances. The conceptof autonomy is universal, but each person will make his orher own autonomous decision, with inevitably differentoutcomes. Similarly, there is no one definition of whatconstitutes “best interests,” applicable to all. The UnitedNations Universal Declaration of Human Rights and theCharter of Fundamental Rights of the European Union arefundamental legal texts. But they are also useful guidesoffering healthcare professionals insights into whatconstitutes highest possible person-centered care. Theprinciples underlying the legal texts – of Fairness, Respect,Equality, Dignity, and Autonomy – in particular, can providehelpful frameworks for clinical decision-making. Ourwork with people living with dementia suggests that, inaddition, a key principle of the application of human rightsin practice must also respect and support our rights topersonal identity.

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UNISON. (2017). Residential care worker survey and residentialcare charter executive summary. Retrieved from www.unison.org.uk/content/uploads/2017/06/residential-care-summary.pdf

United Nations. (2007). Convention on the Rights of Persons withDisabilities (CRPD). Geneva, Switzerland: United Nations.

World Health Organization. (2015). Ensuring a human rights-basedapproach for people living with dementia. Geneva, Switzerland:WHO. Retrieved from http://www.who.int/mental_health/neurology/dementia/dementia_thematicbrief_human_rights.pdf

HistoryReceived May 30, 2018Revision received September 19, 2018Accepted January 24, 2019Published online June 14, 2019

Conflict of InterestThe authors have no competing interests to declare

ORCIDSarah Butchard

https://orcid.org/0000-0002-5943-2575

FundingThe research described in the paper was funded by the NationalInstitute for Health Research (NIHR) Health Services and DeliveryResearch Programme. Reference: HSDR-12-209-53.

Sarah ButchardCommunity Services DepartmentMossley Hill HospitalPark AveLiverpool L18 8BUUnited [email protected]

Sarah Butchard is Clinical Psycholo-gist working with older people andpeople living with dementia at Mer-sey Care NHS Foundation Trust andis Senior Clinical Teacher on theUniversity of Liverpool Doctorate inClinical Psychology Programme. Herresearch interests are in improvinglife after a diagnosis of dementia.

Peter Kinderman is Professor ofClinical Psychology at the Universityof Liverpool. His research interestsare in psychological processesunderpinning well-being and mentalhealth. His most recent book, “APrescription for Psychiatry,” pre-sents his vision for the future ofmental health services. You can fol-low him on Twitter as @peterkin-derman.



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Children’s Rights and EducationalPsychologyJohanna Fee Ziemes and Eveline Gutzwiller-Helfenfinger

Educational Research and Schooling, University of Duisburg-Essen, Germany

Abstract: Psychology aims to be descriptive but depends on norms and values to guide both research and practice. Educational psychology,as a sub-discipline and applied branch of psychology, focuses on describing processes of teaching, learning, and development. This articleaims to connect notions of human and children’s rights with concepts of educational psychology to illustrate the interdependence of normativeand descriptive frameworks. We use Martha Nussbaum’s capability approach as an operationalization to move from a normative legalframework toward concrete research topics and practices within educational and school psychology. According to the Convention on theRights of the Child, children have the right to feel safe, learn, participate, and form an identity. We argue that educational psychology can helpto specify these normative postulations of the CRC and aid the implementation of positive rights. The phenomenon of school bullying isintroduced as a specific area where children’s rights are affected. After a brief characterization of its major features from an ecological-systemic perspective, we draw on research on bullying prevention and the creation of positive learning environments to illustrate the aptnessof educational psychology for realizing children’s positive rights. We conclude that educational psychology is not only able to prevent humanrights infringements but also to promote children’s rights and capabilities, especially in reference to competencies, participation, and identity.

Keywords: educational psychology, children’s rights, positive development, bullying prevention, political mindset

The Convention on the Rights of the Child (CRC) by theUnited Nations General Assembly (1989) does not onlystate protection rights of children against the state but alsoformulates rights which require active provision. The CRCincludes the rights for education, active participation, iden-tity, and self-development (§2, §8, §23, §28, §29). Humanrights in general are increasingly seen as requiring provisionby governments, institutions, societies, and even individualsinstead of being “mere” protection rights (e.g., Clark &Ziegler, 2014; Nussbaum, 2011). Health has been increas-ingly conceptualized as multidimensional and involvingmore than the absence of illness (WHO, 2014, p. 1). Theconsiderable development of the field of positive psychol-ogy indicates that this shift has also reached the disciplineof psychology (e.g., Brown, Arnold, Fletcher, & Standage,2017). In educational research the discussion and promo-tion of competencies has led to a shift away from constructsconceptualized as stable such as intelligence at least sincethe 1970s (McClelland, 1973).

In this paper we will take up the discussion and examinechildren’s rights within a framework of educational psy-chology as a sub-discipline and applied branch of psychol-ogy. Psychology in general, as an overarching discipline,aspires to study the human mind and behavior. As adescriptive science it does not carry an inherent goal butaims to describe lifelong human development. However,

it intends to do so without judging morally or making nor-mative statements about individuals. This aim is impossibleto fully realize. Conceptualizations such as Bronfenbren-ner’s ecological approach (1989) do not free researchersfrom their socialization but do offer a tool to view individ-uals (and research) within different levels of context, suchas student, school, and culture (Atkins, Hoagwood, Kutash,& Seidmann, 2010). Within psychology, the sub-disciplineof educational psychology basically refers to the study ofhuman learning: “Educational psychologists apply theoriesof human development to understand individual learningand inform the instructional process” (American Psycholog-ical Association, 2018, para. 4). More specifically, educa-tional psychology, as a theoretical, empirical, and appliedbranch of psychology, addresses issues of human matura-tion and development, learning in school and further edu-cational settings, teaching–learning methods, guidance,and the evaluation of aptitude and progress using standard-ized tests (cf. Merriam-Webster online, 2018). Accordingly,it is concerned with the study, description and promotion oflearning processes, their determinants, and outcomes in allareas of learning (academic, social, emotional, practical,etc.) involving all ecological levels of the educational sys-tem and its related agents (students, teachers, school staff,parents, etc.). The conceptualization of educational psychol-ogy in this article refers not only to academical, but also


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practical, on-site work on various levels of the educationalsystem, such as the involvement in the preparation andtraining of teachers. We offer a general outline, with subse-quent analyses having to translate and specify it for partic-ular conceptualizations and role descriptions in a givennational and professional context.

While the non-normativity of psychology as a descriptivescience makes it possible to study human functioning froma more objective perspective that is largely free from doctri-nal constraints and inclinations, it engenders also someserious drawbacks. One drawback refers to the danger ofinstrumentalization. A science which aims to describe caneasily be instrumentalized if it lacks a normative founda-tion. Such an instrumentalized psychology could lose itsfreedom of defining its own research directions. Moreover,it is capable of causing great harm. Indeed, psychology hasalready been criticized for enhancing neoliberalism (Sugar-man, 2015) and even torture (Mausfeld, 2009). The ethicaldevelopment of psychology as a discipline has been as long-standing as its clinical function and spans through the his-tory of the Nuremberg Trials and their consequences forresearch and practice (e.g., Golann, 1970). The discussionrelating to professional ethics and research ethics has beenalive ever since (e.g., as reflected by the ongoing discus-sions of the Milgram studies; Miller, 2009).

One way to escape instrumentalization is the criticalengagement with normative frameworks such as humanrights and the capability approach. We deem the capabilityapproach as especially helpful to engage with normativenotions in the context of educational psychology. Nussbaum(2011, p. 65) does not conceptualize human rights as protec-tion rights against governments but claims that “all libertiesare positive (. . .) and all require the inhibition of interfer-ence by others.” At its best, psychology in general andeducational psychology in particular can help us to opera-tionalize and realize these provision rights. Equality ineducation, also regarding the provision of equal resources,is often not enough to provide equal opportunities. Thecapability approach is sensitive to contexts and socialinequalities. Different groups of people may depend on dif-ferential prerequisites for their development of capabilities.For example, basic reading competencies are a prerequisitefor many forms of participation. A “one size fits all”approach may be hurtful for many children, compromisetheir capabilities, and therefore injure their rights. A confi-dent and responsible (educational) psychology needs toreflect on the foundations of its effects and take part in dis-cussions on fundamental rights and their protection (BritishPsychological Society, 2003).

The capability approach, although first formulated foradults, can be applied to children. Nussbaum and Dixon(2012) argue that children are different from adults dueto their vulnerability and developing cognitive abilities,

and that human rights therefore need to be implementedadaptively to enhance the development of capabilities.While the capability approach is focused on individualagency, it does not subscribe to a notion of individualism(Saito, 2003). Accordingly, it is a useful tool for the analysisand critique of social and educational arrangements whichaim to foster positive development and agency (Robeyns,2006; Smith & Seward, 2005).

There are two large areas where psychology as anoverarching discipline is already contributing to theenhancement of human rights: The first role of psychologylies in its commitment toward preventing (psychological)harm. The second, younger part concentrates on positivedevelopment, competencies, and health. This second areapromotes research on successful identity formation, partic-ipation, efficacious citizenship, and the development of anappreciation of diversity, all of them aspects which enhancethe cohesion of society and enable peaceful cooperationand reciprocal support (Christie, Tint, Wagner, & Winter,2008). Both aspects of psychology need not be seen asseparate, especially as they both contribute to the promo-tion of human rights.

Relationship Between EducationalPsychology and Human Rights

Before we proceed to discuss possible benefits of educa-tional psychology within and in interaction with humanrights, we will briefly discuss its relationship with humanrights. Few new arguments have emerged since theexchange between Olssen (1993a, 1993b) and Schwieso(1993a, 1993b) which focused on criticism concerning posi-tivistic and (more importantly) individualistic approaches ineducational psychology. Educational psychology wasclaimed to be blind for structural components and thereforeunable to address the roots of inequalities. This criticism ofindividualism evolved into a criticism of a neoliberal ideol-ogy within psychology, especially regarding positive andeducational psychology. This is relevant for the discussionof human rights, as these approaches may be seen as waysto prevent individuals and societies from acquiring criticalperspectives through education as well as the motivationand opportunities to wield their positive rights. Whileadvocates of competence-oriented international large-scaleassessments stress the importance of the concept of compe-tence for evaluating and improving educational systems(Weinert, 2001), critics lament an overly strong emphasison the individual’s responsibility (Lederer, 2014, pp. 524–535; Sugarman, 2015). There are concerns that interventionswithin positive psychology decrease political engagement,because individuals are taught to focus on their individual


170 J. F. Ziemes & E. Gutzwiller-Helfenfinger, Children’s Rights and Educational Psychology

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well-being and competencies and thus withdraw into the pri-vate sphere.

This critique withstands scrutiny only poorly. The WHOconceptualizes good mental health as an important precur-sor of civic engagement and participation (Friedli, 2009).Depression in particular seems to decrease political partic-ipation and efficacy (Ojeda, 2015). The positive relationshipbetween positive development and political engagementdoes not seem to be restricted to privileged individuals;members of marginalized groups often need to overcomeinternalized negativity in order to engage in activities lead-ing to social change (e.g., Cass, 1984).

But we do not only want to approach the topic on anempirical, but also on a theoretical level. Arguments againstpsychology in general often stem from a social model ofpathology, where diagnoses such as (dis)ability, depressionand happiness, degree or lack of competencies are seen asprimarily socially constructed, while psychologists continueto attach these same attributes to individuals. Thus,psychologists stigmatize others while at the same timeimpeding their opportunities to develop their capabilities.According to Shakespeare (2010) the social model of dis-abilities differentiates between disability and impairmentand declares that disability is purely socially constructed.Supporters of this position generally ask for societal solu-tions for impairment (such as building ramps for wheelchairusers) and criticize individual based approaches, be theymedical or psychological, as stigmatizing. To put it simply:This argument implies that if social inequalities areaddressed at the individual level (e.g., the psychological),the development of equal opportunities cannot be realized.

While the social model is empowering for some peoplewith disabilities, it is criticized by others as too simplistic.In contrast, the biopsychosocial model aims to integratethe perspectives of different disciplines, that is, medicine,psychology, and sociology (Bartolo, 2010; Shakespeare,2010). Each discipline is uniquely equipped to approachtopics of human rights infringement and basic needs.Bartolo (2010, p. 573) notes that “[psychologists] are indeedvery well placed to understand the impact of prejudice anddiscrimination on the lives of individuals and groups.”Psychologists are experts for change within individualsand groups (in contrast to societies) and have to be awareof the barriers within contexts and societies. The biopsy-chosocial model, by aiming to integrate perspectives frommedicine, sociology, and psychology, may be especiallyuseful both to overcome stigmatization and to enable indi-vidualized aids for positive development (Bartolo, Borg,Cefai, & Martinelli, 2010).

Within educational psychology, the influence of contexton individual learning and functioning has always been rec-ognized. International large-scale assessments like PISA,TIMSS, and ICCS allow the usage of multi-level models

and thus permit the statistical separation of different sociallevels, thereby offering insights how structures can bechanged instead of just changing individuals (e.g., Bestet al., 2013).

However, not all initiatives within educational psychol-ogy were directed toward social justice (see e.g., Richards,1997 on racism and eugenics in psychology). The drivetoward assessment and categorization carries the dangerthat such categorization might be abused. Still, as will beexpanded in the next section assessment and categorizationcan also be used for the analysis of processes and inequal-ities, thereby providing information on avenues for positivedevelopment for individuals and educational systems. Closeexchange with neighboring disciplines such as educationalsciences and sociology are fundamental for analyzingchallenges related to human rights from multiple perspec-tives. No single discipline can fulfill the promise of equalcapabilities in isolation.

Prevention in EducationalPsychology

School bullying has been conceptualized as a violation ofhuman rights in general and of children’s rights in particu-lar for two decades now (e.g., Cornell & Limber, 2015;Lansdown, Jimerson, & Shahroozi, 2014; Olweus & Limber,2010; Smith, 2000), indicating that an incorporation ofhuman rights into relevant areas of (educational) psycho-logical research and practice is both feasible and necessary.Educational contexts in which bullying occurs will not beable to foster capabilities. Very basically, classrooms, play-grounds, and schools where bullying occurs are no longersafe places (e.g., Cornell & Limber, 2015; Waasdorp, Pas,Zablotsky, & Bradshaw, 2017). The physical and psycholog-ical safety is a fundamental aspect of both children’s rights(CRC §3) as well as the capability approach. A safe environ-ment is an important prerequisite for learning and positivedevelopment. To better understand why school bullyingharms children’s rights, we first need to address the speci-fics of the phenomenon from an ecological perspective.Afterward, we will identify some of the core rights of chil-dren affected by bullying and discuss the crucial role ofteachers in protecting and, in case these rights have beenviolated, re-establishing these rights.

Bullying is a serious problem, as it negatively affects thesocial and learning climate in classrooms, impedes class-room management, has grave psychosocial consequencesfor bullies, victims, and witnesses, and impairs students’academic achievement (e.g., Cook, Williams, Guerra,Kim, & Sadek, 2010; Cornell, Shukla, & Konold, 2015). Thisdoes not only hold for so-called Western cultures, but has


J. F. Ziemes & E. Gutzwiller-Helfenfinger, Children’s Rights and Educational Psychology 171

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been confirmed by a growing body of research in Asian,South American, African, or Middle Eastern countries aswell as by comparative studies including data from a largenumber of countries. An example is the study by Elgar et al.(2015) involving adolescents from of 79 African, American(North, Middle, and South), South East Asian, European,and Eastern Mediterranean countries. Bullying is character-ized by a certain repetitiveness and an imbalance of powerbetween bully and victim (Olweus, 1991). Aggressive actsagainst the victim are intentional, may be direct (physical,verbal, etc.) or indirect (isolation, relational aggression,etc.), and often include humiliating elements (Perren,Gutzwiller-Helfenfinger, Malti, & Hymel, 2011). The term“bullying” denotes the (more) active part of the process,whereas “victimization” (or bullying victimization) refersto the passive, enduring role (cf. Swearer, Siebecker,Johnsen-Frerichs, & Wang, 2010). Cyberforms of bullyingand victimization include the use of electronic media asan additional element (e.g., Sourander et al., 2010). Asthere is a high degree of overlap between cyber andtraditional (or offline) forms (see e.g., the meta-analysisby Modecki, Minchin, Harbaugh, Guerra, & Runions,2014 or the study by Perren & Gutzwiller-Helfenfinger,2012) we will mainly present results from studies involvingtraditional bullying and victimization.

Bullying can be observed already in preschool (e.g., Alsa-ker & Gutzwiller-Helfenfinger, 2009; Godleski, Kamper,Ostrov, Hart, & Blakely-McClure, 2015), indicating that chil-dren’s safety and well-being are being jeopardized early on.Bullying is a group phenomenon, with everyone presentand/or belonging to the group participating, even if indi-rectly as bystanders (e.g., Cornell et al, 2015; Rodkin,Espelage, & Hanish, 2015). If a child or adolescent is har-assed at least once per week or harasses a peer at least onceper week, s/he is considered a victim or bully, respectively(e.g., Perren & Alsaker, 2006). For example, the meta-analysis by Modecki et al. (2014) based on 80 internationalstudies indicated that 35% (traditional) and 15% (cyber-forms) of adolescents aged 12–18 years were involved inbullying as perpetrators or victims. In the case of elementarychildren, Jansen et al. (2012) found that one third wereinvolved in bullying as perpetrators or victims.

