HW

Knowing Your Values

Learning Objectives

1. Describe how helper values operate in the counseling process.

2. Discuss the ethical issues involved in imposing helper values.

3. Explain the reasons a referral is not an answer for resolving value conflicts.

4. Explain the implications of significant court cases on value conflicts.

5. Identify ways oppression and discrimination are associated with sexual orientation.

6. Explain how values are sometimes related to gender-role identity.

7. Discuss the role of spiritual/religious values in the helping process.

8. List several guidelines for dealing with end-of-life issues.

Focus Questions

1. To what degree are you aware of your core values and how they could affect the way you work with clients?

2. Is it possible for you to interact with clients without making value judgments? Do you think it is ever appropriate to make value judgments? If so, under what circumstances?

3. Can you be true to your own values and at the same time respect your clients’ choices, even if they differ from yours?

4. Do you tend to influence your friends and family regarding “right” choices? If so, what are the implications for the way you are likely to function as a helper?

5. To what extent can you support clients in making their own decisions, even if you believe they would be better served by following a different path?

6. What key values do you believe are essential to the helping process? How would you communicate these values to your clients?

7. Why do you think the imposition of a counselor’s values is an ethical issue?

8. What is one particular value you might find challenging in your work with clients?

9. What do you think is involved in counselors managing their values as they work with a diverse range of clients?

10. Do you think a referral is ever an ethical answer in resolving a value conflict

with a client? 69

The helping professions involve value-laden processes. We must respect our clients’ worldview and understand their value system to be of help to them and to be agents of change and empowerment. Even if we hold a very different set of values, our ethical obligation is to assist clients in meeting therapeutic goals consistent with their worldview and values, not our own. It is our clients who

have to live with the consequences of the changes they make in counseling, not us.

To assist you in clarifying your values and identifying ways in which they might interfere with effective helping, we describe a range of practical situations you may encounter. Value issues pertaining to multicultural populations are of special importance, and Chapter 4 is devoted to this topic. In this chapter, you are encouraged to critically evaluate the possible impact of your personal values on your clients, the effect your clients’ values may have on you, the conflicts that can arise if you and your clients have different values, and the importance of learning to effectively manage these conflicts.

Role of Values in Helping

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Values are embedded in therapeutic theory and practice. Levitt and Moorhead (2013) contend that values not only enter the counseling relationship but can significantly affect many facets of the relationship. Counselors are expected to be able to set

aside their personal beliefs and values when working with a wide range of clients. Although helpers may not agree with the values of some clients, counselors are expected to respect the rights of clients to hold their own views. Effective helpers must learn to work with a variety of clients with diverse worldviews and values.

Complete the following self-inventory as a way of focusing your thinking on the role your values will play in your work. As you read each statement, decide the degree to which it most closely identifies your attitudes and beliefs about your role as a helper. Use this code:

3 = This statement is true for me.

2 = This statement is not true for me. 1 = I am undecided.

1. I believe it is my task to challenge a client’s philosophy of life.

2. I could work objectively and effectively with clients who have values that differ sharply from my own.

3. I believe it is both possible and desirable for me to remain neutral with respect to values when working with clients.

4. Although I have a clear set of values for myself, I feel quite certain that I could avoid unduly influencing my clients to adopt my beliefs.

5. It is appropriate to express my views and expose my values as long as I do not impose them on clients.

6. I might be inclined to subtly influence my clients to consider some of my values.

7. If I discovered sharp value conflicts between a client and me, I would consider referring the client.

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9. I would not have any difficulty counseling a pregnant woman who wanted to explore abortion as one of her alternatives.

10. I have certain views pertaining to gender roles that might affect the way I counsel.

11. I would not have problems counseling a gay couple on relationship concerns.

12. I see the clarification of a client’s values as a crucial task in the helping process.

13. My view of family life would influence the way I would counsel a couple considering divorce.

14. I would have no trouble working with a woman (man) who wanted to leave her (his) children and live alone, if this is what my client decided.

15. I have generally been willing to critically evaluate my values.

16. I might be willing to work in individual counseling with a client who is in a committed relationship and is having an affair, even if the client is not willing to disclose the relationship to his or her partner.

17. I feel quite certain that I can separate my personal values from my professional values in working with clients in an objective way.

18. I think I will work best with clients who have values similar to mine.

19. I think it is appropriate to pray with my clients during a session if they request this of me.

20. If I had a conflict of values with a client, I would talk about this with my client.

There are no “right” or “wrong” answers to these statements. The inventory is designed to stimulate your thinking on how your values are likely to influence the way you carry out your functions as a helper. Select a few items and talk with a fellow student about your views. As you read this chapter, assume an active stance, and think about your position on the value issues we raise.

Avoiding Imposing Values

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The clients with whom you work ultimately have the responsibility of choosing what values to adopt, what values to modify or discard, and what direction their lives will take. Through the helping process, clients can learn to examine values before making choices. You may believe it is a good practice to disclose some

of your values as you work with clients. If you are thinking of disclosing your values, it is critical that you assess the impact this might have on your client. Ask yourself these questions: Why am I disclosing and discussing my values with my client? What therapeutic benefit will my disclosure have for my client? How vulnerable is my client to being unduly influenced by me? Is my client too eager to embrace my value system? It is important that you avoid disclosing a particular value you hold as a way to steer your client toward accepting a value

orientation consistent with your own. As you will discover again and again in this chapter, the counseling process is about the client’s values, not the helper’s values.

Even if you think it is inappropriate to impose your values on clients, you may unintentionally influence them in subtle ways to subscribe to your values. If you are strongly opposed to abortion, for example, you may not respect your client’s right to consider abortion. On the basis of your convictions, you may subtly (or not so subtly) direct your client toward choices other than abortion. Practitioners cannot be completely objective and value-free (Shiles, 2009), but helpers must learn to separate

their personal values from the counseling process. Kocet and Herlihy (2014) describe this process as ethical bracketing: “intentional setting aside of the counselor’s personal values in order to provide ethical and appropriate counseling to all clients, especially those whose worldviews, values, belief systems, and decisions differ significantly from those of the counselor” (p. 182). It is essential that you take into consideration the ways you may influence your clients, either intentionally or unintentionally. Francis and Dugger (2014) emphasize that counselors are ethically responsible to monitor the various ways they may communicate their values

to clients “and be aware of how the power differential that exists within each counseling relationship may result in the imposition of their values” (p. 132).

Some well-intentioned practitioners think their task is to help people conform to acceptable and absolute value standards. It is no easy task to avoid communicating your values to your clients, even if you do not explicitly express them. What you pay attention to during counseling sessions will direct what your clients choose to explore. The methods you use will provide them with clues to what you value. Your nonverbal messages give them indications of when you like or dislike what they are doing. Because your clients may feel a need

to have your approval, they may respond to these clues by acting in ways that mirror your values instead of developing their own inner direction.

Refusing to work with clients simply because you do not agree with their values is unethical. We encourage you to consider this from the client’s perspective. Imagine having the courage to seek help for a personal struggle only to be informed that the therapist will not accept you as a client due to a particular value you hold that may or may not be related to your presenting

concern. It would be natural to feel offended, angry, and rejected. If you have low self-esteem and feel rejected by this therapist, you may feel even worse about yourself and give up on the idea of seeking therapy from a different helper. As you can see, referring clients due to value differences can harm clients.

Our Perspective on Values in the Helping Relationship

From an ethical perspective, it is imperative that helpers recognize the impact their values have on the way they work with clients. If you pay attention to your clients and why they are coming to see you, you will have a basis for inviting a discussion on how values influence your clients’ behaviors.

Our position is that the helper’s main task is to provide those who seek aid with the motivation needed to look at what they are doing, determine the

degree to which what they are doing is consistent with their values, and consider whether their current behavior is meeting their needs. If clients conclude that their lives are not fulfilled, they can use the helping relationship to reexamine and modify their values or their actions, and they can explore a range of options

Dealing With Value Conflicts

Your task is to help clients explore and clarify their beliefs and apply their values to solving their problems. The American Counseling Association (ACA, 2014) states this clearly:

Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature. (Standard A.4.b.)

When you find yourself struggling with an ethical dilemma over value differences, the best course to follow may be to seek consultation in working through the situation so the appropriate standard of care can be provided (Kocet & Herlihy, 2014). Supervision is a useful way to explore value conflicts with clients. If you are having difficulty maintaining objectivity regarding a certain value, consider this your problem rather than the client’s. Perhaps personal counseling will help you understand why your personal values are intruding in your professional work.

Referral Is Not an Answer to Resolving Value Conflicts

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How do you know when and how to refer? How will the client be affected by a referral? Why would you want to refer? What kind of referral might be most appropriate? What if few referral resources are available? Herlihy and

Corey (2015d) state that “referring a client due to a value conflict constitutes a discriminatory referral, which is unethical” (p. 194). Referring clients should not be used as a convenient solution when you are faced with value conflicts.