Victims of bullying suffer discrimination by being treatedas inferior group members (CRC, §2, §30) based onarbitrarily selected (personal) characteristics like ethnicity,personal appearance, sexual orientation, body weight, andso forth (Oliveira et al., 2015). Overweight children, forexample, suffer regular stigmatization in many domainsof their lives which over time leads to pervasive victimiza-tion (see e.g., the review by Puhl & King, 2013). They arebeing excluded, ridiculed, and subject to stereotypes suchas being lazy, stupid, ugly, selfish, and so on. As victimsof school bullying are often not heard or taken seriously

by teachers (e.g., Kochenderfer-Ladd & Pelletier, 2008;see also below), they cannot express their views or tellabout their negative experiences. Moreover, as they arede facto excluded from participation by having no voice,they cannot acquire the self-esteem and confidence neces-sary to empower them for challenging these abuses of theirrights (cf. Lansdown et al., 2014). This large body ofresearch illustrates how educational psychology can helpto identify especially vulnerable groups and advocate fortheir health and safety, enabling the promotion of theircapabilities to learn and explore their identity.

There is a vast international body of research document-ing the grave psychosocial consequences children and ado-lescents involved in chronical bullying suffer from (see e.g.,the meta-analyses by Gini & Pozzoli, 2009, 2013; Nielsen,Tangen, Idsoe, Matthiesen, & Magerøy, 2015; van Geel,Vedder, & Tanilon, 2014). Victims suffer especially frominternalizing behavior problems like low self-esteem, loneli-ness, poor academic performance, school anxiety, depres-sive symptoms, and suicide ideation (e.g., Gini & Pozzoli,2013). All these aspects have been identified as being linkedto core capabilities such as health (Nussbaum, 2011). Perpe-trators show mainly externalizing behavior problems like anincrease in aggressive behavior, affiliation with aggressivepeers, (later) substance abuse and delinquency (e.g., Gini& Pozzoli, 2009). Bystanders display both internalizingand externalizing problems like school anxiety, increasedrisk of school dropout, academic difficulties, and depression(e.g., Blazer, 2005). This is not surprising, as they realizethat school is no longer a safe place. Therefore, the psycho-logical (and physical) wellbeing of all children involved inbullying is impaired (CRC, §19), even that of “mere”bystanders. Furthermore, children’s right to protectionand care to enable health, wellbeing and flourishing(CRC, §3) is violated, as the psychosocial consequencesaffect them both in the short and in the long term (e.g.,Ttofi, Bowes, Farrington, & Lösel, 2014).

School bullying is an indicator of toxic social relationships(cf. Lencl &Matuga, 2010) and is negatively associated withclassroom and school climate (e.g., Cornell et al., 2015; seealso the reviews by Hong & Espelage, 2012; Thapa, Cohen,Guffey, & Higgins-D’Alessandro, 2013). Consequently,children and adolescents in classrooms where bullyingoccurs suffer from a negative learning climate and aredeprived of basic learning opportunities (e.g., Quesel,Möser,& Husfeld, 2014). Their opportunities to actively participatein shaping school life andmaking decisions (CRC, §12.1) arecompromised because part of the students (victims, helpersof victims, passive bystanders) live in fear of the bullies andtheir supporters, who themselves have become powerfulenough to undermine equity and equality in classroomsand schools. Indeed, some scholars see school bullying asa form of anti-democratic behavior (e.g., Lundström,



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2004, cited in Ahlström, 2010) undermining equality andequal rights of some of the students.

Because bullying and the accompanying deprivation ofrights does not occur in isolation but in a given, structuredcontext, we need to more closely examine that context toidentify core actors responsible for promoting children’srights at school. Research has identified the critical roleof adults’, especially teachers’, appropriate interventionand of their preventive actions in successfully tacklingbullying (see e.g., the review by Hong & Espelage, 2012,or Dedousis-Wallace, Shute, Varlow, Murrihy, & Kidman,2014). Both the attitudes (e.g., Kochenderfer-Ladd &Pelletier, 2008) teachers hold and the reactions theyshow in the context of bullying and aggression (e.g., Bau-man & Del Rio, 2006; Dedousis-Wallace et al., 2014) areco-determinants of the establishment and chronificationof bullying. This is especially true when teachers have avery narrow conception of aggression as referring only todirect, physical forms (Bilz, Steger, Fischer, Schubarth, &Kunze, 2016). As school bullying does not simply stop orvanish on its own but often becomes chronical in theabsence of adults’ (especially teachers’) intervention(cf. Bauman & Del Rio, 2006), teachers are among theprimary stakeholders within the school ecology responsiblefor preventing and intervening against bullying. Given theeducational role teachers are invested with, the amountof time they spend with students, as well as the moraland ethical basis of their professional teaching practice(Campbell, 2003), it is most likely that the reactions theyshow in cases of bullying will directly impact their student’sbehavior. In line with socialization theories (Bandura, 1986;Dodge, 2002) children’s experience of significant others’beliefs and attitudes will contribute to modeling their ownset of cognitions and consequently influence their behavior.Teachers are likely to play a fundamental role in affairs thatmainly involve peers, as they send direct and indirect mes-sages on the (in-)acceptability of bullying through their ownbehavior, even if only by ignoring it. Accordingly, if bullyingis conceived of as a violation of several of children’s rights,it follows that schools are responsible not only to maintainchildren’s rights, but to re-establish them in case they havebeen violated. This illustrates the importance of conceptual-izing rights not only as protection rights against the state.

Teachers as state representatives have to take action inorder to provide the positive right of safe development asstated in the capability approach. This in turn makes it nec-essary for teachers to be sufficiently sensitized regardingbullying both in its own right and as a violation of children’srights; to command the necessary skills in addressing bully-ing; and to know about effective and sustainable measuresto tackle bullying and both establish and maintain a positiveclimate in their classrooms. Indeed, a positive school andclassroom climate promoting mutual respect and accep-

tance has been shown both to reduce and to prevent bully-ing (e.g., Guerra, Williams, & Sadek, 2011). Recent researchby Cornell et al. (2015) suggests that an democratic schoolclimate characterized by respect, support, and positive dis-cipline, is conducive to lower bullying and peer victimiza-tion. This example shows that educational psychologicalresearch attends to the role of contextual factors, that is,both the school and the peer ecology and helps identify rel-evant stakeholders responsible for establishing and of pro-tecting children’s rights.

Protecting children’s rights at school and in the class-room does not only refer to preventing harm, but to activelyfostering a positive social and learning climate. Educationalpsychology aids both the analysis of problematic situationsand the development of options to improve social cohesionin classrooms. As the social ecology of bullying includes alllevels of the system, these levels need to be included inanti-bullying work (see e.g., the review by Card & Hodges,2008; the meta-analysis by Ttofi & Farrington, 2011; or thestudy by Cornell et al., 2015). Apart from individual teach-ers and teacher teams, this includes further school person-nel (and associated educational support professionals) likeheadmasters, school social workers, and school/educa-tional psychologists. Recent research indicates that staffconnectedness, that is, the degree to which individuals inthe school environment (students, teachers, administrators,educational support professionals) feel connected to eachother is related to their willingness to intervene in bullyingsituations(O’Brennan, Waasdorp, & Bradshaw, 2014).Moreover, the availability of resources, being trained inthe school’s bullying policy, and involvement in bullyingprevention were associated with staff’s comfort in interven-ing against bullying. Hence, both the protection and the re-establishment of children’s rights (here in the context ofschool bullying) are the responsibility not only of teachersbut of the whole school staff, including educational supportprofessionals like school/educational psychologists.

The specific role of educational psychology includes thereception of up-to-date research findings on bullying pre-vention and intervention as well as the translation of thesefindings into educational practice, for example by summa-rizing and explaining them at school and teacher confer-ences. As O’Brennan et al. (2014, p. 876) conclude: “Thisline of research has considerable relevance for educationalpsychologists interested in improving conditions for learn-ing and engaging school staff in prevention efforts.” Educa-tional psychologists are not part of the “core” school staffand therefore hold the perspective of an interested, related“outsider.” Thus, they are not subjected to the same expec-tations, policies, rulings, and so forth on the part of schooladministrators as for example teachers are. This enablesthem to observe educational practices at school from aless involved viewpoint and offers them the opportunity



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to compare the actual effects of those practices to thoseintended by the underlying pedagogy. Teaching is a highlycomplex process involving not only a multitude of tasks butalso an ever-present degree of uncertainty (e.g., Floden &Clark, 1987) as well as inherent antinomies and tensions(e.g., Helsper, 1996). Thus, it is not possible for teachersto fully monitor and reflect on their practices and on theimpact of those practices on all levels of the teaching–learn-ing process. The same is true for headmasters, who alsoface a multitude of tasks and expectations in a complex,not fully predictable environment (e.g., Davis, Darling-Hammond, LaPointe, & Meyerson, 2005). Having the sup-port of educational psychologists working toward the sameoverarching goals of a positive school, classroom, and learn-ing climate and of protecting children’s rights contributes toschools’ empowerment toward reaching these goals. Here,educational psychological analyses help us to understandwhat teachers, school staff, and teacher educators need inorder to provide students with the opportunity to learn ina safe environment without any infringements on theirmental or physical health. We argue that psychologicalresearch and practice offer a core contribution toward sen-sitization, knowledge and skill building, as well as the pro-motion of agency on the part of students, teachers,headmasters, and further relevant stakeholders at school,in the educational system, and society in general. In thisway not only students’ capabilities are promoted, but thewhole staff can be supported in forming a climate of non-violence. Finally, tackling school bullying requires con-certed actions and programs on the school, district, andstate levels (e.g., Piscatelli & Lee, 2011), which in turnnecessitates a sound empirical foundation to base theseefforts on.

The specific role of psychologists in general and botheducational and school psychologist in particular is twofold:On the one hand, they can take a critical perspective inexamining pedagogical principles and actions from a van-tage point relating to children’s rights. On the other hand,they can act as advocates of youths’ welfare, health andwellbeing, or, generally speaking, of their thriving. Due totheir perspective of an interested associate, they can adda counterweight to the hierarchical structure of schoolwhich places students in a position of relative powerless-ness and dependence, and consider students’ welfare andwellbeing from a unique perspective. As educational psy-chologists are not subject to the normative, pro-bullyingattitudes (i.e., positive attitudes toward bullying) studentsand teachers often hold and share in the absence of a moreinformed view (e.g., van Goethem, Scholte, & Wiers, 2010),they also add a counterweight to detrimental normativeattitudes and related practices. Moreover, based on theirexpertise in both conducting research and interpretingresearch findings, educational psychologists bring an

informed knowledge base into their professional coopera-tion, which helps school staff develop a deeper, up-to-dateunderstanding of the phenomenon, its characteristics andecological embeddedness and discard pro-bullying attitudesby relating back to their educational responsibility. In thecase of teachers, such in-depth understanding inspires theirpedagogical ethos (Gutzwiller-Helfenfinger, 2018).

Promotion in EducationalPsychology

Promotion in a broader sense can be linked to the conceptof flourishing, referring to individuals, groups, and societies.Flourishing, as based on the ancient Greek notion ofEudaimonia (i.e., the good life; Cloninger, Salloum, &Mezzich, 2012) entails more than (mere) survival or gainin wealth or power. Instead, the optimal realization of one’spotential, that is, leading a meaningful life and enjoyingpositive social relationship, is actualized from a positionof care toward others, nature, and humankind. Physical,mental, social, and emotional aspects of health and wellbe-ing are seen as connected (Cloninger et al., 2012).

A psychological formulation for the positive notions ofparticipation can be found within self-determination theory(Ryan & Deci, 2000), in which competence, autonomy, andrelatedness are linked to growth and motivation as well aspositive development. Motivated participation relies on asafe environment, as discussed in the previous section.If a secure environment is created, experiences of compe-tence, autonomy, and connectedness can foster positivedevelopment. Ryan and Niemiec (2009, p. 270) state thatthe “opposite of freedom and capability is voicelessnessand powerlessness: an absence of autonomy and compe-tence to achieve one’s aims.” The theoretical notions ofcapabilities can be translated into the language of self-determination theory and become accessible for quantita-tive analytical approaches. Self-determination theory doesnot close the gap between the tension of paternalism andparticipation, but provides a theoretical framework for oper-ationalizing children’s participatory rights; It can help torecognize children as social subjects endowed with agency(Liebel, 2014), to determinewhen and what forms of partici-pation are healthy and helpful for psychological and moti-vational development, and thereby enhance children’scurrent and future capabilities.

Large-scale assessments such as PISA, TIMSS, and ICCSemploy theories of educational psychology to assess thecapacity of educational systems in fostering competenceand important attitudes. One consistent finding has beenthat educational systems are very differently equipped to



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foster competence in students with few socioeconomicresources (Weinert, 2001). Such assessments can thereforebe seen as indicators of how well educational systemsenable all children to receive basic education (CRC§24(e), §28); such education is a de facto prerequisite forindividuals to (politically) participate in their respective cul-tures (e.g., Hoskins, Janmaat, & Melis, 2017). The Interna-tional Civic and Citizenship Education Study (ICCS) by theInternational Association for the Evaluation of EducationalAchievement (IEA) is not only focused on civic competen-cies, but also on opportunities and intentions to participate,attitudes, tolerance, and identity (Schulz, Ainley, Fraillon,Losito, & Agrusti, 2016). The interaction of these aspectscan be described as the political mindset of students, whichitself is a useful tool to analyze both student’s civic develop-ment and the preparational capacities of educational sys-tems (Abs, Hahn-Laudenberg, Deimel, & Ziemes, 2017).

Participation can be used to foster development, but notall activities and methods that are labeled as being “partici-patory” provide stimulating contexts. Opportunities toparticipate can be brought into a hierarchical order basedon the degree to which they realize some principles of par-ticipation within schools. Hart (1992) uses Arnstein’s(1969) concept of the ladder of citizen participation to differ-entiate between multiple levels of participation, rangingfrom manipulation and tokenism (non-participation), con-sulted and informed participation up to child initiatedshared decisions with adults, and connects them with thenotion of children’s rights to participate. Civic participationoffers emerging citizens the opportunity to escape boredom,form relationships, identifications, and reflect upon norms(Larson, 2000). Work in community organizations is linkedto identity exploration, prosocial norms, and linkage to thecommunity itself (Hansen, Larson, & Dworkin, 2003). It isnot only important for emerging citizens, but also for therespective societies children and adolescents are alreadypart of. Participation can enrich and improve projects andsocieties (Lansdown et al., 2014), and societies ultimatelydepend on their members’ support, illustrating the intercon-nectedness of human rights, capabilities, and societal needs.

Participatory structures can also enhance identity forma-tion, which is both an important developmental task foradolescents and an aspect of their political mindset.Exploratory behavior can be employed constructively ineducational contexts (Waterman, 1989). The protection ofthe child’s identity is explicitly stated in the CRC (§8,§29c). Identity formation is fundamentally important forpersonal development and individuals’ relation to theirenvironment (Erikson, 1959/1994). Identity formation isalso a good example for the psychological connectionbetween different aspects relating to human rights. In a lon-gitudinal study, Crocetti, Garckija, Gabrialaviči�utė, Vosyli,and Žukauskienė (2014) found that identity styles and civic

participation were reciprocally connected, although thepredictive power of identity on participation was somewhatstronger. Identity, especially in developmental psychology,is connected to tolerance and respect (Ziemes & Abs,2017). Fostering tolerance and positive attitudes towardgender equality and different ethnic groups has its founda-tion in the CRC (§29). Those attitudes are not justconnected to identity, but also to competencies. Attitudestoward migrants and especially attitudes toward genderequality were found to be connected to civic competenciesin European countries (Ziemes & Jasper, 2017).

Conclusions for Researchand Practice

School environments have the capability to aid the fulfill-ment of human rights, and (educational) psychology has arole in co-constructing the environment in ways whichenhance the opportunities to fulfill requirements of humanrights (British Psychological Society, 2003). Psychologists ingeneral and educational psychologists in particular can helpto foster learning, participation, and identities. All partici-pating professionals, including educational scientists,should incorporate notions of human and children’s rightswithin their mindset and learn, teach, and advocate themat the appropriate (ecological) level. While some interven-tions are effective at the individual level, others may bemore appropriate at the classroom or school level.Multilevel analyses can aid to separate the levels statisti-cally. Political work therefore can and should be part of thisendeavor as well (Lansdown et al., 2014). Thus, despite notbeing a normative discipline per se, educational psychologyis called upon to incorporate both human and children’srights as a normative framework into their own professionalself-understanding and practice. Notwithstanding, it is bothdesirable and valuable that educational psychology aims tobe descriptive rather than normative. Educational psychol-ogy can offer theories as tools to analyze how human rightscan be positively realized. To achieve this, professionalsneed to take a critical look at processes such as bullyingwithin classrooms. The critical potential of psychology liesnot primarily on the level of societies but on concrete, oper-ationalizable processes. Operationalization can make normsvisible and foster valuable discussions.