It is possible to work through a conflict successfully through a process of self- reflection. What is it about a client or a particular value difference that makes it difficult for you to work with the client? What barriers within you are making it difficult to separate your personal values from your professional responsibilities? Is it necessary that you and your client share a common set of values in a particular area? Mental health practitioners are sometimes too eager to suggest a referral rather than explore how they could work with a client’s problem. Shiles (2009) notes that far too little has been written about situations in which referring a client is inappropriate, unethical, and may constitute an act of discrimination.

For example, inappropriate referrals have been made for clients with differing religious beliefs, sexual orientations, or cultural backgrounds. Referrals should be limited to situations in which you do not have the competence or have not developed a particular skill set to help that individual with her or his concerns. The overuse of client referrals among mental health practitioners often involves discriminatory practices that are rationalized as ways to avoid practicing beyond one’s level of competence.

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Significant Court Cases on Value Conflicts

LO4

In two court cases, conservative Christian counselors-in-training filed suit against their public universities over the requirement that students avoid imposing their personal and moral values on clients.

Ward v. Wilbanks. In Ward v. Wilbanks (2010), Julea Ward, a master’s degree student in counseling, filed suit against her university (Eastern Michigan University) over the requirement that she should be expected to counsel a client even in cases of major value conflicts. Ward frequently expressed a conviction that her Christian faith prevented her from affirming a client’s same-sex relationship or a client’s heterosexual extramarital relationship. During the last phase of her program in 2009, Ward was enrolled in a practicum that involved counseling clients and was randomly assigned to counsel a gay client. She asked her faculty supervisor to either refer the client to another student or to allow

her to begin counseling and make a referral if the counseling sessions involved discussion of his relationship issues. Ward was told that refusing to see a client on the basis of sexual orientation was a violation of the ethics code for the counseling profession and therefore was not ethically acceptable. The counseling program initiated an informal and then a formal review process examining the reasons for Ward’s request for a referral. The program offered her a plan for remediation so that she could keep her values separate from the counseling relationship, but she refused any plan for remediation on the grounds that this was a violation of her basic rights.

Ward was dismissed from the program and later sued the university in

U.S. District Court, claiming that the dismissal violated her religious freedom and her civil rights. The district court ruled that the university was justified in dismissing Ward for violating provisions of the code of ethics that prohibit discrimination based on race, religion, national origin, age, sexual orientation, gender, gender identity, disability, marital status/partnership, language preference, or socioeconomic status. The court also ruled that the university was justified in enforcing a legitimate curricular requirement, specifically that counseling students must learn to work with diverse clients in ways that are nondiscriminatory.

The Alliance Defending Freedom (ADF) is a legal organization that defends individuals and organizations whose conservative religious views or actions are challenged in various arenas of public life. With help from the ADF, Ward appealed her case to the United States Court of Appeals for the Sixth Circuit, which sent the case back to district court for a jury trial. To avoid a costly trial, the case was settled out of court. As part of the settlement, the ADF dropped their demands that the university’s curriculum, policies, and practices be changed. (For more information about this case, see Dugger & Francis [2014]; Herlihy, Hermann, & Greden [2014]; and Kaplan [2014]).

Keeton v. Anderson-Wiley. Jennifer Keeton was a counseling student at Augusta State University (ASU). In Keeton v. Anderson-Wiley (2010), Keeton actively sought to impose her religious and moral values on clients whose

behavior she deemed to be morally wrong. She consistently maintained that she “condemned homosexuality” based on her interpretation of biblical teachings.

She stated her intention to recommend “conversion therapy” to gay clients and to inform them that they could choose to be straight. The faculty had concerns that Keeton would be unable to separate her personal religious views on sexual morality from her counseling practice. She was presented with a remediation plan, which she did not carry out, and she was dismissed from the training program. The federal appeals court upheld the right of the university to enforce standards expected of students in a counseling program, even when a student objects on religious grounds. (For a critical review of the ethical and legal implications of using religious beliefs as the basis for refusing to counsel certain clients, see Herlihy et al. [2014]).

Lessons learned. Kaplan (2014) asserts that Ward v. Wilbanks is the most important legal case for the counseling profession in the last 25 years. In his discussion of the ethical implications of Ward v. Wilbanks, Kaplan makes several salient points:

· Practitioners may not deny professional services to an individual belonging to a legally protected class based on the counselor’s values.

· Referrals are appropriate on the basis of lacking skills-based competency. The focus of ethical referrals is on the needs of the client, not the values of the counselor.

· To avoid client abandonment, a referral should be considered as an option of last resort.

· The counselor’s obligation to an individual begins at the first contact, not at the first session.

Dugger and Francis (2014) were on the faculty of Eastern Michigan University at the time of the lawsuit. They have addressed the lessons they learned from Ward v. Wilbanks and offer the following recommendations:

· It is crucial to have policies and procedures in place before a lawsuit is filed.

· Training programs should clearly articulate expectations for student behavior and performance based on ethical practice, identify consequences for failing to meet these expectations, and spell out due process procedures available to students.

· Training programs are expected to closely adhere to the policies and procedures they have in place.

Implications of court cases and legislation. Some political groups and lawmakers are retaliating against policies and ethics codes that prohibit discrimination on the basis of religion and sexual orientation by passing “freedom of conscience” clauses. For example, Arizona’s Senate Bill 1365 ensures that mental health professionals will not put their licensure status in jeopardy by denying services to clients on the basis of sincerely held religious beliefs. This bill was signed into law by the governor of Arizona in May 2012. Similar bills have been introduced and passed in other states, but counselors must embrace the ethics code of their profession to conform to best practice standards.

The state of Tennessee passed controversial legislation in 2016 that would allow mental health practitioners in that state with “sincerely held principles” to deny services without risk of legal consequences to potential clients who identify as lesbian, gay, bisexual, or transgender. This discriminatory bill under the guise

Wise and her colleagues (2015) maintain that these legislative initiatives (such as the bills enacted in Arizona and Tennessee) limit the ability of educators to train students to provide competent care to diverse client populations. Such legislative actions are potentially in conflict with the ethical commitment to nondiscrimination outlined in the ethical standards for the APA, the ACA, the AAMFT, and the NASW. In light of the contentious court cases and legislative actions, Wise and her colleagues (2015) call for training programs to take a proactive approach to conscience clauses rather than assume a reactive stance.

They recommend that students who are entering a program indicate explicit agreement with nondiscrimination policies.

We fully agree that counselor training programs have a responsibility to be clear with prospective students about what is expected of them as ethical

practitioners. Students enrolling in a program should be told from the outset that trainees cannot ethically discriminate against clients because of a difference in values or refuse to work with a general category of clients. Students need to be aware of these fundamental aspects of the code of ethics as these requirements will influence their development as counselors and will affect their participation in the program.

Mental health professionals should be able to work effectively with the diversity of worldviews, beliefs, and cultural identities they will encounter; conscientious objection acts clearly violate the letter and spirit of the ethics codes of the helping professions. If counseling students are not willing to learn to work with the wide range of clients they will encounter, we suggest that they reconsider whether counseling is the right profession for them.

In the remainder of this chapter, we consider some value-laden issues that you might encounter in your work with a range of client populations.

These areas include concerns of lesbian, gay, bisexual, transgender, and gender nonconforming individuals; family values issues; gender-role identity issues; religious and spiritual values; abortion; sexuality; and end-of-life decisions.

Concerns of LGBTQI People

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The concept of human diversity encompasses more than racial and ethnic factors; it encompasses all forms of oppression, discrimination, and prejudice, including those directed toward people on the basis of their age, gender, socioeconomic status, religious affiliation, disability, and sexual orientation. Working with lesbian, gay, bisexual, transgender, queer or questioning, and intersex (LGBTQI) individuals often presents a challenge to counselors who hold conservative religious values. When serving LGBTQI individuals, counselors must be aware of the attitudes and beliefs they hold that can either enhance or inhibit their

counseling effectiveness with these populations. A counselor who works with LGBTQI people has a responsibility to understand the special concerns of these individuals and is ethically obligated to develop the knowledge and skills to competently deliver services to them (Corey, 2019).

Homosexuality and bisexuality were assumed to be a form of mental illness for more than a century. In 1973 the American Psychiatric Association stopped labeling homosexuality—a sexual orientation in which people seek emotional and sexual relationships with same-gendered individuals—as a form of mental illness. It is generally considered unacceptable to use the term homosexual in clinical practice because it can be associated with a pathological stigma (Kocet, 2019). The mental health system had finally begun to treat the problems of gay, lesbian, bisexual, and transgender people rather than treating them as the problem. Kocet (2019) notes that the literature in the mental health field is clear and consistent: LGBTQI individuals are not mentally disordered.

Although LGBTQI people may suffer with anxiety, depression, or posttraumatic stress, their sexuality or gender identify is not the cause of their mental health diagnosis; instead it is the result of societal and cultural biases, stigma, and harassment from a society that does not embrace the continuum of gender identity.

Heterosexism is a worldview and a value system that can undermine the healthy functioning of the sexual orientations, gender identities, and behaviors of LGBTQI individuals. Helpers need to understand that heterosexism pervades the social and cultural foundations of many institutions and often contributes to negative attitudes and discrimination toward people who are not heterosexual or do not meet the socially accepted standards of stereotypical gender roles and behaviors. Therapists must begin by challenging their own personal prejudices,

biases, fears, attitudes, assumptions, and stereotypes regarding sexual orientation if they hope to understand the ways in which prejudice, discrimination, and multiple forms of oppression are manifested in society toward LGBTQI people.

When working with LGBTQI clients, it is imperative that counselors become aware of their own privilege, marginalization, and potential biases, which could have a negative impact on the counseling relationship (Ginicola, Filmore, & Smith, 2017).

Despite the advances in understanding sexual orientation, bias and misinformation continue to be widespread in society, and many LGBTQI people face social stigmatization, discrimination, microaggressions, and violence. Unless helpers are conscious of their own assumptions and possible countertransference, they may project their misconceptions and fears onto their clients. Some counselors and counselors-in-training consider same-sex relationships to be immoral. Such attitudes of a counselor have the potential of bringing harm

to LGBTQI clients who have the right to expect that they can talk about their intimate relationship concerns in therapy without fearing that their counselor will be judgmental (Herlihy et al., 2014).

Imagine you are counseling a man who is gay and wants to talk about his relationship with his partner and the difficulties they have communicating with each other. As you work with him, you become aware that it is difficult for you to accept his sexual orientation. You find yourself challenging him about this rather than concentrating on the issues he brings forward. You are so focused on his

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sexual orientation, which goes against what you think is morally right, that you and your client both recognize that you are not helping him. What steps could you take in addressing these value differences? Are you willing to explore the impact of your values on your interventions with this man during your supervision?

Helping professionals who have negative reactions to the LGBTQI community are likely to impose their own values and attitudes, or at least to convey strong disapproval. Identify and examine any myths and misconceptions you might hold, and understand how your values and possible biases regarding sexual orientation are likely to affect your work as you consider the cases that follow.

Case example: Confronting loneliness and isolation.

Consider how your values are likely to influence the way in which you would work with Eric, a 33-year-old gay man. You are doing an intake interview with Eric, who tells you that he is coming to counseling because he often feels lonely and isolated. He has difficulty in intimate relationships with both men and women. Once people get to know him, Eric feels they will not accept him and somehow won’t like him. During the interview, you discover that Eric has a lot of pain regarding his father, with whom he has very little contact. He would like a closer relationship with his father, but being gay stands in the way. His father has let him know that he feels guilty that Eric “turned out that way.” He just cannot understand why Eric is not “normal” and why he can’t find a woman and get married like his brother. Eric mainly wants to work on his relationship with his father, and he also wants to overcome his fear of rejection by others with whom he would like a close relationship. He tells you that he would like those he cares about to accept him as he is.

Your stance. What are your initial reactions to Eric’s situation? Considering your own values, would you expect to have any trouble establishing a therapeutic relationship with him? In light of the fact that he lets you know that he does not want to explore his sexual orientation, would you be able to respect this decision? As you think about how you would proceed with Eric, reflect on your own attitudes toward gay men. Would your attitude be different if this client was not a gay man but rather was a lesbian? Think about some of the issues you might focus on in your counseling sessions with Eric: his fear of rejection, pain related to his relationship with his father, desire for his father to be different, difficulty in getting close to both men and women, sexual orientation, and values. With the information you have, which of these areas are you likely to explore with Eric?

Case example: Caught in a conflictual situation.

Margie waits several months after starting counseling to tell you that she is a lesbian. Although she has talked about her feelings of anxiety and depression during every session, she has held back on disclosing the underlying source of her debilitating symptoms—her fear of being alienated from her family if she tells them that her roommate, Sheila, is actually her partner. Margie’s parents hold conservative values and in her presence have openly condemned others who identify themselves as gay or lesbian. She is certain that coming out to them would devastate them and cause them to disown her. At the same time, Margie is experiencing increasing pressure from Sheila to introduce her to her family as her partner. Stuck between wanting to please her partner and wanting to be accepted

by her family, Margie is very conflicted, which is exacerbating her anxiety and depression. She tells you that she was afraid to reveal her sexual orientation to you earlier because she feared you may have a similar reaction to her news as she expects her family would have. She ultimately decided to tell you because she couldn’t hold it in any longer and needed to tell someone.

Your stance. How would it be for you to hear this from Margie? What might you be inclined to say to her? How would your own values influence your perceptions of Margie’s situation and affect the way you intervened in her case? Consider how you would react internally to the conflictual situation that Margie is experiencing and how you would support her in working through it. This would be a critical time to engage in self-reflection to ensure that you would not be tempted to impose your values on Margie regardless of the particular beliefs or values you hold. If your values are similar to those of Margie’s family, what measures can you take to ensure that you work effectively with her and that your biases don’t contaminate the therapeutic process? Would you be able to focus on the issues Margie presents and not the value conflict you have with her?

Discussion. Counselors are not exempt from the influence of negative societal stereotyping and prejudice toward LGBTQI people. Many LGBTQI people internalize the negative societal messages they receive, which causes them to experience psychological pain and conflict.

You may tell yourself and others that you accept the right of others to live their lives as they see fit, yet you may have trouble when you are in an actual encounter with a client. There could be a gap between what you can intellectually accept and what you can emotionally accept. This is something to examine in your supervision sessions and perhaps in your personal counseling.

Understanding the Needs of LGBTQI Clients

Helpers who work with LGBTQI people are ethically obligated not to allow their personal values to intrude into their professional work. The ethics codes of the ACA (2014), the APA (2017a), the AAMFT (2015), and the NASW (2017) clearly state that discrimination, or behaving differently and usually unfairly

toward a specific group of people, is unethical and unacceptable. From an ethical perspective, practitioners must become aware of their personal prejudices and biases regarding sexual orientation. This is particularly important when a client discloses his or her sexual orientation after the helping relationship is firmly established. In such situations, judgmental attitudes on the part of the helper can seriously harm the client. Of course, these biases and prejudices can be harmful when they are communicated to the client, either directly or indirectly, at any point in counseling.

The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC, 2008) recognizes that helping professionals need to be well versed in understanding the unique needs of this diverse population.

ALGBTIC has developed a set of specific competencies for trainees (available on their website) to help them examine their personal biases and values regarding LGBTQI individuals. Helpers who acquire these competencies are in a position to implement appropriate intervention strategies that ensure effective service delivery to this client population.

ALGBTIC (2009) has also developed Competencies for Counseling With Transgender Clients, which is geared toward counselors who work with transgender individuals, families, groups, or communities. These competencies are based on a wellness, resilience, and strength-based approach, and it is felt that counselors are in a unique position to make institutional change that can result in a safer environment for transgender people. This begins with counselors creating a welcoming and affirming environment for transgender individuals and their loved ones. Counselors must respect and attend to the whole individual, and they should not simply focus on gender-identity issues.

You might well be unaware of your client’s sexual orientation until the therapeutic relationship has been established. Or a client who has been involved in only heterosexual relationships may begin to question his or her affectional orientation well into the therapeutic process. This client may need to spend time in counseling exploring his or her affectional orientation to find inner peace, and you must be able to competently facilitate this process. If you expect to provide services in a community agency or any other setting with diverse client populations, you need to have a clear idea of your own values relative to issues associated with sexual orientation. As a way of clarifying your values pertaining to sexual orientation, complete the following inventory, using this code:

3 = I agree, in most respects, with this statement.

2 = I am undecided in my opinion about this statement. 1 = I disagree, in most respects, with this statement.

1. Lesbian, gay, and bisexual clients are best served by lesbian, gay, and bisexual helpers.

2. A gay or lesbian counselor is likely to push his or her values on a heterosexual client.

3. I would have trouble working with either a gay male couple or a lesbian couple who wanted to adopt children.

4. Sexual identity is a choice.

5. A lesbian, gay, bisexual, or transgender person can be as well adjusted (or poorly adjusted) as a heterosexual person.

6. I would have no difficulty being objective in counseling lesbian, gay, bisexual, or transgender clients.

7. I have adequate information about referral sources in the local gay community.

8. I feel a need for specialized training and knowledge before I can effectively counsel lesbian, gay, bisexual, and transgender clients.