Some practical implications for practitioners can bederived from our deliberations regarding the example ofbullying as a violation of several of children’s and adoles-cents’ fundamental rights. Practitioners at school need tobe aware that bullying is harmful, violates children’s rights,and inhibits positive development. Further, they need torecognize that no stakeholder in the various educational



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contexts stands outside the ecological frame, and that theirvery own attitudes and actions can prevent or promote bul-lying. What is especially dangerous is the normalization ofbullying behaviors by practitioners, for example by holdingpro-bullying attitudes. According to our view, it is notappropriate to see children’s rights as inborn or inherent.Children are not in a position to ensure, guarantee, imple-ment, or re-establish their rights in the hierarchical contextof school. Rather, staff and stakeholders in schools and thelarger educational system are responsible to create environ-ments that incorporate and foster children’s rights. Educa-tional psychologists can assist schools and educationalsystems in critically analyzing and – if necessary amending– conditions and practices with respect to children’s rights.

We further expanded some theories on positive develop-ment. By fostering positive relationships, identity formation,and participation within the classroom, the positive formu-lation of children’s rights can be realized to a certaindegree. The capability approach and the notions of positivedevelopment can be aligned with each other, providingresearchers and practitioners with a framework to approachproblems and find solutions. Competencies, identity forma-tion, and participation are good examples for the role ofeducational psychology in fostering capabilities and therights of children.

There are important limitations to our analyses and trans-fers. First, not all human rights can (or need to) be opera-tionalized within the framework of capabilities, and not all(psychological) needs need to be included in human rightsagreements. While it is insightful to analyze human rightsthrough a psychological lens, we must not underestimatetheir political and juridical foundation and scope. Whilehuman rights are often described as inherent or inborn,declarations, theories, and research are the results of socialco-constructive processes, therefore never inherent, butconceptually different and consequently useful for differentends. Constructs are easier to adjust to new insights andresults; they hold the potential to translate rights into inter-ventions and lived experience. Translations can never beobjective and are always in part interpretations. Objectivitycan be strived for, but never fully achieved.

In this paper, psychology in general and educationalpsychology in particular was labeled as a descriptive sciencewhich aims not to reify nor reproduce cultural bias. Eventhough categories can be used in the best interest of provid-ing interventions for positive development, we need to beaware of the stigmas which are connected to categoriesand diagnoses and thus often lead to forms of discrimina-tion (Hinshaw, 2005). Psychologists are not immune tothese processes. While we support the aim of descriptive-ness, we also recognize the impossibility of actually achiev-ing it. Psychologists, and this of course includes the authors,are always part of the ecologies they want to study and

therefore never truly objective nor neutral. As previouslydiscussed, we do not need nor want (educational) psychol-ogists to be neutral, but dedicated to positive developmentof individuals and groups, especially those who aredisadvantaged. Therefore, we must treat all (educational)psychological research and resulting categories as prelimi-nary parts of a discussion of theory, data, and human rightsconsiderations in close cooperation with all stakeholders,especially the vulnerable and disadvantaged.

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HistoryReceived May 14, 2018Revision received January 22, 2019Accepted February 8, 2019Published online June 14, 2019

ORCIDJohanna Fee Ziemes

https://orcid.org/0000-0003-291-4845

Eveline Gutzwiller-HelfenfingerInterdisciplinary Center for Integration and Migration ResearchUniversity of Duisburg-EssenUniversitätsstr. 245127 [email protected]

Johanna Fee ZiemesEducational Research and SchoolingUniversity of Duisburg-EssenUniversitätsstr. 245127 [email protected]

Johanna F. Ziemes is currently a re-search fellow at the University ofDuisburg-Essen. She studied psy-chology and focuses in her researchon questions on identity formationand political support in the adoles-cence. She is part of the NationalResearch Center of the InternationalCivic and Citizenship Education Study2016.

Eveline Gutzwiller-Helfenfinger iscurrently a Guest Professor at theUniversity of Duisburg-Essen. Herresearch and teaching as a develop-mental and educational psychologistrefer to socio-moral developmentacross the lifespan, teachers’ pro-fessional development, and the linkbetween them in the area of socialrelationships at school, specificallyschool bullying.



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A Human Rights and Ethics CrisisFacing the World’s LargestOrganization of PsychologistsAccepting Responsibility, Understanding Causes,Implementing Solutions

Kenneth S. Pope

Norwalk, CT, USA

Abstract: A crisis of human rights and ethics has engulfed the American Psychological Association (APA). The APA acknowledged “this stain onour collective integrity.” What caused this continuing crisis? How did the APA become so ethically lost that the president-elect announced theneed to reset their moral compass? This article documents decisions and policies that address those questions. It reviews factors that weakenour defense of human rights and ethics, such as confusing the map with the territory, legal duties with ethical duties, guild ethics withprofessional ethics, and effective methods with ethical methods. It considers cultural, racial, and religious aspects of the crisis. It examinesthe dangers of euphemism and ambiguity and maps the failure of prohibitions, policies, and public pronouncements. It traces organizationaltendencies to point fingers elsewhere, outsource ethics, and roll back reforms. It highlights our responsibility to search actively for opposingviews and disconfirming information to help us overcome confirmation bias, GroupThink, WYSIATI (What You See Is All There Is) bias, optimisticbias, and false consensus. It discusses the APA’s crisis in the context of the rollback of human rights in most countries and the US’s growingpublic support for torture. It notes current controversies, including reform rollbacks, subordinating ethics to the power of the state, and threelawsuits alleging false and defamatory statements made with malice. The article suggests six principles to help bring APA’s continuing crisis toan end and prevent future crises.

Keywords: human rights, torture, American Psychological Association, Nuremberg, professional ethics

We’ve yet to fully grasp the continuing corrosive damageand unfinished business underlying a decade of newspapercoverage bearing shock-the-conscience titles like “Psychol-ogists Implicated in Torture” (Goodman, 2007); “Psycholo-gists and Torture” (Boston Globe Editorial Board, 2008);“Psychologists ‘Protected CIA Torture Programme’; Profes-sional Body Admits It May Have Contributed to Violationsof Human Rights After Scathing Internal Report Into Post9/11 Collusion With Pentagon” (Crilly, 2015); “Psycholo-gists Who Greenlighted Torture” (New York Times EditorialBoard, 2015); “How America’s Psychologists Ended UpEndorsing Torture; New Revelations Reveal a SurprisinglyCozy Relationship Between the American PsychologicalAssociation and the Department of Defense” (2015);“Psychologists Met in Secret With Bush Officials to HelpJustify Torture; Newly Disclosed Emails Reveal AmericanPsychological Association Coordinated With Officials inCIA and White House to Help Ethically Justify DetaineeProgram” (Jalabi, 2015); and “Psychologists Are FacingConsequences for HelpingWith Torture” (Eidelson, 2017a).

What steps led the world’s largest organization of psy-chologists into this still-unresolved human rights and ethicsbreakdown, which the APA has acknowledged as not only a“crisis” but also a “stain on our collective integrity” (Kaslow& McDaniel, 2015; see also Voice of America, 2015)? Howhas the highly respected American Psychological Associa-tion (APA), which has done so much good, gotten so ethi-cally lost that the president-elect announced at the annualmeeting: “We’re here today to reset our moral compass”(quoted by Wilhelm, 2015; see also Aldhous, 2015; Hanlon,2015; O’Neill, 2016, p. 228)?

This article highlights key decisions, trends, policies, andpublic statements that can help us answer those questionsand avoid repeating the mistakes that have been madeduring what has been called the APA’s “darkest period”(Hanlon, 2015). The history of this crisis suggests that fun-damental principles have been forgotten or swept aside.Holding these principles firmly in mind and making thema focus of undergraduate, graduate, and continuing educa-tion programs can strengthen efforts to resolve the current

European Psychologist (2019), 24(2), 180–194 � 2018 Hogrefe Publishing Distributed under thehttps://doi.org/10.1027/1016-9040/a000341 Hogrefe OpenMind License http://dx.doi.org/10.1027/a000001

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crisis and avoid future wrong turns. Looking at how the cri-sis began and evolved up to the present also gives us achance to think through not only what we have to say aboutthese events but also what the events have to say abouteach of us as an individual. Knowing what we know now,what would we have done differently? What can each ofus do to become a more active and effective supporterand defender of human rights and ethics? How can weescape the passive – and enabling – role of bystander whenhuman rights and ethics are under attack?

Reviewing this history can also help us remember whathas actually happened so far in this evolving crisis andavoid lapsing into revisionism, denial, institutional amnesia,dismissing it as fake news or false narratives, or trying to“move past it” when “move past it” means “pretend itnever happened” or “forget about it.” Santayana remindsus that freeing ourselves from the past hinges on memory:“Progress. . .depends on retentiveness. . .. Those who can-not remember the past are condemned to repeat it” (San-tayana, 1905/2017, p. 103).

Searching the past to learn how we can promote and pro-tect human rights more effectively seems fiercely urgentbecause those rights now face widespread attacks and thoseattacks meet little resistance. The UN High Commissionerfor Human Rights reports:Time and again, my office and I have brought to theattention of the international community violations ofhuman rights.. . . Time and again, there has been mini-mal action. . .. Today oppression is fashionable again;the security state is back, and fundamental freedomsare in retreat in every region of the world. (Zeid, 2018)

The Amnesty International Secretary General sounds a sim-ilar alarm, warning us that perpetrators face only weak resis-tance as they bear us back into a past stripped of basic rights:“The feeble response to crimes against humanity and warcrimes. . .underscored the lack of leadership on humanrights. Governments are shamelessly turning the clock backon decades of hard-won protections” (Shetty, 2018). Writingthe introduction to the Human Rights Watch World Report2018, the Executive Director points out a tragic result ofthe “minimal action” and “feeble response” to attacks onhuman rights: “The retreat of many governments thatmight have championed human rights has left an openfield for murderous leaders and their enablers” (Roth,2018, p. 1). Since 2016, fundamental human rights have beensuccessfully rolled back in 71 out of 113 countries accordingto 2018 Rule of Law Index (Bordell & Robins, 2018).

Governments often pay no price for violating humanrights. Individuals who try to prevent or expose those viola-tions can face threats, assaults, prison, torture, or death. TheAmnesty International Report 2017/18: The State of theWorld’s Human Rights warns that “the cost of speaking outagainst injustice continues to grow” (Amnesty International,

2018, p. 13). Survey data show a “34% global rise in attacksagainst human rights activists last year” (Kelly, 2018). Inthe past year alone, hundreds of human rights defenderswere killed, and hundreds more threatened or detained(United Kingdom Mission to the United Nations, 2018).

Torture

As attacks on both human rights and defenders of humanrights grow, one human rights violation – torture – contin-ues to gain wider support. The Roper Center for PublicOpinion Research (2015) found the percentage of those inthe US saying that torture is sometimes or often justifiedclimbed from 43% in 2004 to 51% in 2015. A 2016 Reu-ters/Ipsos poll found that just short of two-thirds of USadults believed that torturing “suspected terrorists to obtaininformation about terrorism” could be justified (Kahn,2016; see also Mayer & Armor, 2012).

This growing public support for torture provides a contextfor the APA’s human rights and ethics crisis. Does the stron-ger support in the US, compared to most other countries,help explain why it is a US-based organization of psycholo-gists that created this crisis? A 2015 Pew Research Centersurvey of 38 nations found that 58% in the US believed tor-ture was justified to prevent terrorist attacks, and that only 5other countries showed larger percentages of support: Nige-ria, Kenya, Israel, Lebanon, and Uganda (Wyke, 2016). AnInternational Committee of the Red Cross (2016) surveyof 16 nations found only 2 other countries (Nigeria andIsrael) had smaller percentages of people answering “no”when asked “Can a captured enemy combatant be torturedto obtain important military information?” (InternationalCommittee of the Red Cross, 2016, p. 10).

Mindful of the growing support for torture, which isstronger in the US than in most other countries, and thefierce urgency of finding ways to avoid continuing to repeatcritical mistakes, we turn now to major markers in thishuman rights and ethics crisis.

Mapping the Failure of Prohibitionsand Public Pronouncements

Professions profess their values, making clear what theystand for. Professionals adopt policies and elect leaderswho will express those values and keep their professionon track. The APA’s history includes strong public standssupporting human rights and opposing torture. Theseformal stands intensified during the post-9/11 period when,as the newspaper articles cited earlier showed, the APA’sprofessed commitment to human rights started comingunder sharp questioning.

� 2018 Hogrefe Publishing Distributed under the European Psychologist (2019), 24(2), 180–194Hogrefe OpenMind License http://dx.doi.org/10.1027/a000001

K. S. Pope, Crisis of Human Rights 181

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Responding to the 9/11 terrorist attacks on civilian men,women, and children, the US interrogated suspected terror-ists at the Detention Centre at Bagram Airbase in Afghani-stan; Abu Ghraib Prison in Iraq; Camps Delta, Iguana, andX-Ray at Guantánamo Bay Naval Base; and other sites. TheAPA saw psychologists as central to these interrogations,explaining to the US Senate Select Committee on Intelli-gence that “conducting an interrogation is inherently apsychological endeavor. . .. Psychology is central to this pro-cess” [emphasis in the original] (APA, 2007b). The APA’sstrong advocacy for psychologists’ central involvement inthe US interrogation programs, in sharp contrast to theAmerican Psychiatric Association’s stance, convinced thePentagon to include psychologists when designing interro-gation methods.

Pentagon officials said they would try to use only psy-chologists, not psychiatrists, to help interrogatorsdevise strategies to get information from detaineesat places like Guantanamo Bay, Cuba. The new policyfollows by little more than two weeks an overwhelm-ing vote by the American Psychiatric Association dis-couraging its members from participating in thoseefforts (Lewis, 2006).

In “Advocacy As Leadership,” the American PsychiatricAssociation president described a stark difference in ethicalvalues to explain why his organization took a differentstance from the APA’s:

I told the generals that psychiatrists will not participatein the interrogation of persons held in custody. Psy-chologists, by contrast, had issued a position statementallowing consultations in interrogations. If you wereever wondering what makes us different from psychol-ogists, here it is. This is a paramount challenge to ourethics. . .. Our profession is lost if we play any role ininflicting these wounds (Sharfstein, 2006, p. 1713).

The public was assured that psychologists would keep allinterrogations safe, legal, and ethical, in line with the APA’sstrong stance opposing torture and other violations ofhuman rights. For example, an APA Ethics Office statementin Psychology Today underscored what psychologists wouldachieve in all interrogations: “The ability to spot conditionsthat make abuse more likely uniquely prepares psycholo-gists for this task. Adding a trained professional ensures thatall interrogations are conducted in a safe, legal, ethical, andeffective manner. . .” (Hutson, 2008; italics added).

The APA backed its stance that psychologists were centralto the interrogations and would keep them safe, legal, andethical (see Pope, 2011 for additional examples and discus-sion) with a series of strong anti-torture policies. Thesepublic statements against torture had begun long before.For example, in the mid-1980s, the APA adopted “AgainstTorture: Joint Resolution of the American Psychiatric

Association and the American Psychological Association”(APA, 1985) and the “Resolution Against Torture” (APA,1986, p. 661). After 9/11, the APA repeatedly restated itsanti-torture policy in a “Reaffirmation of the 1986ResolutionAgainst Torture” (APA, 2006, p. 459), a new “ResolutionAgainst Torture” (APA, 2007a, p. 448), a “Reaffirmationof the APA Position Against Torture” (APA, 2008, p. 412),an amendment to the “Reaffirmation of the APA PositionAgainst Torture” (APA, 2009, pp. 425–426), and a “Resolu-tion to. . .Safeguard Against Acts of Torture. . .in All Settings”(APA, 2016, pp. 378–380). The APA’s public commitmentwas not just to oppose torture but also to advance all humanrights. The “APA Vision Statement” set forth a vision of theAPA as “the primary resource for all psychologists” and“champion of the application of psychology to promotehuman rights” (APA, 2009, p. 451).

The APA mapped out its anti-torture and human rightsvalues in formal policies and public assurances, but asKorzybsky reminds us: “A map is not the territory it repre-sents. . .” (1933/2010, Kindle location 1179). Mistaking themap for the territory is a slip I often find myself makingand I believe this error was widespread during this period,helping to create the APA’s continuing crisis of humanrights and ethics. It is easy for us to think that our work isdone once we choose good leaders and adopt policies thatstate our values clearly. Leaders and non-leaders alike mayforget that policies, prohibitions, and public statements arenecessary but not sufficient, that maps may misleadbecause they fail to match the territory itself. It is as if wetry to shift our own ethical responsibility away from our-selves and onto written and spoken words. But we can’t out-source our ethical responsibility, even to the best policiesand leaders. The inescapable ethical duty stays with eachof us. When fundamental ethics are at stake, it falls to eachof us to ask “Does the map accurately reflect the territory?”The territory itself may show a spreading “stain on our col-lective integrity” that is missing from the map.