9. I expect that I would have no difficulty conducting family therapy if the father were gay.

10. I think that lesbian, gay, bisexual, and transgender people of color are subject to multiple forms of oppression.

After you finish the inventory, look over your responses to identify any patterns. Are there any attitudes that you want to change? Have any of your attitudes been modified as a result of this discussion? Are there any areas of information or skills that you are willing to acquire?

Family Values

The value system of helpers has a crucial influence on the formulation and definition of the problems they see in a family, the goals and plans for therapy, and the direction the therapy takes. Helpers have their own values pertaining to marriage, the preservation of the family, divorce, same-sex marriages, gender roles and the division of responsibility in the family, adoption of children by same-gender couples, child rearing, and extramarital affairs. Helpers may take sides with one member of the family against another; they may impose their

values on family members; or they may be more committed to keeping the family intact than are the family members themselves. Helpers who, intentionally or unintentionally, impose their values on a couple or a family can do considerable harm. Wilcoxon, Remley, and Gladding (2013) maintain that therapists who work with families need to be aware that their personal values are significant aspects of their professional work, and they caution therapists to avoid imposing their values on clients. It is not the helper’s role to decide how members of a family should change. The role of the therapist is to help family members see more clearly what they are doing, to help them make an honest evaluation of what their present patterns are, and to encourage them to make the changes they deem necessary. Consider the following case examples.

Case example: Counseling a mother who is restless.

Veronika has lived a sheltered life. She was married at 17, had four children by the age of 22, and is now going back to college at age 32. She is a good student— excited, eager to learn, and discovering all that she had missed. She finds that she is attracted to a younger peer group and to professors. She is experiencing her “second adolescence,” and she is getting a lot of affirmation that she did not have before. At home she feels unappreciated, and the members of her family are mostly interested in what she can do for them. At school she is special and is respected for her intellect.

Veronika is close to a decision to leave her husband and her four children, ages 10 to 15. Veronika comes to see you at the university counseling center and is in turmoil over what to do. She wants to find some way to deal with her guilt and ambivalence.

Your stance. How do you react to Veronika’s statement that she is considering leaving her husband and her four children? Would you encourage her to follow her inclinations? If Veronika gave this matter considerable thought and then told you that, as painful as it would be for her, she needed to leave her family, would you be inclined to encourage her to bring her entire family in for some counseling sessions? For a moment, consider your own value system. What values might you impose, if any? If Veronika said that she was leaning toward staying married and at home, even though she would be resentful, what interventions might you make? If a parent or spouse had left you at some point, how might this experience affect you in working with Veronika?

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Discussion. Your values as a helper have the potential to influence the outcome of therapy, and it may be difficult to refrain from making any judgments in this case. If you think Veronika should be true to herself and follow her heart no matter the cost, you may encourage her to act on her impulse to leave her family before she has fully processed her options and contemplated the potential repercussions. As Veronika examines her own values, she may discover that she can improve her family situation by establishing boundaries with her husband and children so that her needs are no longer neglected.

Case example: A family in crisis.

A wife, husband, and three adolescent children come to your office. The family was referred by the youngest boy’s child welfare and attendance officer. The boy is acting out by stealing and is viewed as the problem person in the family.

The husband is in your office reluctantly. He appears angry and unapproachable, and he lets you know that he doesn’t believe in this “therapy stuff.” He makes excuses for the boy and says he doesn’t see that there is much of a problem, either in the marriage or in the family.

The wife tells you that she and her husband fight a lot, that there is much tension in the home, and that the children are suffering. She is fearful about what might happen to her family. She is concerned about supporting herself and her three children if she were to separate from or divorce her husband.

Your stance. How would you be affected by this family? What course of action would you take? How would your values pertaining to family life influence your interventions with this family? Would you expose your own values in this case, even if the family members did not ask you? If they asked you what you thought of their situation and what you thought they should do, what would you say?

Discussion. It is imperative to remain mindful of the power inherent in your professional role at all times. Even if you are careful not to impose your values in working with this family in crisis, what you say is likely to be influenced by your core values. If you believe the wife should be more assertive with her husband in this situation, you might encourage her to challenge him. Such a strategy could endanger the relationship, and you must be mindful of the anger issues between the parents and how this may escalate. A key task for this counselor is to find ways to encourage the father to participate and to engage the whole family in the therapy experience.

Case example: Confronting infidelity.

A couple seeks your services for marital counseling. The husband has confessed to his wife that he is having an affair, and the incident has precipitated the most recent crisis in their relationship. Although the wife is highly distraught, she wants to stay married. She realizes that their marriage needs work and that there is a lack of emotional connection between the two of them, but she thinks it is worth saving. They have children, and the family is well respected and liked in the community.

The husband wants to leave, yet he is struggling with conflicting feelings and is not sure what to do. He is very confused and says he still loves his wife and children. He is aware that he is going through some kind of midlife crisis, and each day he comes up with a different decision. His wife is in pain and is uncertain about what actions to take.

Discussion. It is helpful to remind yourself that the clients will live with the consequences of their decisions, not you. As much as they may want you to tell them what direction to take, your task is to empower your clients to make their own decisions when they are ready to make them. The unraveling of an intimate relationship is painful for those involved, and you may be inclined to lessen their pain by steering them in a particular direction, especially when they seem to be stuck and are asking for your guidance in making a decision. By exercising patience with the process and modeling that for your clients, you will help them to explore their options fully before taking action. More therapeutic work needs to be done before a clear direction will become apparent to either of them. It is important for the couple to decide the option that they can best live with going forward.

Gender-Role Identity Issues

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All helpers need to be aware of their values and beliefs about gender. Helpers who work with couples and families can practice more ethically if they are aware of the history and impact of gender stereotyping as it is reflected in the socialization process in families, including their own. The way people perceive gender has a great deal to do with their cultural background. You can become a more effective practitioner if you are willing to evaluate your beliefs about appropriate family roles and responsibilities, child-rearing practices, multiple roles, and nontraditional careers for women and men. With self-reflection, it is possible for you to become more culturally sensitive, gender sensitive, and to avoid imposing your personal values on individuals, couples, and families.

Case example: Challenging the traditional role as a mother.

John and Emma recently entered couples therapy for help resolving conflict over Emma’s recent return to work after several years as a full-time mother and homemaker. Both report that they “argue a lot about this issue.” John states that he prefers to have Emma stay home full time and care for their two young children and the household responsibilities. Emma reports feeling happier when she works part time and contributes financially to the family. It also allows them to hire extra help for household tasks and child care. She loves her work and the social interactions with her colleagues and does not want to give it up. John believes mothers are better for children than babysitters, and because he has the greater earning capacity, Emma should be the one to stay home. Emma states her perception that it is more important for children to have a happy mother than a full-time mother, and her desire to have an outside work interest above and

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beyond her family should not be tied to income. Both John and Emma are very invested in their relationship, but they can’t get past this hurdle.

Your stance. How would your own personal values regarding parenting and gender roles influence your assessment and approach to working with John and Emma? What are the ethical boundaries regarding the therapist’s values in such a case? How do you avoid imposing your own beliefs and persuading or directing this couple?

Discussion. If you have strong personal values about gender roles in marriage and family, it might be easy for you to impose your own values in this case. Alignment, collusion, and triangulation are all unhealthy possible outcomes when counselors insert their own values into these discussions. A belief that women should have choices and not be bound by traditional family roles might lead you to align with Emma and try to persuade or convince John of this. Conversely, a view that children should have a mother at home versus another caregiver may lead you to try to convince Emma she needs to be home and to abandon her personal goals, resulting in alignment with John. It is unethical for the therapist to determine the goals of the individuals involved, with the exceptions of abuse and danger.

Case example: Parenting in a traditional family.

Fernando and Elizabeth describe themselves as a “traditional couple.” They are in marriage counseling with you to work on the strains in their relationship arising from rearing their two adolescent sons. The couple talk a lot about their sons. Both Elizabeth and Fernando work full time outside the home. Besides working as a school principal, Elizabeth has another full-time job as mother and homemaker. Fernando says he is not about to do any “women’s work” around the house. Elizabeth has never really given much thought to the fact that she has a dual career. Neither Elizabeth nor Fernando shows a great deal of interest in examining the cultural values and stereotypes that they have incorporated. Each of them has a definite idea of what women and men “should be.” Rather than talking about their relationship or the distribution of tasks at home, they focus their attention on troubles with their sons. Elizabeth wants advice on how to deal with their problems.

Your stance. If you become aware of the tension within this couple over traditional gender roles, will you call it to their attention in your counseling with them? Do you see it as your job to challenge Fernando on his traditional views? Do you see it as your job to encourage Elizabeth to want more balance of responsibilities in their relationship? If Fernando is from a Latino background, could his views on “women’s work” reflect the values of his family of origin? Would you want to learn about the role relationships of Elizabeth’s parents? Would you want to explore the cultural values each learned while growing up? If you were counseling this couple, what do you think you would say to each of them? How would your values influence the direction in which you might go? What bearing would your own gender-role conditioning and your own views have on how the counseling process might unfold?

Discussion. If you will be working with couples and families, it is essential that you appreciate the fact that gender-role stereotypes serve a purpose and are not easily modified. As a helper, your role is to guide your clients in the process

In a classic journal article, Margolin (1982) provides some recommendations on how to be a nonsexist family therapist and how to confront negative expectations and stereotyped roles in the family. One suggestion is that helpers should examine their own behavior and attitudes that would imply sex-differentiated roles and status. For example, helpers can show their bias in subtle ways by looking at the husband when talking about making decisions and looking at the wife when talking about home matters and rearing children. Margolin also contends that practitioners are especially vulnerable to the following biases: (1) assuming that remaining married would be the best choice for a woman, (2) demonstrating less interest in a woman’s career than in a man’s career, (3) encouraging couples to accept the belief that child rearing is solely the responsibility of the mother,

(4) showing a different reaction to a wife’s affair than to a husband’s, and

(5) giving more importance to satisfying the husband’s needs than to satisfying the wife’s needs. Margolin raises two critical questions for those who work with couples and families:

· How does the counselor respond when members of the family seem to agree that they want to work toward goals that (from the counselor’s vantage point) are sexist in nature?

· To what extent does the helper accept the family’s definition of gender-role identities?

Religious and Spiritual Values

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There is a growing awareness and willingness today to explore spiritual and religious beliefs and values in counseling and in training programs for helpers (Dobmeier & Reiner, 2012; Hagedorn & Moorhead, 2011; Johnson, 2013). Religion and spirituality are oftentimes part of the client’s problem, and they can also

be part of the client’s solution to a problem. Spiritual values help many people make sense out of the universe and the purpose of their lives. Because spiritual and religious values can play a major part in human life, these values should be viewed as a potential resource in the helping relationship rather than as something to be ignored (Johnson, 2013). Exploring spiritual or religious values

with clients can be integrated with other therapeutic tools to enhance the helping process, if doing so is what clients want.

Counselors cannot ignore a client’s spiritual and religious perspective if they want to practice in a culturally competent and ethical manner (Johnson, 2013; Robertson & Young, 2011; Young & Cashwell, 2011a, 2011b). Johnson (2013) believes spiritually informed therapy is a form of multiculturalism.

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Johnson contends that a client-defined sense of spirituality can be a significant avenue for connecting with the client and can be an ally in the therapeutic change process. However, he admits that not all clients are interested in discussing spiritual or religious concerns. With such clients, it is important to avoid imposing a spiritual perspective on them. Helpers need to acquire the skills of listening for how clients talk about existential concerns of meaning, values, mortality, and being-in-the-world. Some clients do not talk explicitly about spirituality, but existential themes tend to emerge in therapy. By listening to the unique ways clients make sense of their lives and derive meaning, helpers can remain open to how clients define, experience, and access whatever helps them stay connected to their core values and their inner wisdom. Asking questions about a client’s religious or spiritual background at the outset of

the professional relationship conveys their potential relevance to the helping process (Barnett & Johnson, 2011). If counselors do not raise questions about a client’s spiritual or religious values and concerns during assessment, the client may be hesitant to bring up these concerns in treatment.

In clarifying your values pertaining to religion and counseling, consider these questions: Does an exploration of religion or spirituality belong in formal helping relationships? Is the helping process complete without a spiritual dimension? If a client’s religious needs arise in the therapeutic relationship, is it appropriate for a therapist in a secular setting to deal with them? Do you have to hold the same religious beliefs, or any beliefs at all, to work effectively with clients who have religious struggles?

Even if spiritual and religious issues are not the focus of a client’s concern, these values may enter into the sessions indirectly as the client explores moral conflicts or grapples with questions of meaning in life. Can you keep your spiritual and religious values out of these sessions? How do you think they will influence the way you counsel? If you have little belief in spirituality or are hostile to organized religions, can you be nonjudgmental? Can you empathize with clients who view themselves as being deeply spiritual or who feel committed to the teachings of a particular religious institution?

Johnson (2013) believes that therapists would do well to spend time reflecting on their own spiritual identity and journey, especially on experiences that were emotionally intrusive and fostered reactivity. If therapists understand and have worked through their spiritual emotional baggage, they can listen to their clients without becoming emotionally reactive or trying to impose their personal agenda on clients. Helpers are in a position to assist their clients in exploring spiritual or religious concerns.

It is important that we do not neglect the beliefs and concerns of people who identify as nonreligious (Sahker, 2016). Individuals experiencing spiritual or religious struggles may seek therapy when they decide to leave the religion of their family of origin. These clients may want a safe place to discuss their doubts and distress related to internal conflicts involving nonbelief. Some who have

left the religion of their family of origin experience rejection by family members, and clients often want to express and explore the pain they experience as a result of their choice. The assessment process is crucial in identifying any religious or spiritual concerns, both positive and negative, that an individual may have. If clients say they want to talk about these matters, helpers should be able to meet their needs (Corey, Corey, & Corey, 2019).

Case example: Finding comfort in spirituality.

Peter has definite ideas about right and wrong, as well as sin, guilt, and damnation; and he has accepted the teachings of his fundamentalist faith. When he encountered difficulties and problems in the past, he was able to pray and find comfort in his relationship with his God. Lately, however, he has been suffering from chronic depression, an inability to sleep, extreme feelings of guilt, and an overwhelming sense of doom that God is going to punish him for his transgressions. He consulted his physician and asked for medication to help him sleep better. The physician and his minister both suggested that he seek counseling. At first Peter resisted this idea because he felt strongly that he should find comfort in his religion. With the continuation of his bouts of depression and sleeplessness, he hesitantly comes to you for counseling.

He requests that you open the session with a prayer so that he can get into a proper spiritual frame of mind. He also quotes you a verse from the Bible that has special meaning to him. He tells you about his doubts about seeing you for counseling, and he is concerned that you will not accept his religious convictions, which he sees as being at the center of his life. He inquires about your religious beliefs.

Your stance. Would you have any trouble counseling Peter? He is struggling with trusting you and with seeing the value in counseling. What are your reactions to some of his specific views, especially those pertaining to his fear of punishment? Do you have reactions to his strong fundamentalist beliefs? Would you be able to work with him objectively, or would you try to find ways to sway him to give up his view of the world? If you have definite disagreements with his beliefs, would that be an obstacle to working with him? Would you challenge him to think for himself and do what he thinks is right? How could you challenge yourself not to allow your views to influence him?

Discussion. Ethical practice requires that you avoid indoctrinating clients with a particular set of spiritual or religious values. You have an ethical responsibility to be aware of how your beliefs affect your work and to make sure you do not unduly influence your clients. Assume that you have a religious orientation, yet you believe in a God who loves whereas Peter believes in a God he fears. You discuss the differences in the way the two of you perceive religion. Yet you also say that you want to explore with him how well his religious beliefs are serving him in his life and also examine possible connections between some of his beliefs and how they may be contributing to his symptoms.

As you think over your own position on the place of spiritual and religious values in the helping relationship, reflect on these questions:

· Is it appropriate to deal with religious issues in an open and forthright manner as clients’ needs are presented in the helping process?

· Do clients have the right to explore their religious concerns in the context of the helping process?

· If you have no religious or spiritual commitment, how could this hinder or help you in working with diverse clients?

· Are you willing to refer a client to a rabbi, minister, imam, priest, or other religious leader if the client has questions you are not qualified to answer?

Attention to spirituality can be part of an integrated and holistic effort to help clients resolve conflicts and improve health, as well as to find meaning in life (Shafranske & Sperry, 2005). The beliefs, values, and faith systems of clients are often sources of support in difficult times, and they can be used by the counselor to help the client in the healing process (Francis, 2016).

Case study: Counseling and spirituality.

Guiza is a student intern who feels deeply committed to spirituality and also claims that her religious faith guides her in finding meaning in life. She does not want to impose her values on her clients, but she does feel it is essential to at least make a general assessment of clients’ spiritual/religious beliefs and experiences during the intake session. One of her clients, Alejandro, tells Guiza that he is depressed most of the time and feels a sense of emptiness. He wonders about the meaning of his life. In Guiza’s assessment of Alejandro, she finds that he grew up without any kind of spiritual or religious guidance in his home, and he states that he is agnostic. He never has explored either religion or spirituality; these ideas seem too abstract to help with the practical problems of everyday living. Guiza becomes aware that she is strongly inclined to suggest to Alejandro that he open up to spiritual ways of thinking, especially because of his stated problem with finding meaning in his life. Guiza is tempted to suggest that Alejandro at least go to a few church services to see if he might find any meaning in doing so. She brings her struggle to her supervisor.