Like the APA, the US mapped out public policies prohibit-ing torture and public assurances from leaders that the USwould not torture and was leading the fight to rid the worldof torture. Griffin (2015) wrote that the “US had the mostrestrictive ban against torture, compared to the definitionsof the World Health Organization [and] the UnitedNations” (see also “Legal Prohibition Against Torture,”2004; “Summary of International and US Law ProhibitingTorture and Other Ill-treatment of Persons in Custody,”2004). President Bush insisted early on that “the UnitedStates is committed to the world-wide elimination of tortureand we are leading this fight by example” (2003) and latergave assurance that was strong, absolute, and unambigu-ous: “I want to be absolutely clear with our people andthe world: The United States does not torture. It’s againstour laws and it’s against our values” (2006).

European Psychologist (2019), 24(2), 180–194 � 2018 Hogrefe Publishing Distributed under theHogrefe OpenMind License http://dx.doi.org/10.1027/a000001

182 K. S. Pope, Crisis of Human Rights

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Our shared human tendency to assume the map matchesthe territory complicates the crisis and makes it harder forus to sort through our ethical responsibilities when theyconflict with our duties to the state, which is the focus ofthe next section.

When the Demands of the StateEclipse Ethical Responsibilities

When caught committing an ethically questionable act, USpoliticians frequently follow a familiar script. They assurethe public that they have broken no law, as if followingthe law places their behavior safely beyond question. Thisstrategy cleverly confounds legal and ethical standards.It exploits our difficulty untangling legal and ethical dutiesand the ways in which the power and demands of thestate – expressed through laws, regulations, and legalauthority – can eclipse ethics.

The APA struggled to speak clearly on the relationbetween ethical responsibilities and the demands of thestate during this period. But a key principle was downplayed,denied, and distorted: That obeying the orders of the statenever allows us to escape our ethical responsibilities.

On August 21, 2002, the APA adopted a revised ethicscode allowing the power of the state to trump ethics. Thecode made a sharp break with how the APA had previouslybalanced ethics and state power. The APA took anextremely radical stand that whenever our “ethical respon-sibilities” cannot be reconciled with state authority, “psy-chologists may adhere to the requirements of the law,regulations, or other governing legal authority” (APA,2002, section 1.02, p. 1063). An earlier draft required thisabdication of ethics in deference to state power to be “inkeeping with basic principles of human rights” both in thecode’s introduction and in the enforceable section. How-ever, the APA adopted the new code only after cutting thatrequirement out of the code’s enforceable section.

No other profession adopted the APA’s ethically question-able policy during the 8 years (2002–2010) that the APApromoted, the APA Ethics Committee endorsed, and psy-chology students were taught this new code’s approach ofallowing the power of the state to eclipse ethics. After back-ing away from the position in 2010, APA would not revisitthis issue again until 2018, when it began to outsource ethicsenforcement to the government and other organizations.However unintentionally, this new approach would in manycases again grant the state power over ethics.

As discussed in more detail in a later section, “Out-sourcing Ethics Complaints & Adjudication,” the APArecently announced: “Starting immediately, complaints willbe accepted against APA member psychologists only if

there is no alternative forum to hear the complaint,” notingthat the APA does “not have powers of investigation thatgovernmental bodies and others possess” (American Psy-chological Association Ethics Committee, 2018). Conse-quently, when a complaint involves a conflict betweenethical responsibilities and the government’s power (e.g.,“law, regulations, or other governing legal authority”), theAPA now defers to government bodies (e.g., an InspectorGeneral, the military chain of command, or the other gov-ernment channels addressing complaints against militarypsychologists, police psychologists, psychologists workingfor the Department of Homeland Security (DHS) or forDHS-funded centers, and so on) to adjudicate conflictsbetween a psychologist’s ethical responsibilities and whatthat government is ordering, requiring, or compelling thepsychologist to do or refrain from doing.

As noted earlier, the President of the American Psychi-atric Association described how contrasting approaches tothe interrogations at Guantánamo and other sites showedthat psychiatrists and psychologists embraced starkly differ-ent ethical values. The APA’s decision to outsource ethicsenforcement to the government and other bodies, eachforum enforcing whatever standards it has adopted and pri-oritized, also differentiates the APA from the American Psy-chiatric Association, which continues to hold its membersaccountable to its own ethical values by receiving and adju-dicating complaints against its members (American Psychi-atric Association, 2010).

Less than a year after the APA adopted the 2002 code,Dr. Kati Myllymaki, President of the World Medical Associ-ation (WMA), issued a stark reminder:

“At Nuremberg in 1947, accused physicians tried todefend themselves with the excuse that they wereonly following the law and commands from theirsuperiors. . .. This defence was condemned. . .andthe court announced that a physician could notdeviate from his ethical obligations even if legislationdemands otherwise.” (WMA, 2003)

Predictably, an ethics code allowing state power andauthority to override ethical responsibilities has evoked ascalding cascade of criticism, for example:� An issue of The British Medical Journal displayed a

gruesome photograph from the Abu Ghraib Prison onthe cover. It included a special statement from the jour-nal editor that the Nuremberg trials

“. . . made clear that obeying commands from superi-ors didn’t remove personal accountability. Doctorscouldn’t deviate from their ethical obligations evenif a country’s laws allowed or demanded other-wise. . .. It’s surprising, even shocking, to find thatthe same code isn’t shared by psychologists, at leastin the United States.” (Godlee, 2009, p. 7704)



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� An article in the British Psychological Society’s The Psy-chologist also placed the APA ethics code change intohistorical context:

“Most concerning of all, the APA allows its membersthe ‘Nuremberg defence’ that ‘I was only followingorders.’. . . The implication is that psychologists arepermitted to assist in torture and abuse if they canclaim that they first tried to resolve the conflictbetween their ethical responsibility and the law, reg-ulations or government legal authority. Otherwisethey can invoke the Nuremberg defence.” (Burton& Kagan, 2007, p. 485)

� A former president of the Canadian PsychologicalAssociation (CPA) wrote:

“During the decade of ‘enhanced interrogations,’both CPA and APA revised their codes of ethics.APA’s changes made it easier to cooperate with theUS Department of Defense. CPA’s went in the oppo-site direction, strengthening the link between profes-sional ethics and respect for international law.”(O’Neill, 2016, p. 228)

� The founding director, codirector, and associate direc-tor of the Criminal Justice and Health Program at theUniversity of California, San Francisco, have focusedon how

“. . . APA’s misplaced loyalty to the state directlyundermined the health and human rights of patientsat Guantanamo Bay. APA policy. . .allowed psycholo-gists to participate in practices termed “enhancedinterrogation” and was used by the US Departmentof Defence and others to justify, expand, and prolongtorture ostensibly approved by experts from health-care profession.” (Ahalt, Rothman, & Williams, 2017)

The continuing criticism confronting the 2002 ethics code’scontroversial section 1.02 presented the APA with a chal-lenge: How to respond to criticism and to information thatwas critical but unwanted, which is the focus of the nextsection.

Criticism and Critical Information

During the post-9/11 period, the APA has faced criticismnot just from individuals but also from human rights orga-nizations and related associations. For example, AmnestyInternational, Physicians for Human Rights, the Centerfor Constitutional Rights, and 10 other organizations sentan open letter condemning the APA for “providing ethicalcover for psychologists’ participation in detainee abuse”(American Friends Service Committee et al., 2009).

The APA has confronted not only criticism but also infor-mation and evidence – coming from diverse sources – that

called APA’s public stance into question. For example, soonafter the detainee interrogations began, reports fromnewspapers, humanitarian organizations, and the US gov-ernment contradicted the APA’s assurances that psycholo-gists were keeping interrogations safe, legal, and ethical.TheNew York Times spotlighted the 2003 and 2004 reportsby the International Committee of the Red Cross dis-cussing psychologists’ role in abuses at Guantánamo. TheCentral Intelligence Agency (CIA) Inspector General(2004) noted that an array of psychologists, both outsideand on-site, provided assurances that waterboarding causesno lasting psychological harm (US Central IntelligenceAgency, Inspector General, 2004; see also Davis, 2011;Mayer, 2008). McCoy (2006) documented how “Guantá-namo’s integration of psychologists into routine interroga-tion perfected the CIA’s paradigm, moving beyond abroad-spectrum attack on human senses, sight and sound,to a customized assault on individual phobias or culturalnorms, sexual and religious” (Kindle locations 3390-3392).

James Risen, a Pulitzer Prize-winning investigative repor-ter for the New York Times, uncovered primary source doc-uments that include e-mails secured by a CIA-connectedresearcher. He reported that the APA’s actions conflictedwith its anti-torture policies and public statements. “Theemails reveal how the American Psychological Association(APA), the nation’s largest professional group for psycholo-gists, put its seal of approval on those close ties [amongleading psychologists and CIA and Pentagon officials] andthus indirectly on torture” (Risen, 2014a, p. 178; see alsoRisen, 2014b, 2015).

A vital principle passed into hibernation during the post-9/11 period: We need to do more than just welcome criti-cism and critical information. We need to actively searchfor them, and evaluate them carefully, openly, and non-defensively. Hunting for facts, views, and possibilities thatcall into question what we assume, suspect, believe, or wantto believe helps us overcome such shared human tenden-cies as confirmation bias, GroupThink, WYSIATI (WhatYou See Is All There Is) bias, optimistic bias, and false con-sensus. I’m guessing this is one of the hardest principles forall of us to practice. And it can be much harder during timesof great stress and uncertainty, such as the years falling inthe shadow of the 9/11 attacks.

In late 2014, the APA turned away from its stance ofrejecting criticism and critical information that conflictedwith its policies and public statements. During the post-9/11 years, the APA had held out a vision of itself as “cham-pion of the application of psychology to promote humanrights” (APA, 2009, p. 451) and as establishing and main-taining “the highest standards of professional ethics”(APA, 2004, Article 1; see also APA, 2005, p. 2) despitesteps like adopting an ethics code (APA, 2002) that con-tained a loophole – one rejected by the Nuremberg courts



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– allowing members to escape their ethical duties wheneverthose duties stood in irreconcilable conflict with thedemands of the state. However, in October 2014, theAPA took a decisive step requiring courage and leadership.It commissioned “a definitive, independent and objectivereview” (APA, 2014) to be conducted by David H. Hoff-man, a former Inspector General, federal prosecutor, andSupreme Court clerk, who had directed hundreds of inves-tigations, and advised numerous public and private entitieson ethics and compliance matters.

When organizations facing scandal hire an experiencedinvestigator, it is a tacit acknowledgment that organizationsare not unbiased judges of serious charges against them.An outside independent investigation is less likely to steerclear of information that an organization has kept secret ormisrepresented, to whitewash findings, to push responsibilityaway from those in power, or to recommend superficial fixes.

The Independent Review Report (Hoffman et al., 2015)and the six binders of e-mails and other supportive docu-mentation that accompany it describe in detail how the“APA intentionally decided not to make inquiries. . .thuseffectively hiding its head in the sand” and “remaineddeliberately ignorant” (p. 11). Prior to the IndependentReview Report, the New Jersey Star-Ledger Editorial Boardpublished an editorial, “Doctors Without Ethical Borders,”which summarized a separate study – conducted andreleased prior to the Hoffman Report – of e-mails and otherdocuments. The Star-Ledger condemned the APA’s “See NoEvil” policy, as had Boulanger (2009) much earlier. ScottHorton, national security contributor for Harper’s Magazineand former president of the International League forHuman Rights, was one of earliest to write about this refusalto acknowledge unwanted information: “Of all the majorprofessional organizations addressing the torture and pris-oner abuse issue, one has an unbroken record of clear eth-ical evasion. It has adopted a new professional mantra, itseems: hear no evil, see no evil, speak no evil” (Horton,2007). What has been termed APA’s “Head in the Sand”or “See No Evil” tendency has continued to be a theme inthe literature for over a decade (see, e.g., LoCicero, 2018).

The Independent Review Report also documents waysin which criticism was deflected and critics disparaged(see also Elkins, 2016; Gómez, Smith, Gobin, Tang, &Freyd, 2016; Pope, 2016; Thomas, 2016, 2017). APAmember Jean Maria Arrigo serves as a vivid example.The Independent Review Report (2015) describes howshe was attacked in a highly personal manner thatincluded claims about her supposedly “troubled upbring-ing.” The Guardian reported how she had been “largelyignored and the subject of a smear campaign for soundingalarms about psychologists’ post-9/11 torture complicity”(Ackerman, 2015). The American Association for theAdvancement of Science (AAAS) honored her with the

AAAS Scientific Freedom and Responsibility Awardbecause she “confronted systematic efforts by the Amer-ican Psychological Association (APA) to allow and concealthe involvement of psychologists in the torture and abuseof detainees” (Korke, 2016). To its credit, the APA finallyformally acknowledged that this whistle-blower faced notonly “efforts to discredit, isolate, and shun” that were“orchestrated movements by those in positions of power”but also “harsh, hostile personal criticism and attacks”(Watt, 2015). And to her credit, Jean Maria Arrigo contin-ues to speak out and bring to light new information aboutthis continuing crisis (e.g., Franz & Arrigo, 2017).

If we are to bring the current crisis to a just resolutionand prevent future crises of human rights and ethics, theevents of this period suggest we must be ready to speakup, as Jean Maria Arrigo did, despite the costs, an act thatmay require moral courage (Pope & Vasquez, 2016,Chapter 10: “Moral Distress and Moral Courage”; Pope,2017, Chapter 7: “Finding Moral Courage and Putting ItTo Work”); listen respectfully to whistle-blowers, critics,and those with contrary views and unwanted news;and avoid the role of passive – and enabling – bystanderwhenever whistle-blowers, critics, and reporters of badnews are threatened, bullied, or attacked.

Ethics, Effectiveness, Euphemisms,and Ambiguity

US detainee interrogations have been described as “harsh,”“rough,” “aggressive,” “enhanced,” “extreme,” “coercive,”“abusive,” or “torture-lite.” These terms carry many mean-ings. Sometimes, they point to a large, vague group of accu-satory or aversive interrogation techniques that might – ormight not – include torture. Other times, they seem to hidetorture behind euphemism (Bennett, Lawrence, & Liv-ingston, 2006; Council of Europe, 2007, p. 3; Henley,2007; McGreal, 2012).

More than other countries, the US tends to use ambigu-ous categories and euphemisms to describe interrogations.A comparison of news articles from leading publications inseven countries found striking differences in reporting the2004 Abu Ghraib prison story:

“At one extreme, American journalists overwhelminglyavoided torture to describe Abu Ghraib, emphasizinginstead more ambiguous, and arguably more innocu-ous, terms such as abuse or mistreatment. At the otherextreme, German, Italian, and Spanish journaliststended to define what happened at the prison as torturerather than as abuse or mistreatment.” (Jones &Sheets, 2009, p. 278; see also Downie, 2004; Graber& Holyk, 2009; Rosen, 2014; Umansky, 2014)



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Ambiguity and euphemism create a fog of conceptual con-fusion around methods of interrogation. The confusionmakes it easier to assume that the central ethical questionis: “Do the methods work to save American lives?” Accord-ing to this view, if methods work, using them is not just eth-ical but an ethical duty. A member of the APA’s specialethics task force explained “the real ethical consideration”underlying this duty. To address such ethical considera-tions, the APA created a select “blue ribbon” committee(James 2008, Kindle location 3163) of experts – the Presi-dential Task Force on Psychological Ethics and NationalSecurity – who would craft the APA’s ethics policies in thisarea. The task force member noted that the idea of psychol-ogists inflicting pain seems

“. . . at first blush, something that would be wrongbecause we do no harm. But the real ethical consider-ation would say. . .by producing pain or questioning ofsomebody, if it does the most good for the mostpeople, it’s entirely ethical, and to do otherwise wouldbe unethical.” (“Military Psychologist Says HarshTactics Justified,” 2009; see also Richey, 2007)

More recently, a group of six university-based psychologistspresented a similar view based on consequentialist ethics,deontological ethics, virtue ethics, and efficacy. They con-cluded “that psychologists, in order to behave consistentlywith their moral obligations to the community, to their eth-ical duties, in order to minimize harm, and to act virtuouslymay, in certain circumstances, need to participate in tor-ture” (O’Donohue et al., 2014, p. 121; see also O’Donohue,Maragakis, Snipes, & Soto, 2015; for critiques and sharplyopposing views, see Arrigo, DeBatto, Rockwood, & Mawe,2015; Eisenhower, 2017).

Evaluating these claims requires commitment to clarity.To defend human rights and ethics effectively, we mustscrub euphemism and ambiguity out of what we say andwrite. We need to know the difference between tortureand other interrogation techniques, some of which may beaccusatory or aversive, that do not violate human rights.

If we humans possess inherent, inalienable rights – asopposed to human privileges or perks that the state can giveor refuse – then perhaps an ethical analysis of whethertorture “works” falls into the same category as askingwhether genocide or slavery “works” for a country is usefulin defending the country, or benefits a majority of itscitizens.