Your stance. Consider Guiza’s situation as you reflect on how your values can influence your approach with clients. When, if ever, would you recommend to your client that he or she talk to a minister, priest, rabbi, or other faith leader? If you sought consultation from your supervisor, what key issues would you most want to explore and clarify? Could you maintain your objectivity? Would you consider suggesting a referral because of your problems with respect to the spiritual or religious beliefs and values of your client?

Discussion. You may experience conflicts in values with your clients in the spiritual realm. Holding a definite system of religious values is not a problem, but wanting your clients to adopt your values is problematic. Without blatantly pushing your values, you might subtly persuade clients toward your religious beliefs or lead them in a direction you hope they will take. Conversely, if you do not place a high priority on spirituality and do not view religion as a salient force in your life, you may not be open to assessing your client’s religious and spiritual beliefs.

Case study: Resolving a value conflict.

Yolanda is a devout Catholic. After a marriage of 25 years, her husband left her. She has now fallen in love with another man and very much wants a relationship with him. But because her religion does not recognize divorce, Yolanda feels guilty about her involvement with another man. She sees her situation as hopeless, and she cannot find a satisfactory solution. Living alone for the rest of her life scares her. But if she marries the man, she fears that her guilt feelings will eventually ruin the relationship because her church may not recognize the marriage as legitimate. Your stance. Consider these questions as a way to clarify how your values could affect your work with Yolanda. Do you know enough to inform Yolanda

of the options available to her in terms of being remarried in a Catholic church? Would you recommend that Yolanda talk to a priest? Why or why not? If Yolanda asked you what she should do or what you think about her dilemma, how would you respond?

Discussion. There are many paths toward fulfilling spiritual or religious needs, and it is not the helper’s task to prescribe any particular pathway. However, we think it is the helper’s responsibility to be aware that spirituality or religion is a significant force for many clients. It is especially important for a practitioner to pursue spiritual or religious concerns if the client initiates them. Practitioners need to be finely tuned to the client’s story and to the purpose for which he or she sought professional assistance. It may also be important to have referral sources available for specific needs of clients.

Case study: A case of karma?

Pratiksha, a Hindu woman, comes to therapy to address her depression and anxiety. She has a daughter with a physical disability, and when her siblings share good news about the accomplishments and success of their own children, she becomes upset. She loves her nieces and nephews and is happy about their success, but their successes remind her of her daughter’s limitations. In conversations with her siblings, she rarely talks about her daughter. She feels ashamed of her daughter’s limitations, which intensifies her feelings of guilt. Pratiksha believes that the suffering both she and her child are experiencing in this life are due to karma. She is convinced that she and her daughter must have behaved badly in a former life to deserve this punishment.

Your stance. As Pratiksha’s therapist, how would you respond to her conviction that she and her daughter are being punished in this life for transgressions in a previous life? Would you convey understanding and acceptance of her belief system, or would you be inclined to challenge this belief? If you challenge her belief, might you run the risk of imposing your own values on her and conveying the message that her Hindu values make no sense? On a personal level, how would you react to this case?

Discussion. It is important to respect the client’s religious views, and to listen to Pratiksha’s interpretation of how karma is functioning in her life. As her therapist, you might ask Pratiksha to consider alternative ways of thinking about her daughter’s disability that will help her to feel more optimistic and hopeful. For instance, rather than viewing her daughter’s disability as a punishment, Pratiksha may come to feel that this is an opportunity for her to learn important life lessons on a spiritual level.

It is important to empathize with Pratiksha’s internal experience. If you choose to intervene by having Pratiksha reframe the meaning of her daughter’s condition within the framework of her religious and cultural values, you need to consider the timing of this intervention. If this intervention is introduced prematurely, it could leave Pratiksha feeling invalidated. It is crucial that this client be given the opportunity to fully express her concerns without feeling judged so a warm and trusting therapeutic environment can be established. Having the time and space to process her feelings about her daughter with an empathic listener may go a long way in helping her to resolve her feelings of shame and guilt.

Helpers may experience a value clash with their clients on the issue of abortion. Clients who are exploring abortion as an option often present a challenge to helping professionals, both legally and ethically. From a legal perspective, mental health professionals are expected to exercise “reasonable care”—acting in accordance with what is expected of professionals—and if they fail to do so, clients can take legal action against them for negligence.

We suggest that you familiarize yourself with the legal requirements in your state that impinge on your work with clients, especially if you are in a position of working with minors who are considering an abortion. The matter of parental consent in working with minors varies from state to state. It is also important to know and apply the policies of the agency or school where you work.

In working with clients who are facing choices around unplanned pregnancy, it can be useful to invite them to talk about the value systems they hold and in what ways these values support or conflict with the choices they are considering. When clients seem stuck over making a difficult decision, counselors sometimes attempt to make this decision for clients or to give them advice. It is crucial

for the counselor to help the client explore her options while being sure to use the client’s frame of reference for the discussion. Would you be able to provide an unbiased atmosphere where clients can consider options without being influenced by your beliefs and values?

Case study: Balancing contradictory advice.

Connie, a 19-year-old college student, seeks your assistance because she is contemplating having an abortion. Some of the time she feels that ending the pregnancy is the only answer; other times she feels that she wants to have the child. She is also considering the option of having her child and giving it up for adoption. Connie contemplates telling her parents but is afraid they would have a definite idea of what she should do. She is unable to sleep and feels guilty for putting herself into this situation. She has talked to friends and solicited their advice, and she has received many contradictory recommendations from them. Connie lets you know that she is not at all sure of what she should do and asks you to help her.

Your stance. With the information you have, what are some things you would say to Connie? Think about your values pertaining to abortion. Would you dissuade her from having an abortion and suggest other options? To what extent do you think you could keep your values out of this session? Sometimes we hear students say that they would refer a pregnant client who was considering an abortion to another professional because of their values. They would not like to sway the woman, and they fear that they could not remain objective. Does this apply to you? If a client in treatment with you for some time became pregnant and indicated she was considering getting an abortion, what would you do?

Discussion. Deciding whether to terminate a pregnancy or to give birth to a child, and then whether to keep the child or place it for adoption, are major life decisions. Connie’s case illustrates the confusion and stress common to women who find themselves in a similar predicament. She has a relatively narrow window of time in which to make a decision that is likely to have a significant

impact throughout her life. Because of the urgency of making a decision, Connie may need to engage in focused exploration that involves a psychoeducational component. By examining the implications of all the potential options, while keeping her values (not the therapist’s values) at the forefront of discussion, Connie will be in a better position to make an informed decision.

If a helper has difficulty honoring the decision that a client makes with regard to keeping a child or having an abortion, the helper should consider raising this issue in supervision or consultation rather than burdening the client with it. Making a referral because you have a value-based conflict with this client would be considered unethical.

Sexuality

Consider your values with respect to sexuality, as well as how you acquired them. How comfortable are you in discussing sexual issues with clients? Are you aware of any barriers that could prevent you from working with clients on sexual issues? How would your experiences in sexual relationships (or the lack of them) influence your work with clients in this area? Would you promote your sexual values? For example, if a teenage client was acting out sexually and this behavior was in large part a form of rebellion against her parents, would you confront her behavior? If a teenage client took no birth-control precautions yet was sexually active with multiple partners, would you urge him or her to use birth control, encourage abstinence, recommend that he or she be more selective in choosing sexual partners, encourage the client to consider the consequences of his or her action, or pursue a different course?

Although you may say that you are open-minded and that you can accept sexual attitudes and values that differ from your own, it may be that you are inclined to try to change clients who you believe are involved in self-destructive practices. Assess your attitudes toward casual sex, premarital sex, teen sexuality, and extramarital sex. What are your attitudes toward monogamy? What do you consider to be the physical and psychological hazards of sex with more than one partner? How would your views on this issue influence the direction you would take with clients in exploring sexual concerns?

When you have made this assessment, ask yourself whether you would be able to work objectively with a person who had sexual values sharply divergent from yours. If you have very conservative views about sexual behavior, for example, will you be able to accept the liberal views of some of your clients? If you think their moral values are contributing to the difficulties they are experiencing in their lives, will you be inclined to persuade them to adopt your conservative values?

From another perspective, if you see yourself as having liberal sexual attitudes, how do you think you would react to a person with conservative values? Assume your unmarried client says that he would like to have more sexual experiences but that his religious upbringing has instilled in him the belief that premarital sex is a sin. Whenever he has come close to having a sexual experience, his guilt prevents it from happening. He would like to learn to enjoy sex without feeling guilty, yet he does not want to betray his values. What would you say to him? Could you help him explore his own value conflict without contributing to his dilemma by imposing your own values?