Professional Ethics and Guild Ethics

A key question that helps reveal the depth of an organiza-tion’s ethical commitment is: Has the organization set itsmoral compass to protect itself over public interest? The

set point of the moral compass divides professional ethicsfrom guild ethics. Sometimes, professions seem virtuallyidentical to guilds. Both may be made up of deeply dedi-cated, highly skilled members. Membership in both maycome only after years of training and tests that supposedlyshow expertise or at least competence. Both may point withpride to their lofty ideals and aspirations, their rich history,their impressive accomplishments, their leadership, andtheir record of significant contributions to the public good.But professional ethics protect the public against the abusesof professional power, specialized knowledge, and promi-nent positions. They place protecting the public interestabove advancing the profession’s self-interest. They holdmembers truly accountable for violating these values. Guildethics, on the other hand, place members’ interest abovethe public interest when both come into conflict. They tendto blur or evade accountability when it clashes with self-interest. Guild ethics are written to masquerade as profes-sional ethics, exploiting our tendency to mistake the mapfor the territory. Guild ethics can find ways around eventhe most absolute, unambiguous prohibitions, discoverloopholes in seemingly solid standards, and offer theappearance but not the reality of fair, just, and meaningfulmechanisms of accountability.

The APA’s vulnerability to a human rights and ethics cri-sis in the post-9/11 era may have been created in part byhaving shifted from a professional ethics code to a guildethics code almost a decade earlier, and later revising theethics code to express an even more extreme version ofguild ethics. The 1992 revision of the APA ethics codemarked the start of this trend. Bersoff (1994), the APA’sformer legal council and later an APA president, wrotefrankly about his own assessment and summarized thejudgments of others who reviewed the code. In “ExplicitAmbiguity: The 1992 Ethics Code as an Oxymoron,” hewrote that “commentators agreed that the 1992 code”seems “to protect the profession rather than the public”(p. 382), adding that “as almost all the reviewers pointedout, the code is full of such lawyer-driven ‘weasel words’as reasonable and feasible” (p. 383).

Carolyn Payton was a widely known and respected psy-chologist who wrote a landmark evaluation of the code.Payton was the first woman and first African-American toserve as director of the Peace Corps. She had served onthe APA Policy and Planning Board, the Committee onWomen in Psychology, the Committee on Lesbian, Gayand Bisexual Concerns, and the Public Policy Committee,and had received the APA award for Distinguished Profes-sional Contributions to Public Service among other honors.Placing the new code into historical context, Payton notedthat “all previous codes seemed to have been formulatedfrom a perspective of protecting consumers. The new codeappears to be driven by a need to protect psychologists.



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It reads as though the final draft was edited by lawyers. . .”

(Payton, 1994, p. 317). She described how the code providedloopholes that opened wide avenues of escape fromaccountability and enforcement:

“The forcefulness of the proscriptions on harassment,e.g., is diminished in. . .Standard 1.12, which brings upthe qualifier ‘knowingly’. . .as in psychologists do notknowingly engage in harassment. Try using the argu-ment of ignorance with the Internal Revenue Ser-vice” (p. 320).

For more details and documentation of the APA’s shift fromprofessional ethics to guild ethics, and how the APAadopted a more extreme version of guild ethics in a subse-quent revision of the code, please see Pope (2016), uponwhich this section is based.

The Unfinished Business of Race,Religion, and the Victims

Jennifer Gómez (2015) and the Ethnic Minority InterestCaucus of the APA Council of Representatives (2015) areamong those who call attention to one of the most unat-tended and actively disregarded pieces of unfinished busi-ness: that the torture that psychologists helped enable –

and in some instances helped design and implement – felldisproportionately on those who, in the United States,would be considered cultural, racial, and religious minori-ties. Gómez et al. (2016) remind us that various psychologyassociations such as

“. . . the American Middle Eastern/North African Psy-chological Network. . ., the Asian American Psycho-logical Association. . ., the Association of BlackPsychologists. . ., the National Latina/o PsychologicalAssociation. . ., and the Society of Indian Psycholo-gists, have condemned APA for its lack of protectionof minorities in this context.” (pp. 533–534)

Three years ago, the American Middle Eastern/North Afri-can Psychological Network (2015) asked the APA to “for-mally apologize to communities of color” who weredisproportionately harmed by the APA’s acts and failuresto act during this period. The APA continues to decline thisrequest.

It seems worth exploring why the APA has apologized to“Psychology Colleagues,” stating that the APA is “deeplysorry” that “these events have cast a pall on psychologyand psychologists in all countries, with the potential to neg-atively affect perceptions of the integrity of our disciplineworldwide” (Kaslow & McDaniel, 2015) but has never

addressed an apology for “these events” to the victims oftorture and their families.

Externalizing, Outsourcing, andBacktracking

The APA faces the continuing challenge confronting allorganizations struggling to end a crisis: Once the spotlightof public attention that shines most intensely at the heightof the crisis moves on, can it follow through on its promisesof reform? Can it avoid airbrushing history and headingback toward “the way things were before” the crisis?

Decades of research and case studies in organizationalpsychology show how hard it is for organizations to followthrough on resolutions to reform made when a crisis breaksopen. As time passes, the urgency of reform fades and theurge to externalize accountability, outsource responsibility,and backtrack takes hold. Powerful incentives inside andoutside the organization, as well as organizational charac-ter, culture, and other factors that caused the crisis andallowed it to metastasize reassert themselves, often withrenewed force and determination. The map of reform startsto look less and less like the territory.

This section presents three recent examples of APA’sstruggle with the tendency to externalize, outsource, andbacktrack.

Externalizing Accountability

Eidelson was one of the earliest to identify, trace, and doc-ument the push to externalize accountability by attackingthe Hoffman report and to point fingers elsewhere. His arti-cle “Making a Choice: APA reform or business as usual? Anew campaign aims to discredit the Hoffman Report”(2015), written only 3 months after the report’s release,notes that if successful, the campaign “will obstruct analready rugged path toward accountability and reformwithin the APA.” The article documents attempts to attackand discredit not only the Independent Review Report itselfbut also the report’s authors and those who support it. Hisdocumented examples include “attack[ing] the patriotismof Hoffman and those who have criticized psychologists’participation in abusive detention and interrogation opera-tions,” denouncing the report as a “classic attack of cow-ards,” and accusing those who had a hand in releasingthe report of being “a willing co-conspirator to the likesof al Qaeda and ISIS.” He uses an APA letter to the editorof theWashington Post to illustrate externalizing responsibil-ity and pointing fingers elsewhere. Eidelson (2017b) writesthat the APA’s letter holds the “APA blameless, portrayingthe profession’s dark-side participation as solely that of ‘tworogue psychologists.’”



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Outsourcing Ethics Complaints andAdjudication

As noted in the section “When the Demands of the StateEclipse Ethical Responsibilities,” the APA recently announcedthat “Starting immediately, complaints will be acceptedagainst APA member psychologists only if there is no alterna-tive forum to hear the complaint,” noting that the APA does“not have powers of investigation that governmental bodiesand others possess” (APA Ethics Committee, 2018).

Outsourcing the adjudication of ethics complaints to gov-ernment bodies and others (e.g., corporations for whichpsychologists conduct research, consult, etc.) allows theseorganizations to define the enforceable ethical standardsfor psychologists. Unless the government, corporation, orothers have adopted the APA’s ethics code as their standardand made enforcement a priority, they may enforce stan-dards that differ sharply from or conflict with the APA’sethics code.

Ethics complaints against psychologists regarding workat Guantánamo Bay Naval Base and other detention sites,human rights, interrogation, torture, and so on can nowbe resolved by an Inspector General, the military chain ofcommand, or other government grievance channels, asthe APA no longer accepts ethics complaints regardingthese ethics policies. This ethics outsourcing promptedDavid H. Mills (2018), who had served as director of theAPA Ethics Office for over 10 years, to write an open letterto the APA noting his decades of active membership as wellas what he had learned from his military service. He wrotethat the outsourcing of ethics adjudication shows “that APAhas not adequately appreciated the issues which wereraised in the Hoffman Report. . .. For that matter and withgreat sadness I tender my resignation from APA for bothethical and moral reasons.” (for discussion of 5 far-reachingconsequences of this outsourcing policy, see Pope, 2018).

A Proposal to Backtrack

At its 2018 annual convention, the APA considered a pro-posal that would backtrack on reforms taken at the heightof its human rights and ethics crisis. The APA Board ofDirectors backed the proposal even though an array ofhuman rights organizations had strongly condemned itand urged that it be rejected.

The proposed change would remove a prohibition thatthe APA had adopted almost unanimously in response toits human rights and ethics crisis. On August 7, 2015, theAPA Council voted overwhelmingly (157-1) to adopt Resolu-tion 23B, which emphasized that it was

“. . . a violation of APA policy for psychologists towork at the Guantánamo Bay detention facility,‘black sites,’ vessels in international waters, or sites

where detainees are interrogated under foreign juris-diction “unless they are working directly for the per-sons being detained or for an independent third partyworking to protect human rights’ or providing treat-ment to military personnel.” (APA, 2015)

This key reform prohibits psychologists working directly forthe US government (e.g., military psychologists employedby the Department of Defense, or psychologists workingunder contract for the CIA or Homeland Security) frommonitoring, conducting assessments, or engaging in otherpsychological interventions with detainees in settings likeGuantánamo or Abu Ghraib. Psychological services are tobe provided only by psychologists working directly for thedetainee or for independent organizations like the RedCross or Amnesty International, and not by psychologistsworking as employees or agents of the US government.

This mandating of clear and nonconflicting roles andresponsibilities avoids potential ethical, clinical, and practi-cal problems of conflicting roles. Clear roles and responsi-bilities are critical in special settings in which the USgovernment asserts the right to hold detainees indefinitely– potentially for their entire lifetime (Jindia, 2018; Rosen-berg, 2018; Ryan, 2018) – without charges or trial. Clarifyingroles and responsibilities so that clinical services are pro-vided by independent organizations and those working di-rectly for the detainees avoids the obvious dilemma facedby detainees asked to trust a therapist or other clinicianemployed by the same government that (1) has imprisonedthem for an indefinite time without charges or trial, (2) hasclassified them as enemy combatants, and (3) is interrogat-ing them in order to obtain accurate, actionable informa-tion, perhaps on an urgent, mission-critical basis toprevent an imminent terrorist attack. It avoids the govern-ment “owning” the detainee’s clinical chart. If a detaineereports being tortured or subjected to other violations ofhuman rights, it avoids putting the psychologist in the posi-tion of having to chart and formally report these allegationsof human rights violations regarding fellow soldiers – per-haps the psychologist’s commanding officers or supervisors– and others working for the government. Finally, it avoidsissues of conflicting dual loyalty (e.g., to the detainee and toa critical mission).

The article “Mixed Agency in Military Psychology: Apply-ing the American Psychological Association Ethics Code,”published in an APA journal, addresses issues of conflictingdual loyalties: “At times, psychologists employed by govern-ment agencies may feel compelled to limit the freedom oroverlook the best interests of one person to promote orsafeguard the best interests of a larger group, or even soci-ety at large” (Kennedy & Johnson, 2009, p. 27). One ofexperts APA appointed to its “Blue Ribbon” presidentialethics panel (described in the earlier section on “Ethics,Effectiveness, Euphemisms, and Ambiguity”) to guide



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ethics policy in the area of national security provided anethical analysis:

“The ethical consideration is always to do the mostgood for the most people. And America happens tobe my client. Americans are who I care about. I haveno fondness for the enemy, and I don’t feel like I needto take care of their mental health needs” (MilitaryPsychologist Says Harsh Tactics Justified, 2009).

The 2015 reform that the APA enacted to avoid conflictingroles and responsibilities is based on more than considera-tions of potential ethical, clinical, or practical issues. It isbased on what has actually happened at Guantánamo, AbuGhraib, and similar settings. Two of the major prob-lems concerned what has happened to the information thatdetainees disclose to clinicians working for the government.

First, a specific category of information seemed simply todisappear – it was never reported to the proper authoritiesnor was it recorded in the charts. Researching this problemof information missing from charts, Iacopino and Xenakis(2011) found “that allegations by these nine detainees oftorture were corroborated by forensic evaluations by non-governmental medical experts and that DoD medical andmental health providers at GTMO failed to document phys-ical and/or psychological evidence of intentional harm.”Similarly, Clark (2006) wrote:

“Although knowledge of torture and physical andpsychological abuse was widespread at both theGuantanamo Bay detention facility and Abu Ghraibprison in Iraq, and known to medical personnel, therewas no official report before the January 2004 Armyinvestigation of military health personnel reportingabuse, degradation or signs of torture. Military med-ical personnel are placed in a position of a ‘dual loy-alty’ conflict.”

Second, other categories of information obtained by clini-cians were supposedly protected by clear rules, policies,and assurances of confidentiality, thus creating a clear wallbetween clinical work and interrogations. But despite out-right denials of any breaches, clinical information wasweaponized for use against detainees in interrogations(Bloche & Marks, 2005; Buckley, Rokadiya, Kessel, Porter,& Dar, 2014; Clark, 2006; Fink, 2016; Institute on Medi-cine as a Profession, 2013; Lewis, 2004; Miles, 2004;Physicians for Human Rights, 2014). Taking advantage ofwhat they had learned either from clinical charts or in somecases directly from clinicians, some interrogators devisedtactics based on diagnoses, phobias, sources of shame, reli-gious beliefs, sexual issues, concerns for family membersfrom whom they were separated, and other vulnerabilitiesthat detainees had confided to therapists or other clinicians.

Prior to the APA’s 2018 vote, human rights organizationsand experts voiced strong opposition to this proposal. Juan

Méndez, former UN Special Rapporteur on Torture (2010–2016) and current Professor of Human Rights Law, wrotethat adopting the proposal “at this time – and risking areturn to a situation where member psychologists partici-pate in systematic human rights violations – would not onlyundermine the fundamental human rights of detainees butsignal the APA’s indifference to the protection of theirrights” (Méndez, 2018). Physicians for Human Rightswarned that this proposal “scheduled for a Council voteat the August 2018 meeting and closely monitored by thehuman rights community, would undermine APA’s hard-won position against torture and ill-treatment” (Physiciansfor Human Rights, 2018). Amnesty International USA,Human Rights Watch, the American Civil Liberties Union,the Center for Victims of Torture, Human Rights First, andfour other organizations issued a news release stating thatthey were “deeply concerned that the American Psycholog-ical Association (APA) is considering rolling back criticalprotections instituted to safeguard psychologists from com-plicity in torture and abuse and to facilitate ethical andindependent mental health care for detainees at the Guan-tánamo Bay detention center” (American Civil LibertiesUnion, 2018). They stated that the proposal “turns a blindeye to history, undermines detainee welfare, and puts psy-chologists back at risk of being asked or ordered to partic-ipate in human rights abuses.”

This controversial proposal came to a vote at APA’s 2018annual convention. BuzzFeed News (Aldhous, 2018)described what it termed an “emotional fight” leading upto “the American Psychological Association’s governingcouncil [voting]. . .against a proposal made by its militarypsychology division and backed by the body’s leaders.”LoCicero (2018) notes factors making it likely that this pro-posal and others like it will return andmay ultimately prevail.

Practicing Humility

The chronicle of APA’s continuing crisis of human rightsand ethics is by no means settled and complete (Handels-man, 2017, p. 282). Controversies continue on many fronts.For example, five psychologists whose names appeared inthe Independent Review Report filed suit in Ohio againstthe APA, David Hoffman, the law firm of which Hoffmanis a partner, and several other parties whose names andaddresses were yet to be determined. The suit focuses onallegations of “unprivileged, false and defamatory state-ments made in the report with actual malice.” An appellatecourt upheld an Ohio trial court’s dismissal of the originalsuit on jurisdictional grounds (James et al. v. Hoffmanet al., 2018). That appellate decision may itself be appealed.A second, similar suit filed by the same plaintiffs against thesame defendants in the District of Columbia (Behnke et al.



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v. Hoffman et al., 2017) has not yet been resolved. Theplaintiffs filed a third, similar suit in Massachusetts (Behnkeet al. v. Soldz et al., 2018), adding a psychologist to thedefendants named in the previous cases.

More will be revealed as these complex controversiesunfold, as the lawsuits in Ohio, Washington DC, and Mas-sachusetts progress and reach resolution, and as investigativereporters and researchers turn up new information. But the e-mails and other public and private documents from individu-als and organizations – including confidential governmentpapers which were later declassified – that have becomeaccessible so far are instructive. And we have learned fromthe fact-finding investigations by the CIA, newspaper repor-ters, human rights organizations, and others. The facts athand suggest that several principles may help bring APA’scontinuing crisis to an end and prevent future crises.

They also suggest that we need to practice humility. Ibelieve that all of us psychologists have been seeking to“do the right thing” as each understood it, though in sharpdisagreement about the best path. But events remind usthat however justly proud we are of a profession that hasdone so much good, none of us acted effectively to preventthe crisis or to resolve it. Each of us could probably think ofways that we could have put in more time, more thought, ormore effort – done some things differently – to help preventthis crisis, lessen its harm, or bring about a just resolution.Perhaps, we can think of what more we can do from now onas the crisis continues to unfold.

We can also prepare psychologists to meet future chal-lenges by making human rights a central focus of ourundergraduate, graduate, and lifelong education. “Througha structured human rights education curriculum, psycholo-gists would gain better access to knowledge and developthe necessary set of skills that would allow them to relatehuman rights to professional practice, and professionalcodes of ethics and conduct” (Experts Meeting: HumanRights Education and Fundamental Rights Awareness forPsychologists, 2016; see also Gauthier, 2009; Hagenaars,2016; LoCicero et al., 2016; McFarland, 2015; Oomen,2016; Plavšić, 2016).

Recognizing the tragic and potentially deadly conse-quences if we fail to safeguard human rights and ethics,we can remember what our own history teaches us aboutthe vital importance of the following principles:(1) The map is not the territory – prohibitions, policies,

and public statements can mislead us.(2) The power, authority, and demands of the state can

never relieve us of our individual ethical responsibili-ties or our duty to support and defend human rights.

(3) When human rights and fundamental ethics are atrisk, we must always be prepared to speak up despitethe costs, search actively for opposing views and dis-confirming information, and avoid the role of passive

bystander when whistle-blowers, critics, bearers ofbad news, or others are threatened, bullied, smeared,or attacked.

(4) We are more likely to think, speak, and write clearlywhen we avoid euphemisms, ambiguous terms, andequating “is it ethical?” with “is it effective?”

(5) If we – as organizations or individuals – allow self-interest to eclipse our ethical responsibilities to otherindividuals, specific groups, or the general public, weweaken our ability to defend – or even to recognizeand respect – human rights and ethics.

(6) Searching our own attitudes and behaviors for arro-gance can save us from countless blunders (as well asmaking life a lot easier for our friends and colleagues).If we look back at what we have written, said, and donesince this crisis began and see nothing wrong – no flaws,mistakes, or “I wish I could take that back” – it is likelywe have yet to completely master this principle.

The post-9/11 period is not the first human rights and ethicscrisis for psychologists – Geuter’s book The Professionaliza-tion of Psychology in Nazi Germany, for example, reviewedhistorical archives to reveal how “psychologists cooperatedwith the army, state, party, and industry, and yet stillseemed to believe that they were acting as reformers” ofthe Third Reich (1992, p. 284) – but if we take its lessonsto heart, include them in our formal education, and putthem into action, we may help it become the last.

Acknowledgments

After the manuscript was accepted on June 21, 2018, therewas a subsequent revision to document and discuss morerecent developments in the area of human rights and ethics(e.g., at the APA convention in August, 2018). The subse-quent revision was accepted August 28, 2018.

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Star-Ledger Editorial Board. (2015, May 4). Doctors without ethicalborders. New Jersey Star-Ledger. Retrieved from http://www.nj.com/opinion/index.ssf/2015/05/psychologists_collusion_with_the_cia_makes_your_he.html

Summary of International and US Law Prohibiting Torture andOther Ill-treatment of Persons in Custody. (2004, May 24). NewYork, NY: Human Rights Watch.

Thomas, N. K. (2016). “We Didn’t Know”: Silence and silencing inorganizations. International Journal of Group Psychotherapy,66, 492–505.

Thomas, N. K. (2017). Gaslighting, betrayal and the boogeyman:Personal reflections on the American Psychological Associa-tion, PENS and the involvement of psychologists in torture.

International Journal of Applied Psychoanalytic Studies, 14,125–132.

Umansky, E. (2014, August 8). How American journalists coveredtorture after 9/11 Coverage of the brutal practice was playeddown in print and on airwaves. Columbia Journalism Review.Retrieved from https://archives.cjr.org/feature/failures_of_imagination.php

United Kingdom Mission to the United Nations. (2018, March 1).Human Rights Council 37: Torture and Situation of HumanRights Defenders. London, UK: Author. Retrieved from https://www.gov.uk/government/news/human-rights-council-37-torture-and-situtation-of-human-rights-defenders

US Central Intelligence Agency, Inspector General. (2004). Specialreview: Counterterrorism detention and interrogation activities,Appendix C. Langley, VA: Central Intelligence Agency.

Voice of America. (2015, July 11). Report: US psychologistscolluded with torture program. Retrieved from https://www.voanews.com/a/report-us-psychologists-colluded-with-torture-program/2857739.html

Watt, S. M. (2015, August 10). Psychologists honor anti-torturewhistleblower. ACLU [Blog post]. Retrieved from https://www.aclu.org/blog/national-security/torture/psychologists-honor-anti-torture-whistleblower-government-now-its?redirect=-blog/speak-freely/psychologists-honor-anti-torture-whistle-blower-government-now-its-your-move

Wilhelm, I. (2015). Meeting of psychologists becomes a moment ofsoul searching. Chronicle of Higher Education. Retrieved fromhttp://chronicle.com/article/A-Meeting-of-Psychologists/232267

World Medical Association (WMA). (2003, June 23). Physiciansunder threat, warns WMA president. [Press release]. Retrievedfrom http://web.archive.org/web/20030715220823

Wyke, R. (2016, February 9). Global opinion varies widely on use oftorture against suspected terrorists. Washington, DC: PewResearch Center. Retrieved from http://www.pewresearch.org/fact-tank/2016/02/09/global-opinion-use-of-torture/

Zeid, R. A. (2018, February 26). Opening statement by UN HighCommissioner for Human Rights at the 37th session of theHuman Rights Council. Retrieved from http://www.ohchr.org/EN/HRBodies/HRC/Pages/NewsDetail.aspx?NewsID=22702&LangID=E

Received April 2, 2018Revision received June 20, 2018Accepted June 21, 2018Published online November 19, 2018

Kenneth S. PopePO Box 777Norwalk, CT [email protected]

Kenneth S. Pope (PhD, ABPP) is alicensed psychologist who began hisindependent practice of clinical andforensic psychology, concentratingon providing services and resourcesfor underserved groups, over 30years ago. Many of his researcharticles and books on psychologyteaching, training, and practice fo-cus on ethics. He believes that hu-man rights and ethics must be atthe heart of psychology education.



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Psychology and Its Response toMajor Human Rights AbusesThe Case of Australian Immigration Detention

Ryan Essex1,2,3

1Sydney Health Ethics, School of Public Health, The University of Sydney, Australia2APNS, Faculty of Education and Health, The University of Greenwich, London, United Kingdom3Bart’s Health NHS Trust, London, United Kingdom

Abstract: Australian immigration detention has been criticized both domestically and internationally for the harm that it creates andpromotes and for violating human rights and international law. Psychologists have worked within centers and have thus been central to theiroperation, but have also long called for reform of these policies. Despite this and despite broader criticism from all corners of Australiansociety, the government has continued to consolidate power in relation to the administration of these policies and has actively attempted toshut down dissent. How should Psychologists respond? This article will argue that current approaches are inadequate and more adversarialaction is needed. Supporting such an approach, social movement theory will be introduced and applied to examine how it may inform futureaction. Psychologists have an obligation to protect human rights and health, and while more adversarial action may not typically fit intraditional repertoires, there are few other professionals who are better skilled to begin to deal with these questions. In light of this,Psychologists in Australia and across the globe should carefully consider their roles in social change and whether they can do more in the faceof major human rights abuses.

Keywords: refugees, human rights, immigration detention, social movements, psychology

Australian Immigration Detention

In 2017, 68.5 million people were forcibly displaced. Ofthese people, 25.4million were refugees and 3.1million asy-lum seekers (United Nations High Commissioner for Refu-gees [UNHCR], 2018). Those seeking safety often facenumerous adverse experiences. In addition to a range oftraumatic experiences in their countries of origin, danger-ous journeys and protracted uncertainty in camps or thirdcountries, there has been a growing hostility toward migra-tion more generally, often from countries who are best posi-tioned to help. While this has been a global phenomenon,Australia has demanded complete impenetrability of itsborders for over two decades. Below I will discuss thesepolicies, the involvement of psychologists and how I believethey should respond.

Australian immigration detention was introduced in1992. Onshore detention centers have been maintainedsince this time, while offshore detention centers on ManusIsland (Papua New Guinea) and Nauru were introduced in2001, repealed and then re-introduced in 2012 (Phillips &Spinks, 2013). While anyone without a valid Australian visacan be detained for an indefinite amount of time, the most

punitive elements of this policy have targeted refugees andasylum seekers and particularly those who have traveled toAustralia by boat. Offshore detention was re-introducedexplicitly as a deterrent to others seeking to reach Australiaby boat (Abbott, 2013; Dutton, 2015; Morrison, 2014a,2014b, 2014c; Rudd, 2013). That is, the Australian govern-ment detains men, women, and children seeking Australia’sprotection in environments where violence, sexual andphysical abuse, self-harm, and suicide have all been welldocumented as a means of deterring others traveling toAustralia (Australian Parliamentary Select Committee,2015; The Guardian Australia, 2016). The suffering pro-duced by these policies is deliberate and completely avoid-able. This has led a number of authors to draw comparisonsbetween these policies and torture (Berger, 2016; Bouchani,2016; Doherty & Hurst, 2015; Essex, 2016d; Isaacs, 2015a;Perera & Pugliese, 2015; Sanggaran & Zion, 2016). Othershave described these policies as “state-sanctioned. . . childabuse” (Owler, 2016) and “a crime against humanity”(Doherty, 2017).

Australian immigration detention has long been criticizedby human rights organizations both domestically and inter-nationally. In late 2014, the UN High Commissioner for


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Human Rights raised concerns about Australia’s policies ofoffshore processing and boat turn-backs, noting that thesewere “leading to a chain of human rights violations, includ-ing arbitrary detention and possible torture following returnto home countries” (Al Hussein, 2014, p. 48). Shortly after,the UN Committee against Torture released its periodicreview which again cited concerns about offshore process-ing (United Nations Committee against Torture, 2014). In2015, the Special Rapporteur on torture and other cruel,inhuman, or degrading treatment or punishment found thatAustralia’s policy of offshore processing had systemicallyviolated the convention against torture, more specificallyviolating the “right to be free from torture or cruel, inhu-man or degrading treatment” (Mendez, 2015, p. 8).

For over 25 years, the government has been belligerentand combative in the face of criticism and has continuedto consolidate its power to administer these policies. Underthe Australian constitution, immigration detention is con-sidered administrative detention. That is, it is administeredby the executive rather than the judiciary. Such detention islegal as long as it is not used as a form of punishment.Despite what was outlined above, the High Court of Aus-tralia has found the indefinite mandatory detention ofmen, women, and children to be legal and not constitutepunishment (Al-Kateb v. Godwin, 2004). Since its introduc-tion, the government has expanded its power, further shut-ting out the judiciary and leaving little room for legalredress. Additionally, these policies have received supportfrom both major political parties, limiting any scope forpolitical reform, as discussed by Grewcock (2013, p. 11):

“. . .both the ruling Labor party and the oppositionLiberal-National party coalition share a mutual dis-dain for the arrival of any new boat bringing refugeesinto Australian waters, distinguishing themselvesonly by a willingness to blame the other for allowingsuch breaches of Australia’s forward defences orindulging in squabbles over the impact of govern-ment policy on refugee movements in the region.While this occasionally throws up superficial differ-ences in emphasis about how best to ‘stop the boats’,there is, fundamentally, a high level of bipartisanagreement that unauthorised refugees should bedeterred through measures such as the mandatoryand indefinite detention of all unauthorised non-citi-zens; the use of offshore processing; extensive navalinterdiction programmes; and a punitive anti-peo-ple-smuggling regime.”

Despite near legal impunity and despite the power heldover Australian immigration detention, the governmenthas also sought to limit oversight and increase secrecy inrelation to Australian immigration detention. The Border

Force Act (2015) was passed on July 1, 2015 with bipartisanpolitical support. For 15 months, it outlawed current andformer employees speaking about any aspect of theiremployment in detention. Only after ongoing protest, withthis legislation creating controversy where the governmentwanted none, was it quietly amended to allow clinicians (in-cluding psychologists) to speak out (Doherty, 2016a; Hutch-ens, 2017; Newhouse, 2015).

The Border Force Act was not the only means employedby the government to attack information they saw as unfa-vorable. Journalists have had little to no access to centers(Jabour & Hurst, 2014). The offices of contractors havebeen raided and their equipment seized in attempts to findjournalists sources (Farrell, 2015b, 2015c). The governmenthas also referred journalists and clinicians who have spokenabout the conditions within detention centers to the Aus-tralian Federal Police (Farrell, 2015a, 2016). Attacks haveextended to the Australian Human Rights Commission(AHRC). After the release of the AHRC (2014) ForgottenChildren Report, which found that “[t]he mandatory andprolonged immigration detention of children is in clear vio-lation of international human rights law” and that immigra-tion detention had “profound negative impacts on themental and emotional health of children” (p. 29), the gov-ernment called for the resignation of the Commission’sPresident, Gillian Triggs (Borrello & Glenday, 2015). Thisdisdain for human rights extends beyond Australia withthe former Prime Minister Tony Abbott attempting todeflect international criticism by suggesting that “Aus-tralians are sick of being lectured to by the United Nations”(Kozaki, 2015, p. 5).

Responses From Psychologists and theAustralian Psychological Society

Health care is provided within Australian immigrationdetention centers by a private company, InternationalHealth and Medical Services (IHMS). IHMS employs arange of healthcare professionals, including Psychologists,and has held the contract to deliver health services in immi-gration detention since 2007. Psychologists have thereforehad a central role working within immigration detentioncenters.

Delivering health care in Australian immigration deten-tion has been described as a Sisyphean task (Joint SelectCommittee on Australia’s Immigration Detention Network,2012). As can be imagined from the above introduction, inaddition to having a devastating impact on the health andwell-being of those detained Australian immigration deten-tion also changes the nature and scope of health care. Theprinciples that underpin clinical and ethical decisionmaking in more orthodox settings are either absent or


196 R. Essex, Psychology and Its Response to Major Human Rights Abuses

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compromised with this transformation going beyond simplyfalling to meet generally accepted standards of clinicalpractice (Essex, 2016a, 2016b). Psychologists (and otherclinicians) have long documented the near futility of provid-ing care in these environments. This mental health profes-sional was quoted during the Australian Council of Headsof Schools of Social Work People’s Inquiry (ACHSSW,2006, p. 44); little has changed since this time:

“You could have the Rolls Royce of mental healthservices in Baxter and I don’t think it would make ascrap of difference, because the environment is sotoxic that you can’t treat anything meaningfully. Ithink that half a dozen of the most damaged peoplethat I’ve ever seen are the adults that I’ve seen inBaxter and Woomera, both parents and single men.The thing is that it is all caused by being in detention.Provided you get them in time, you take these peopleout of detention and they’re not depressed any more.Of course the interpretation of that from DIMA is tosay they’re putting it on, “Isn’t it convenient for them,the thing that was going to cure them from theirdepression is taking them out of detention.” The rea-son it’s going to cure them is because detention is aplace that drives people mad and yeah, they wantto get out of the place that is driving them mad.”

Psychologists have also taken action outside of detention.The inadequacy of simply working within the system hasnot gone unrecognized. This action has taken a range offorms but broadly has included protest, advocacy, research,and whistle-blowing (Doherty, 2016b; Tazreiter, 2013). Psy-chologists have formed a small but important part of a lar-ger chorus of criticism outside of detention and in callingfor broader social and political change.

Along with a range of other professional healthcare bod-ies, the Australian Psychological Society (APS) has alsocalled for change. The APS (2011) Position Statement onthe Psychological well-being of refugees and asylum seek-ers in Australia, like statements from other bodies, setsout to do at least two things, makes explicit the positionof the APS and provide guidance in relation to these issues.The APS calls on the Australian government to meet itshuman rights obligations and uphold the fundamental rightof refugees to seek protection. It calls for immigrationdetention to be used only as a short-term option and notin offshore or remote locations. The APS opposes the deten-tion of children. They have also notably framed their posi-tion statement more broadly than other professional bodies,avoiding the discussion of how clinicians should managethe dilemmas faced while working within immigrationdetention. The position statement instead raises concernsabout the impact of xenophobia and racism, along with

their consequences for health and well-being. The APS callsfor national debates on policies such as immigration deten-tion and for the government to refrain from actions andcomments that inflame negative sentiments toward refu-gees and asylum seekers. They also promote Psychologiesrole in assisting Australian residents in adjusting andresponding to refugee migration (e.g., understanding contri-butions refugees make, developing awareness of humanrights obligations, de-bunking myths and misperceptions,and assisting them with any concerns) and promoting com-munity-level responsibility for positive inter-ethnic relation-ships, understanding, collaboration, and unity.