Case study: Sexuality in a group home for the disabled.

You are a social worker in a group home for disabled adults and discover that some of the residents are having sexual intercourse with each other. Although these clients are adults, you wonder if their parents or conservators need to be contacted.

Your stance. What would your initial reaction be if you discovered that clients were having sexual relations with each other in the group home? How might you react if the parents expressed strong disapproval and demanded that the group home staff take action to prevent sexual activity? If certain clients expressed their love for each other and made it clear that they were going to continue pursuing a sexual relationship regardless of their parents’ approval, what would you do? Given the disability status of these adults, what are the legal implications in this case?

Discussion. There are several factors to consider in this case. If you were the helper in this setting, you would do well to raise these questions: Why are my values entering into this situation? Could I bracket my values so that they do not interfere with the clients’ decisions and behaviors? What is the policy of the agency on this matter? What legal considerations might I want to discuss with a supervisor at the agency? Reflect on the vulnerability of the people in the group home, especially if abuse or coercion is taking place. In this situation, discussing these questions with a colleague and a supervisor would be an important step to take.

End-of-Life Decisions

Psychological services are useful for healthy individuals who want to make plans about their own future care. Such services are also beneficial to individuals with life-limiting illnesses, families experiencing the demands of providing

end-of-life care, and bereaved individuals. With growing public support and continuing efforts by states to legalize physician-assisted suicide, it is likely that an increasing number of clients will seek professional assistance in making end- of-life decisions. It is essential to know the laws in your jurisdiction and state and to be familiar with the ethical guidelines of your professional organization concerning an individual’s freedom to make end-of-life decisions. Seek legal consultation in cases involving a client’s request for more explicit assistance with hastened death.

Some of you will be faced with assisting clients in making end-of-life decisions, including deciding whether to take active steps to hasten death. As a helper, you need to be willing to discuss end-of-life decisions when clients

bring such concerns to you. If you are closed to any personal examination of this issue, you may interrupt these dialogues, cut off your clients’ exploration of their

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feelings, or attempt to provide your clients with your own solutions based on your personal values and beliefs.

Some end-of-life decisions are made more broadly than is the case with physician-assisted suicide. Some individuals will refuse all treatment as a choice of ending life. This option should not be considered as a passive approach because some action must be taken or not taken to allow death to occur. In this situation, does a helper have an ethical responsibility to explore the client’s decision to refuse treatment? Even though it is not against the law to refuse treatment, the client may have made this decision based on misinformation.

A counselor could help the client assess the nature of the information upon which his or her decision was based.

Gamino and Bevins (2013) identify a host of ethical challenges and dilemmas that counselors may need to consider regarding end-of-life care: respecting client autonomy; assessing an individual’s capacity for decision making; honoring advance directives; respecting an individual’s cultural values; maintaining confidentiality; dealing with medical futility; establishing and maintaining appropriate boundaries; and including families in the scope of care. In addressing these ethical issues, practitioners should assist their clients in making decisions within the framework of their clients’ own cultural beliefs and value systems. Counselors must struggle with the ethical quandaries of balancing the need to protect client rights to autonomy and self-determination with meeting their ethical and legal responsibilities regarding end-of-life care. They must be prepared to work with both those who are dying and their family members.

Cultural considerations also affect the relationship helpers have with people who are near the end of life (Kwak & Collet, 2013). Cultural beliefs influence decisions about many concerns related to the end of life. Although it is not possible to be fully informed about every cultural group, counselors are expected to engage in discussions about the beliefs of the dying person and family members early in the process as a way to be prepared for times when culture intersects with the counseling process (Werth & Whiting, 2015).

Guidelines for Dealing With End-of-Life Issues

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For helpers who ask for assistance in clarifying and exploring end-of-life decisions, Werth and Holdwick (2000) provide these guidelines:

· Assess your personal values and professional beliefs regarding the acceptability of rational suicide.

· As a part of the informed consent process, give prospective clients information about the limitations of confidentiality as it applies to assisted death, if applicable.

· Make full use of consultation throughout the process.

· Keep risk-management-oriented notes.

· Consult the ethics codes and state laws that apply.

· Assess your clients’ capacity to make reasoned decisions about their health care.

· Review clients’ understanding of their condition, prognosis, and treatment options.

· Involve physicians in this process, as counselors may not fully understand these medical issues.

· Strive to include clients’ significant others in the counseling process.

· Assess the impact of external coercion on clients’ decision making.

· Determine the degree to which clients’ decisions are congruent with their cultural and spiritual values.

Consider these guidelines as you contemplate your own position with respect to key questions on end-of-life decisions. Do individuals have a right to decide whether to live or die? Do some individuals who are in pain have a

difficult time distinguishing between ending their life and ending their suffering? If so, do you feel ethically obligated to help clients clarify whether they merely want their suffering to end or whether they truly have a desire to end their

life? Are you aware of the laws of your state and the ethical standards of your professional organization concerning an individual’s freedom to make end-of-life decisions? If your personal or professional value system is not accepting of an individual ending his or her own life, how might your beliefs get in the way of assisting your client who may be struggling with this decision? What could you do to manage a conflict in values between you and your client?

Case study: The right to choose to die.

A man in his 30s, Andrew, discovers that he has tested positive for HIV. Some of his friends have died from AIDS, and he sees nothing ahead for him except a bleak future. He has been your client for several months and has been successfully exploring other issues in his life. Andrew is clearly leaning in the direction of ending his life before he becomes very ill. Andrew is rational, and he believes that taking this action would be reasonable and in accord with his basic human rights. How would you begin a discussion with Andrew about his future?

Your stance. AIDS was once a deadly disease, and people suffered from a social stigma as well as debilitating illness. With the medications available today, HIV has become a chronic and manageable condition, and Andrew can live a long and full life. As a mental health worker, would you attempt to help Andrew understand that he can live? Would you explore with Andrew the fears that have led him to consider ending his life? What is the role of mental health professionals in working with a person considering some form of hastened dying? Is it the proper role of the helper to steer the client in a particular direction? Is your role to prevent Andrew from taking actions that would hasten his death?

Discussion. What is your position on an individual’s right to decide about matters pertaining to living and dying? Is this issue now more complicated by the fact that this condition can be successfully managed? Should he be prevented from ending his life, even if it means taking away his freedom of choice? It is your responsibility to clarify your own beliefs and values pertaining to end-of-life decisions so you can assist your clients in making decisions within the framework of their own belief and value systems. Once you understand your own perspective on end-of-life decisions, you can focus on the needs and personal values of your clients.

Case study: Confronting the right to die.

Esmeralda, who is in her early 40s, is suffering from advanced rheumatoid arthritis. She is in constant pain, and many of the pain medications have serious side effects. This is a debilitating disease, and she sees no hope of improvement. She has lost her will to live and comes to you, her therapist of long-standing, and

says: “I am in too much pain, and I don’t want to suffer anymore. I don’t want to involve you in it, but as my counselor, I would like you to know my last wishes.” She tells you of her plan to take an overdose of pills, an action she sees as more humane than continuing to endure her suffering.

Your stance. Think about how your values might influence your interventions in this case. To what degree can you empathize with Esmeralda’s desire to end her life? What role would your beliefs play in your counseling? Would you want to be kept alive at all costs, or might you want to end your life? Would you feel justified in doing so? What would stop you?

Discussion. Mental health counselors must understand their own values and attitudes about end-of-life options (such as clients’ autonomy and their right to participate in hastening their own death). In addition, counselors need to understand their role in the decision-making process of clients who may choose to hasten their dying process (Bevacqua & Kurpius, 2013). Do you have an ethical and legal responsibility to prevent Esmeralda from carrying out her intended course of action? Do you think you would be able to find meaning through suffering in an extreme circumstance? If you were in full agreement with her wishes, how would this influence your intervention?

Case study: The counselor’s legal duty to report.

Josh, a 65-year-old former client of William Park, returns to see him. He is now widowed, his only child is dead, and he has no living relatives. He has been diagnosed with a slow, painful, terminal cancer. Josh tells William that he is contemplating ending his life but would like to explore this decision. William fears being put in a bind because of the potential legal requirement to report him if he decides to end his life. Josh comes weekly, discusses many things with his therapist, and talks lovingly of his deceased wife and daughter. He thanks William for his kindness and his help throughout the years. He has made up his mind to end his life in the next few days, and after a last farewell he goes home.

Your stance. Do you think William should make a report as a way to protect Josh? What would you do in this case? Explain your position in the context of your own values regarding end-of-life decisions. Do you see any conflict between ethics and the law in this case?