The Need to for an Adversarial Approach

The first and most obvious reason as to why Psychologyneeds to reflect on its current approach to Australian immi-gration detention is that people remain detained, peoplecontinue to suffer, and the Australian government remainsrecalcitrant. Psychologists also remain central to the opera-tion of these centers. Another reason is that Psychologistsare too often involved in human rights abuses. Even recenthistory shows, responses from Psychologists and profes-sional bodies have not only been inadequate, they haveresulted in collusion with abuses (Boyd, 2015).

What can be learnt from Australian Psychologists’engagement with these policies over the last two decades?First, little will be achieved from working within the system.This is well established. This is not to say that Psychologistsshould not be involved (and the debate in relation to a boy-cott is beyond the scope of this article; e.g., Berger & Miles,2016; Essex, 2018; Jansen, Tin, & Isaacs, 2017; Sanggaran,2016); however, such involvement is unlikely to lead to jus-tice or redress for the many and ongoing rights abuses. Thisis why it is encouraging that the APS has framed its positionstatement broadly, debates are needed, racism and xeno-phobia are a problem, and Psychologists should have aleading role in public discourse. However, simply callingfor change often does little to remedy these issues. In fact,discussion on what to do, particularly in the face of a recal-citrant government, has evolved little beyond McNeill’s(2003, p. 501) recognition of this fact over 15 years earlier:

“The acceptable public health strategies of dissemi-nating information and advocacy may not be enough.Something more is needed. Not violence – althoughthe Australian Government has resorted to it – forthe obvious reason that in resorting to violence webecome the perpetrators of harm ourselves. Rea-soned advocacy may not be sufficient. It is time fora more passionate response... These actions may gobeyond dissemination of information and reasoned


R. Essex, Psychology and Its Response to Major Human Rights Abuses 197

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advocacy, and could include any number of politicalactivities including: participating in demonstrations,direct lobbying of government members and politicalparties, and withdrawal of services.”

While since this time, demonstrations, sit-ins, protests, andwhistle-blowing have occurred, the literature has remainedrelatively stagnant in its approach, largely focusing on therole of clinicians within Australian immigration detentioncenters. While this is of course necessary and there remainsa need to support psychologists who work in these environ-ments, this appears to have largely distracted from strate-gies that deal with the complexities of social and politicaland change. Greer et al. (2017, p. 40) discuss this frustra-tion more generally:

“Numerous ‘calls to action’ exist in the literature,alongside calls for ‘political will’. Still more articlesidentify problems but offer at most policy recommen-dations that go unheard beyond our paywalls, as ifthe politicians were to blame for not reading our jour-nals and inferring what to do. This reveals a weakunderstanding of politics. Public health professionalswould not, for example, call for ‘individual will’ as asolution to obesity. Nor should we call for politicalwill as a solution to policy problems.”

In moving toward a more sophisticated approach, it is use-ful to turn to a distinction drawn by Raphael (2009) whosuggests two possible avenues for action, “professionally-oriented rational or knowledge-based approaches” and “so-cial and political movement-based materialist or politicaleconomy-oriented approaches” (p. 145). Professionally ori-ented approaches entail “research, knowledge dissemina-tion, and public policy advocacy with the aim ofconvincing policymakers to enact health-supporting publicpolicy” (p. 160) and assume that governments will bereceptive to ideas, whereas a movement-based approachrecognizes powerful interests may be resistant to such ideasand “suggests the need for developing strong social andpolitical movements with the aim of forcing policymakersto enact health-supporting public policy” (p. 160). Raphael(2009) argues that a movement-based approach is moreeffective when attempting to shift “liberal political econo-mies” (p. 161).

Given the circumstances found in Australia, in particularthe limited avenues for legal and political redress, includingthe governments’ recalcitrant attitude, a movement-basedapproach should be pursued. Psychologists (and otherhealthcare professionals) should re-orient their approachaccordingly. Some clinicians have already taken suchaction. It was only recently that a boycott was debated, inlarge part because it appeared as though all other options

had been exhausted (Berger & Miles, 2016; Essex, 2016c;Jansen et al., 2017; Sanggaran, 2016). Doctors have alsobeen involved in civil disobedience and disruption (Essex& Isaacs, 2018; Isaacs, 2015b). While Professional bodieshave typically supported such action, there has been areluctance to fully embrace more adversarial approach withlittle leadership in this area (Laughland & Davey, 2014; Safi& Farrell, 2015). Often overlooked as it relates to Australianimmigration detention, the social movements literature hasthe scope to not only better explain how Australian immi-gration detention is currently approached, but also assistsin applying these lessons to future responses.

Protest and Social Movements

Social movements form in the face of injustice and recog-nize that change must be fought for. Social movementscan be defined as “collective challenges, based on commonpurposes and social solidarities, in sustained interactionwith elites, opponents, and authorities” (Tarrow, 2011, p.9). In short, social movements are collective sustainedaction that attempt to bring about social, cultural, or politi-cal change (Della Porta & Diani, 2009, 2015; Martin, 2015).The relationship between human rights and social move-ments goes beyond simple legal aspirations, with this rela-tionship best summarized by Nash (2015, p. 11):

“Social movements have a crucial role to play in con-structing human rights if they are to be realized inpractice. Rights are never effective simply becausethey are legal rights. Enjoying human rights in prac-tice depends on how people use them—on what theyclaim, and how they make rights claims. This, in turn,depends on collective identity, on the pressure thatpeople bring to bear because they have a “right torights”—even where they do not have rights in law,or law is administered unjustly. . . Collective actionis needed at every level if human rights are to makea real difference. Grassroots organizing is necessaryif people are to be able to define human rights inways that are appropriate to dealing with the injus-tices they face.”

The social movements literature is large and diverse, theo-rizing all aspects of movements including the action theyemploy, how the gain and galvanize support and how theyrespond to political threats and opportunities (Tarrow, 2011,2013). While Australian immigration detention has galva-nized a number of social movements and has been one ofthe most contentious political issues in Australia, the litera-tures on these respective topics have rarely met. Exceptionsinclude Tazreiter (2010) who provides a descriptiveaccount of social movements in response to the Howard



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government in Australian from 1996 to 2007 and Gosden(2006) who also examines the rise of an asylum seekerand refugee advocacy movement. There is scope for greaterengagement with this literature and a need to connect it toaction that has already been undertaken. There are a num-ber of reasons for this, but most importantly because it pro-vides a foundation on which future action can be evaluatedand planned.

More specifically, how could social movement theoryinform a response to Australia’s policies? Social movementtheory first and foremost provides a more sophisticatedvocabulary to describe social and political action. It movesbeyond describing a lack of political will or a simple reper-toire of action, identifying important elements of move-ments and introducing concepts such as politicalopportunities, threats, and cycles of contention.

Social movement theory allows for reflection on the typeof action employed and the reasons for doing so. Move-ments do not simply cycle through action, moving fromone action to the next until something works. Civil rightswere not won by simply staging boycotts. Movementsemploy a range of action, all of which have differentimpacts, but that also come with different trade-offs. Dis-ruptive action, for example, while drawing attention to acause, may only serve to further polarize those on eitherside of the debate. This is perhaps best evidenced by refu-gee protest within detention (Fiske, 2013, 2016). While itmay garner sympathy from those who already support morehumane policy, others have used refugee protest to rein-force their position that such protest is one of the reasonswhy detention is needed. More contained action, which islikely to attract less committed supporters, and thus, largernumbers, while less risky, may simply go unnoticed. Forexample, the recent Palm Sunday rallies across Australia,while large, failed to garner any significant media attention(SBS News, 2018). Beyond this, social movement theoryalso explores how movements organize and network, howthey frame their grievances and utilize emotion to gainnew supporters and galvanize existing support, and howthey exploit political opportunities and respond to politicalthreats. Below two recent examples that touch upon manyof these areas are discussed through the lens of socialmovement theory.

Whether action is successful or not depends on a rangeof external factors, some more controllable than others.For example, (and as was briefly discussed above) afterthe AHRC Forgotten Children Report (2014) was releasedthe government went on the attack, calling for the resigna-tion of the then Commissioner, Gillian Triggs (Borrello &Glenday, 2015). This report, while shocking, said little thatwasn’t already known about the impact that detention hadon children and families. So why was there such a vitriolicreaction that inevitably increased the profile of this report?

There were a number of external factors that explain this.The government at the time was defensive, attempting tojustify their policies against ongoing reports of violence,assault, riots, self-harm, and suicide. The then Prime Min-ister was particularly sensitive to criticism, blaming the cur-rent circumstances on the previous government and evendismissing international calls for reform (Kozaki, 2015).This report came at a time when the government wasactively attacking the credibility of alleged whistle-blowersand was soon to pass the Border Force Act (Doherty &Davidson, 2016; Farrell, 2015b, 2015c). The focus of thisreport was also a more vulnerable group (children and fam-ilies) where public emotions could more easily be tapped.Thus, it was not the report itself which added anythingshockingly new to the debate, but a range of external fac-tors that led to this report gaining significant attention.Through the lens of social movement theory, the govern-ments’ particular sensitivity to criticism could be seen asan opportunity, to further highlight the harms of these poli-cies and generate further pressure. While protests ensuedafter the release of this report and children were eventuallyreleased from detention in May 2016 (Department ofImmigration and Border Protection [DIBP], 2016), onecan only speculate the impact of a more coordinated action.

Another important and relatively impactful campaignwas the #LetThemStay campaign (Hall et al., 2018) whichwas launched in February 2016. National protests werestaged against the transfer of 267 asylum seekers, including54 children and 37 infants, from Australia to Manus Island(in Papua New Guinea) and Nauru. This action occurred atthe same time of a High Court challenge into the legality ofoffshore detention and a hospitalized infant who becameknown as Baby Asha (Essex & Isaacs, 2018). Flown to Bris-bane after being accidentally burnt, doctors at Lady CilentoHospital in Brisbane refused to discharge her to be returnedto Nauru. The media promoted this case and a protestmobilized outside of the hospital around the clock for 10days, placing the government under increasing pressureto honor the doctors refusal to discharge (Hall et al.,2018). A number of things can be learnt from this case. Likethe AHRC Report, a political opportunity was exploited.However, most importantly in this case, this opportunitywas communicated to others, the media and those alreadysympathetic to this cause. This only further leveraged thedoctors, power in refusing to discharge. What this examplealso shows is that without the media or the mobilization ofthe broader #LetThemStay campaign, the actions of thesedoctors may have gone unnoticed. This is a particularlyimportant point; clinicians have often effectively leveragedtheir already powerful positions by engaging with themedia. Doctors4Refugees are another organization whohave taken similar steps. Doctors4Refugees President BarriPhatarfod provided this account:



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“One of the first cases we successfully advocated forwas that of an 11-year-old boy who sustained a doublefracture of his forearm when he fell off his bicycle inNauru in 2015. The hospital plastered it up and senthim on his way, but after two weeks when he still expe-rienced debilitating pain his mother contacted us withhis X-rays. Doctors for Refugees obtained the opin-ions of various Australian specialists, including paedia-tricians, orthopaedic surgeons, radiologists andemergency physicians, who all reached the same con-clusion: this boy needed an urgent surgical repair(ORIF) to avoid permanent disability and that the timeto do this had almost passed. When the ImmigrationDepartment essentially fobbed us off, with the permis-sion of the boy’s mother we went to the media – com-plete with the X-ray. The result was quite astounding.Within a week the Government flew an Australianorthopaedic surgeon (and an entire operating theatre)to Nauru to do the requisite surgery on this youngboy. The absurdity of this expense aside, this appearedto be a successful outcome and almost immediatelyour group was inundated with requests from othersto similarly assist them” (Phatarfod, 2018, pp. 15–16)

Before moving forward, there are some potential criticismsthat should be addressed. The first being that more adver-sarial action, to this point, has not led to change. Australia’spolicies remain, rights violations are ongoing, and even inthe case of Baby Asha, the family was eventually returnedto Nauru (Hall et al., 2018). This is of course a reasonableposition to take; however, it should also be said that othermovements that have historically (and many to this day)pushed for equality and justice, such as the civil rightsmovement, feminist movements, the anti-apartheid strug-gle in South Africa, have all demonstrated that socialchange does happen, but often over long periods of timeand in a nonlinear fashion. Social movement theory is thusnot a silver bullet, it does not offer immediate solutions or ablueprint for success.

Why should Psychologists engage in such action? Firstthere is a moral case. The harms of this system and the gov-ernment’s refusal to act on evidence have already been out-lined; few would deny that these circumstances areexceptional. Psychologists have also played a central rolein allowing this system to function, providing health carewithin centers. They thus have a particular responsibilityto take action, which is only amplified by the close relation-ship between health, human rights, and justice. There isalso another good reason. There is substantial empiricalevidence concerned with social change and collectiveaction, most of which has come from psychologicalresearch. There are few other professionals who are betterskilled to begin to deal with these questions. Psychologists

should be familiar with how emotions, beliefs, and behav-iors impact attitude and how these may be shifted. Thereis a growing body of work that has examined strategies tochallenge prejudice and build community cohesion and ulti-mately solidarity with refugees and asylum seekers (Suba-šić, Reynolds, & Turner, 2008). Other research hasfocused on collective action (Louis, 2009) including whypeople engage in (Fielding, McDonald, & Louis, 2008; Tho-mas & Louis, 2013; Thomas, McGarty, & Mavor, 2009b)and persevere with collective action (Thomas, McGarty,& Mavor, 2009a). Research has also explored the impactof different types of collective action (Thomas & Louis,2014), how objectives (or demands) are shaped and pur-sued (Blackwood & Louis, 2012) and how social move-ments network and organize (McGarty, Thomas, Lala,Smith, & Bliuc, 2014). Closely related to the #LetThemStaycampaign above, there is also a substantial literature whichhas examined the role of the media in creating and shapingopinion related to asylum seekers and refugees (McLaren &Patil, 2016). Such breadth of research in this area re-enforces the moral responsibility to take action. Addition-ally, it also puts Psychology is a position to respond withaction that is based on theory and evidence.

Beyond Australian immigration detention and Australianpsychologists, the social movements literature has broaderrelevance. Migration throughout Europe has becomeincreasingly contentious with governments taking increas-ingly harsh measures to stop people crossing borders(Walker, 2018a). Immigration detention has also prolifer-ated, increasingly become the go-to option for many states(Blomfield, 2017; Bosworth & Fili, 2016; Mainwaring,2016). Furthermore, European governments or those seek-ing power have expressed a growing disdain for the rightsof migrants and for those defending them (Walker,2018b). More generally, throughout Europe and globally,at a time which has been characterized by the growth ofpopulism and xenophobia (Roth, 2017) and where evidenceand reasoned argument appear to be under increasingthreat, Psychology is well positioned to take a central rolein fighting for health, justice, and human rights.

Conclusions

Psychologists can and should engage in more adversarialaction in the face of human rights abuses, particularly whenthose in power are unwilling to listen and other more ortho-dox forms of action have been exhausted. This applies notjust in Australia but globally. While in this article Iexpressed skepticism about calls to action, this conclusionis, somewhat ironically, just that. This call to action how-ever should only be the beginning with substantial scope



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to further our understanding of how Psychologists may con-tribute to social change. A more sophisticated understand-ing and engagement with politics is needed as is a shift inhow Psychology views itself in the face of authority. Futurework should also be informed by history; one does not haveto look far for a repentant literature that attempts to makesense of atrocities in which psychology has played a part.And finally, for those outraged, take to the streets, considerhow your skills may be used be used in combatting humanrights abuses and in pursuing the greater good.

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HistoryReceived April 4, 2018Revision received December 19, 2018Accepted January 10, 2019Published online June 14, 2019

AcknowledgmentsI would like to thank Chris Jordens and Angus Dawson for theirfeedback and guidance.

FundingNo funding was received for this article.

Conflict of InterestThere are no conflicts of interest.

Ryan EssexSydney Health EthicsLevel 1, Building 1Medical Foundation Building K25The University of SydneySydney, NSW [email protected]

Ryan Essex is a Psychologist and PhDCandidate at Sydney Health Ethics,The University of Sydney.



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CommentaryUS Attitudes Toward Torture

Commentary on Kenneth S. Pope, 2019(https://10.1027/1016-9040/a000341)

David J. Armor and Jeremy D. Mayer

Schar School of Policy & Government, George Mason University, Arlington, VA, USA

A recent essay by Kenneth Pope (2019, published online-first November 2018) addresses major ethical and humanrights issues facing the APA over its past involvement inUS policies promoting prisoner torture. This commentarydoes not address the broader principles of professionalethics for psychologists. Rather, we are concerned aboutone portion of the Pope essay which argues that “. . .onehuman rights violation – torture – continues to gain widersupport” (Pope, 2019, p. 181). In the next paragraph hestates, “This growing public support for torture provides acontext for the APA’s human rights and ethics crisis.”

Pope supports his argument with several citations,including a Roper Center article in 2015 (Roper Centerfor Public Opinion Research, 2015, March 6) and a studyon this topic by Mayer and Armor published in 2012. TheMayer and Armor paper uses most of the data points usedin the Roper Center article, starting with a Pew poll in July2004 showing that 42% of Americans agree that torturecan often or sometimes be justified for suspected terrorists.That support increased somewhat over the next 5 years,with some ups and downs, until late 2009 when anotherPew poll found support had reached 54%, for an overallgain of 12% points. Our characterization was that “publictorture has increased over time, although not dramatically.”

The 2015 Roper Center article adds two more data pointsfor this trend analysis, one in 2012 and one in 2015 (seeFigure 1). However, the actual level of support is not pro-vided for the 2009 and 2012 poll, which is 54% and 53%,respectively. Understandably, a casual observer might seean increasing trend. A more accurate characterization ofthe trend is increasing support for torture between 2004and 2009 and then slightly declining support for torturebetween 2009 and 2015. In the comparative context, theUS is an outlier among developed democracies in its levelof public support for torture, but there’s little reason to think

it is becomingmore so (Mayer & Koizumi, 2017). We favor acharacterization that the US public is pretty much dividedinto two relatively stable camps when it comes to supportof torture, and it has been divided for some time.

Perhaps more important, when one examines correlatesof support, political party is the strongest single predictor,and it is about twice as strong as the second strongest pre-dictor, political ideology. Over the past several decades,there has been a deep partisan divide between Democratsand Republicans on many issues, particularly what mightbe called “law & order” issues. For example, similar divi-sions have been observed in the US over gun control,border security, and support of strong police enforcement.

Seen in light of other political controversies in the US, thepublic opinion divide on torture is neither growing norexceptional, which may or may not explain ideologicaldivisions in professional associations.

References

Mayer, J. D., & Armor, D. J. (2012). Support for torture over time:Interrogating the American public about coercive tactics. TheSocial Science Journal, 49, 439–446. https://doi.org/10.1016/j.soscij.2012.10.001

Mayer, J. D., & Koizumi, N. (2017). Is there a culture or religion oftorture? International support for brutal treatment of sus-pected terrorists. Studies in Conflict & Terrorism, 40, 758–771.https://doi.org/10.1080/1057610X.2016.1235352

Pope, K. S. (2019). A human rights and ethics crisis facing theworld’s largest organization of psychologists: Acceptingresponsibility, understanding causes, implementing solutions.European Psychologist, 24, 180–194. https://doi.org/10.1027/1016-9040/a000341

Roper Center for Public Opinion Research. (2015, March 6). Apublic divided: Americans’ attitudes about torture. New York,NY: Author. Retrieved from https://ropercenter.cornell.edu/a-public_divided_americans_attitudes_about_torture/


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HistoryReceived December 16, 2018Accepted December 19, 2018Published online June 14, 2019

David J. ArmorSchar School of Policy and GovernmentGeorge Mason University3351 Fairfax Dr.Arlington, VA [email protected]

Jeremy D. MayerSchar School of Public PolicyGeorge Mason University3351 Fairfax Dr.Arlington, VA [email protected]

Figure 1. American’s belief about whether torture is justified (adapted with permission from Roper Center for Public Opinion Research, 2015).


Commentary 205

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CommentaryHas US Support for Torture Continuedto Increase? Reply to David J. Armorand Jeremy D. Mayer, 2019Kenneth S. Pope

Norwalk, CT, USA

I wish to thank David Armor and Jeremy Mayer – two of themost respected and influential researchers of attitudestoward torture – for providing such a thoughtful and well-documented commentary (Armor & Mayer, 2019) on myarticle (Pope, 2019).

Before discussing our point of disagreement, I’ll com-ment on one of our areas of agreement. Armor and Mayernote that “the US is an outlier among developed democra-cies in its level of public support for torture” (2019, p. 204).The surveys cited in my article show that the US is indeedan outlier and is among a handful of countries (includingNigeria, Kenya, Israel, Lebanon, and Uganda) with the lar-gest percentage of support for torture. This significantlystronger support for torture relative to most other countriesseems an important context for understanding the Ameri-can Psychological Association’s continuing human rightsand ethics crisis.

Armor and Mayer question my view that torture contin-ues to gain support in the US. They write that “a more accu-rate characterization of the trend is increasing support fortorture between 2004 and 2009 and then slightly decliningsupport for torture between 2009 and 2015” (p. 204) andthat “the public opinion divide on torture is neither growingnor exceptional” (p. 204). I respectfully disagree. The data,in my view, suggest that US support for torture has contin-ued to grow rather than peaking around 2009 and thenremaining at that level or declining slightly. For example,Payne wrote in Harvard Political Review:

“With a heightened sense of anxiety created by terrorattacks in San Bernardino, Paris, and Brussels, publicsentiment against enhanced interrogation techniqueshas shifted. In March [2016], 63 percent of Ameri-cans polled responded that they believe torture is‘often’ or ‘sometimes’ justified. This represented an18 percent increase since Amnesty International con-ducted a similar poll in 2014.” (Payne, 2017)

Future surveys will give us a better grasp on whether find-ings such as this 18% jump in US acceptance of torture from2014 to 2016 represent a continuing upward pattern asopposed, for example, to a temporary rise that will fall backtoward 2009 or 2014 levels.

Whether US support for torture has stayed stable since2009 or has expanded since that time and continues tospread, the surveys from 2009 forward show alarminglyhigh support for torture, higher in the US than in all butfew other countries. This exceptionally strong US supportfor torture, a violation of human rights, provides contextfor and underscores the urgency of addressing the continu-ing human rights and ethics crisis facing the American Psy-chological Association (Pope, 2019).

References

Armor, D. J., & Mayer, J. D. (2019). US attitudes toward torture:Commentary on Kenneth S. Pope, 2019. European Psychologist,24, 204–205. https://doi.org/10.1027/1016-9040/a000366

Payne, H. (2017, January 10). Surprising changes in public views ontorture, immigration. Harvard Political Review. Retrieved fromhttp://harvardpolitics.com/united-states/surprising-changes-public-views-torture-immigration/?mc_cid=1a196cd1fc&mc_eid=9cb265aff7

Pope, K. S. (2019). A human rights and ethics crisis facing theworld’s largest organization of psychologists: Acceptingresponsibility, understanding causes, implementing solutions.European Psychologist, 24, 180–194. https://doi.org/10.1027/1016-9040/a000341

Received March 22, 2019Published online June 14, 2019

Kennth S. PopePO Box 777Norwalk, CT [email protected]

European Psychologist (2019), 24(2), 206 � 2019 Hogrefe Publishinghttps://doi.org/10.1027/1016-9040/a000374

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EFPA News and ViewsMeeting Calendar

June 4–6, 2019

World Anti-Bullying Forum – WABFDublin, IrelandContact: https://wabf2019.com/

June 5–7, 201919th International Conference onDiversity in Organizations, Com-munities & NationsPatras, GreeceContact: https://ondiversity.com/2019-conference/call-for-papers

June 14–16, 201916th ESTSS Conference – Traumain TransitionRotterdam, The NetherlandsContact: Europe for Traumatic StressStudies, https://estss2019.eu/

June 20–22, 201926th International Conference ofEuropeanists Sovereignties inContention: Nations, Regions andCitizens in EuropeMadrid, SpainContact: https://councilforeuropeanstudies.org/conferences/upcoming-conferences/2019-conference

June 25-26, 2019ICHRHS 2019: International Con-ference on Human Rights andHuman SecurityParis, FranceContact: https://waset.org/conference/2019/06/paris/ichrhs

July 2–5, 2019XVI European Congress ofPsychologyMoscow, RussiaContact: https://ecp2019.ru

July 4–6, 201918th International Forum on Moodand Anxiety Disorders – IFMADVienna, AustriaContact: http://www.ifmad.org/2019/

July 7–10, 201915th European Conference on Psy-chological AssessmentBrussels, BelgiumContact: https://ecpa15.com/

August 8–11, 2019127th Annual Convention of theAmerican Psychological AssociationChicago, IL, USAContact: http://www.apa.org/convention

September 3–7, 2019European Health PsychologySociety – Annual ConferenceDubrovnik, CroatiaContact: https://2019.ehps.net/

September 11–14, 201910th Conference of the EuropeanFamily Therapy Association (EFTA)Naples, ItalyContact: https://www.efta2019naples.org/

September 16–17, 2019Aging & Social Change: NinthInterdisciplinary Conference –

University of ViennaVienna, AustriaContact: http://agingandsocialchange.com/2019-conference/call-for-papers

August 6–9, 2020128th Annual Convention of theAmerican Psychological Asso-ciationWashington, DC, USAContact:http://www.apa.org/convention

� 2019 Hogrefe Publishing European Psychologist (2019), 24(2), 207https://doi.org/10.1027/1016-9040/a000375

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European Federation ofPsychologists’ AssociationsWhat is EFPA?

EFPA is the leading Federation of National PsychologistsAssociations. It provides a forum for European cooperation in awide range of fields of academic training, psychology practiceand research.

There are 37 member associations of EFPA representing about300,000 psychologists.The member organizations of EFPA are concerned with promo-ting and improving psychology as a profession and as adiscipline, particularly, though not exclusively, in applied settingsand with emphasis on the training and research associated withsuch practice.

The psychologists in the member associations include practi-tioners as well as academic and research psychologists.

The Federation has as one of its goals the integration ofpractice with research and the promotion of an integrateddiscipline of psychology.

What EFPA Does

• Representation, advocacy, and lobbying at European level• Promotion of psychology education, research and profession• EuroPsy certification• Test User Accreditation• Support for Member Associations• European projects• Advice on professional affairs, work areas, new developments• Publicity and information sharing• European Congress of Psychology• European Psychologist (Official Organ of the EFPA, http://

www.hogrefe.com/j/ep)• The EFPA News Magazine (http://efpa.magzmaker.com/)

EFPA Membership

Membership is open to the national psychologist association ofall European countries but there may be only one memberassociation per country. EFPA has no individual members.

In countries where there is more than one national psychol-ogist association, the Federation should endeavour to identify themost representative organization and, if appropriate, encouragethe development of a national federation in order to promote co-operation among psychological associations.

Membership is determined by the General Assembly uponpresentation of the applicant association’s articles, statutes, andcode of ethics plus details of the membership (see EFPA StatutesArticle 5).

As a European federation representing the interests ofpsychologists in Europe, EFPA is committed to making contactwith member associations of psychologists from Europeancountries, which are not yet members of EFPA.

This is particularly the case in relation to psychologists’associations from countries in the east of Europe, with whomEFPA is concerned to make contacts, to share information and topromote collaboration.

A member of the EFPA Executive Council has responsibility fordeveloping these links and contacts, and the EC will attempt tohelp to support initiatives.

A full list of all EFPA members associations can be found athttp://www.efpa.eu/members

A full list of all EFPA associate members can be found athttp://www.efpa.eu/associate-members

European Psychologist

Members of EFPA Member Associations and other Europeanpsychology organizations supporting the European Psychologistare entitled to a special subscription rate of

149.00 per year

The European Psychologist is published quarterly. Only calendaryear subscriptions are available. Prices exclude shipping andhandling charges. All subscriptions include print issues andaccess to full-text online.

EFPA Executive Council (EC)

President: Telmo Mourinho Baptista (2015-2019)Vice President /Secretary General: Robertas Povilaitis (2011-2019)Vice President /Treasurer: Christoph Steinebach (2011-2019)EC Member: Tor Levin Hofgaard (2011-2019)EC Member: Eleni Karayianni (2015-2019)EC Member: Josip Lopizic (2017-2021)EC Member: Bruna Zani (2015-2019)

EFPA Head Office Brussels

Director: Sabine SteyaertOffice Manager: Julie Van den BorreManagement Assistant: Valerie BoniManagement Assistant: Ivana MarinovicCommunicationCoordinator: Ruth Mozagba

EFPA Head OfficeGrasmarkt 105 / 391000 BrusselsBelgiumTel.: +32 2 503-4953Fax: +32 2 503-3067E-mail: [email protected] http://www.efpa.eu/

For further information on EFPA events please visit theEFPA website: http://www.efpa.eu/allevents

European Psychologist (2019), 24(2), 208 � 2019 Hogrefe Publishing

208 EFPA News and Views

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Instructions to Authors- European PsychologistEuropean Psychologist is a multidisciplinary journal that serves asthe voice of psychology in Europe, seeking to integrate across allspecializations in psychology and to provide a general platform forcommunication and cooperation among psychologists throughoutEurope and worldwide.

European Psychologist publishes the following types of articles:Original Articles and Reviews, EFPA News and Views.

Manuscript Submission: Original Articles and Reviewsmanuscripts should be submitted online at http://www.editorialmanager.com/EP. Items for inclusion in the EFPA New and Viewssection should be submitted by email to the EFPA News and Viewseditor Eleni Karayianni ([email protected]).

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Copyright Agreement: By submitting an article, the authorconfirms and guarantees on behalf of him-/herself and anycoauthors that he or she holds all copyright in and titles to thesubmitted contribution, including any figures, photographs, linedrawings, plans, maps, sketches and tables, and that the articleand its contents do not infringe in any way on the rights of thirdparties. The author indemnifies and holds harmless the publisherfrom any third-party claims. The author agrees, upon acceptanceof the article for publication, to transfer to the publisher on behalfof him-/herself and any coauthors the exclusive right to reproduceand distribute the article and its contents, both physically and innonphysical, electronic, and other form, in the journal to which ithas been submitted and in other independent publications, withno limits on the number of copies or on the form or the extent ofthe distribution. These rights are transferred for the duration ofcopyright as defined by international law. Furthermore, the authortransfers to the publisher the following exclusive rights to thearticle and its contents:

1. The rights to produce advance copies, reprints, or offprints ofthe article, in full or in part, to undertake or allow translationsinto other languages, to distribute other forms or modifiedversions of the article, and to produce and distributesummaries or abstracts.

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3. The rights to store the article and its content in machine-readable or electronic form on all media (such as computerdisks, compact disks, magnetic tape), to store the article andits contents in online databases belonging to the publisher orthird parties for viewing or downloading by third parties, and topresent or reproduce the article or its contents on visualdisplay screens, monitors, and similar devices, either directlyor via data transmission.

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Online Rights for Journal Articles: Guidelines on authors’ rightsto archive electronic versions of their manuscripts online aregiven in the document ‘‘Guidelines on sharing and use of articlesin Hogrefe journals’’ on the journals’ web page at http://www.hogrefe.com/j/ep

November 2016

� 2019 Hogrefe Publishing European Psychologist (2019), 24(2)

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www.hogrefe.com

Ingrid Lunt / José Maria Peiró / Ype Poortinga / Robert A. Roe

EuroPsyStandards and Quality in Education for Professional Psychologists

2015, xiv + 218 pp. US $34.80 / € 24.95 ISBN 978-0-88937-438-6 Also available as eBook

EuroPsy has been accepted and ad-opted as the European standard for education and training in psychology by EFPA. This book, written by its initiator and leading members of the working groups that set EuroPsy up, is the only comprehensive text avail-able about this European bench-mark. It first reviews the development of EuroPsy in the historical context of psychology as science and profession and policies for higher education set by international bodies, and in particular the European Union.

This handbook then goes on to ad-dress the curricula of university

courses and programmes following from the Bologna Agreement, the flexibility allowed to reflect diversity in Europe, licencing and accredita-tion, and benchmarking, as well as other prerequisites for meeting the EuroPsy standards. These include the use of a competence model to assure professional standards, supervision, continued professional development, supervision, and ethics.

Finally, the authors examine the cur-rent and future role of EuroPsy in psychology in Europe, including practical examples of how it has been applied in practice.

The European standard and benchmark for education and training in psychology

“This book is right now a landmark in current analyses of the profession.”Roger Lécuyer, Emeritus Professor in Developmental Psychology. University Paris Descartes, France

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“It is the bene� ts that our productscan bring, both for individualsand for society, that spur us on.”

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Alexander Thomas (Editor)

Cultural and Ethnic DiversityHow European Psychologists Can Meet the Challenges

2018, x + 222 pp. US $56.00 / € 44.95 ISBN 978-0-88937-490-4 Also available as eBook

Culture and diversity are both chal-lenge and opportunity. This volume looks at what psychologists are and can be doing to help society meet the challenges and grasp the opportuni-ties in education, at work, and in clin-ical practice. The increasingly international and globalized nature of modern societies means that psy-chologists in particular face new challenges and have new opportuni-ties in all areas of practice and research.

The contributions from leading Euro-pean experts cover relevant intercul-tural issues and topics in areas as

diverse as personality, education and training, work and organiza-tional psychology, clinical and coun-selling psychlogy, migration and international youth exchanges.

As well as looking at the new chal-lenges and opportunities that psy-chologists face in dealing with people from increasingly varied cultural backgrounds, perhaps more impor-tantly they also explain and discuss how psychologists can deepen and acquire the intercultural competen-cies that are now needed in our pro-fessional lives.

Cultural diversity – challenge and opportunity

“It’s a book that we were all waiting for, and will be useful not only to psychologist practitioners and students, but also to stakeholders and policy makers in education.”Bruna Zani, Professor of Social and Community Psychology, Department of Psychology, Alma Mater Studiorum-University of Bologna, Bologna, Italy; EFPA Executive Council Member

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