Discussion. Suppose you felt like ending your life even after trying various ways of making your life meaningful. Imagine you felt as if nothing worked and that nothing would change. What would you do? Would you continue to live until natural causes ended your life? Do you believe that any reason would justify you taking your own life? How might your personal decision process influence how you assist clients in their decision making?

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By Way of Review

· There are numerous areas in which your values can potentially conflict with the values of your clients. Ethical practice dictates that you seriously consider the impact of your values on your clients and that you learn how to manage any value conflicts you may have with clients.

· Ultimately, it is the responsibility of clients to choose in which direction they will go, what values they will adopt, and what values they will modify or discard.

· It is not the helper’s role to push clients to adopt the personal values of the helper.

· Students and practicing counselors have a right to embrace their own personal and moral values, but it is crucial that they do not use their personal values as a yardstick by which to measure the validity of the values of their clients.

· Simply because you do not embrace a client’s values does not mean that you cannot work effectively with the person. By bracketing your personal values from your professional duties, you are being objective, nonjudgmental, and respecting your client’s right to autonomy.

· Referring a client may be inappropriate, unethical, and may constitute an act of discrimination. Client referrals among mental health practitioners who hold specific, rigid values often involve discriminatory practices that are rationalized as ways to avoid harming the client or practicing beyond one’s level of competence.

· Counselors who work with LGBTQI clients have a responsibility to understand the special concerns of these individuals and are ethically obligated to acquire the knowledge and skills to competently deliver services to them.

· With self-reflection, it is possible for helpers to become more culturally sensitive and more gender sensitive and to avoid imposing their personal values on individuals, couples, and families.

· In two Supreme Court cases, the university’s right to require students to comply with nondiscrimination guidelines in counseling clients were found not to infringe on the students’ rights to religious freedom. Students in both cases were offered remediation but declined this educational assistance in clarifying the boundaries of their personal values when counseling clients with different values.

· Several states have added freedom of conscience clauses to legislation to ensure that the licensure status of mental health professionals will not be in jeopardy if they refuse services to clients on the basis of sincerely held religious or personal values.

· Clients facing decisions due to an unplanned pregnancy can be invited to talk about the value systems they hold and how their values support or conflict with the choices they are considering.

· Assess your own sexual attitudes and values, and ask yourself whether you would be able to work objectively with a person whose sexual values are very different from your own.

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· With continuing efforts by states to legalize physician-assisted suicide, an increasing number of clients may seek professional assistance in making end- of-life decisions. Know the laws in your jurisdiction and state, and consult the ethical guidelines of your professional organization regarding end-of-life decisions.

What Will You Do Now?

1. Spend some time reflecting on the role you expect your values to play in your work with a range of clients. How might your values work for you? Against you? Reflect on the source of your values. Are you clear about where you stand on the value issues raised in this chapter? In your journal, write some of your thoughts about these questions. Under what circumstances would you be inclined to share and perhaps explore your values and

beliefs with your clients? Can you think of situations in which it might be counterproductive for you to do so?

2. Consider a personal value that could get in the way of your being objective when working with a client. Choose a value that you hold strongly, and challenge it. Do this by going to a source that holds values opposite to your own. If you are strongly convinced that abortion is immoral, for instance, consider going to an abortion clinic and talking with someone there. If you are uncomfortable with issues pertaining to sexual orientation because

of your own values, go to a LGBTQI organization on campus or in your community and talk with people there. If you think you may have difficulty with religious values of clients, find out more about a group that holds religious views different from yours.

3. Mental health practitioners are sometimes too eager to suggest a referral rather than explore how they could work with a client’s problem. In small groups, discuss how you would handle a situation in which you encountered a value conflict but could not refer your client. What steps would you take to ensure that you were providing quality services to your client and were not imposing your values on him or her?

4. For the full bibliographic entry for each of the sources listed here, consult the References at the back of the book. For books dealing with the role of

spiritual values in the helping process, see Cashwell and Young (2011), Frame (2003), and Johnson (2013). For an excellent treatment on end-of-life issues, see Werth (2013a).

Ethics in Action Video and Workbook Exercises

5. For supplemental activities that accompany this chapter, see Part Two: Values and the Helping Relationship of the Ethics in Action DVD and Workbook program or the online program. Complete the response to each of the vignettes and bring your completed responses to class for discussion.

6. In video role play 8, Sexuality: Promiscuity, the client (Suzanne) is having indiscriminate sexual encounters, and her counselor (Richard) expresses concern for Suzanne when he learns about her sexual promiscuity.

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Richard then focuses on how Suzanne’s behavior plays out the recurring theme of abandonment by her father, but Suzanne doesn’t see the connection. If you were Suzanne’s counselor, how would you deal with the situation as she presents it? What ethical issues does this role play illustrate? Is it ethically appropriate for you to strongly influence your client to engage in safer sex practices, even if she did not ask for this?

Demonstrate how you would approach Suzanne through role playing.

7. In video role play 9, Being Judgmental: The Affair, the client (Natalie) shares with her counselor that she is struggling with her marriage and is having

a long-term affair. The counselor (Janice) says, “Having an affair is not a good answer for someone—it just hurts everyone. I do not think it is a good idea.” How would your values influence your interventions in this situation? In what value areas pertaining to relationships might you have difficulty maintaining objectivity? Are there situations in which you might want to get your client to adopt your values?

This vignette can be useful in small group discussions and also in role playing. Have one student role-play the counselor and show how he or she might work with Natalie. In a second role play, have one student become the counselor’s supervisor and demonstrate what issues the supervisor might explore with Janice.

8. Video role play 10, Imposing Values: A Religious Client, portrays a conflict of values between the client and the counselor. The client (LeAnne)

thinks prayer should be the answer to her personal problems. She doesn’t believe she is hearing the Lord clearly. Her counselor (Suzanne) has some trouble understanding what religion means to LeAnne, and Suzanne has difficulty working within LeAnne’s religious framework in the counseling relationship. Instead, Suzanne comments that she feels she is in competition with God and the client’s religion. Suzanne wants her client to put more faith in the counseling process rather than relying on her religion to solve her problems.

In small groups discuss some of these questions: Is it ethical for you to challenge your client’s belief in the power of prayer and her reliance on God to solve her problems? Explain. If a client introduces spiritual or religious concerns, what ethical issues arise if the counselor does not want to explore these concerns with the client? If LeAnne were your client, how might you proceed with her? What concerns do you have, if any, about your ability to remain objective with LeAnne if she wants to talk about finding her answers in her religion?

9. In video role play 11, Value Conflict: Contemplating an Abortion, the values of the client and the counselor clash. The client (Sally) is considering an abortion and the therapist (Lucia) has difficulty with this possible decision. Lucia feels uncomfortable because of her belief that life begins at conception, and she tells Sally that she will have to get some consultation to sort out her thinking.

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In small groups, discuss the ethical issues involved in this situation. How do you imagine Sally feels about her counselor’s responses? What are your thoughts about a counselor disclosing her beliefs about abortion to the client? Would it be ethical for this counselor to suggest a referral because of this value conflict? This would be a good case to role-play and show various ways of dealing with the client. When should a counselor seek supervision and consultation if value conflicts arise with a client?

10. In video role play 12, Counselor Disapproval: Coming Out, the client (Conrad) discloses his homosexual orientation. Conrad states that this is something he is struggling with, mainly because it is not accepted in his culture or in his religion. The client admits that he trusts his counselor (John) and that it feels good to be able to make this disclosure. Conrad wants his counselor’s help in coming out to his friends and family. John is not receptive and says, “Are you sure this is the best thing for you?” Then John discloses that he does not approve of homosexuality, emphasizing that he does not see this as “being very healthy.” Conrad reacts negatively to John’s judgmental attitude and lack of acceptance of who he is as a person.

In small groups discuss some of these questions: How does John’s disclosure of his values affect the client–counselor relationship? If you were John’s supervisor, what would you want him to look at? If you were the counselor in this situation, how would you respond to Conrad? If the counselor were to refer Conrad because of a value conflict, this would be a discriminatory referral, which is unethical. What steps can the counselor take, short of referral, to work effectively with this client?

11. In video role play 13, An Ethical and Legal Issue: End-of-Life Decision, the client (Gary) tells his counselor that he just found out he is HIV-positive and is seriously considering ending his life. The counselor (Natalie) tells Gary that she can’t believe what she is hearing. Natalie is doing her best to persuade Gary not to take his life. She tells him that he is taking the easy way out if he chooses to end his life. She asks him if he has a plan. Natalie suggests that he think about his family and other options. She lets Gary know that he may be in a crisis state and not able to make a good decision.

Can you see any potential conflict between the ethical and legal issues in this situation? If you were Gary’s counselor, would you respect his decision to end his life, or would you attempt to influence him to search for alternatives to suicide? After discussing the issues involved in this case, practice role playing the way you might deal with Gary.