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Volume 35INumber 3IJuly 2OI3IPages 245-261

Ensuring Ethical Practice: Guidelines for Mental Health Counselors in Private Practice

Cécile Brennan

Since mental health counselors in private practice often work in relative isolation, it is espe- cially important that they attend to ethical issues. This article reviews four dimensions of ethical knowledge: the foundation of ethical actions, counselors as agents of ethical action, the need to establish a decision-making process, and the importance of sustaining ethical practice by keeping current with clinical developments and attending to their own well-being.

One of the benefits of being in private practice is freedom to conduct an independent professional life. While insurance companies ean affect what occurs in the consulting room, their influence is at a distance. Fears of a malpractice charge or an ethics board eomplaint may sometimes rise to consciousness, but they are easily put to rest by refleeting that relatively few mental health counselors (MHGs) ever face such charges (Glosoff & Freeman, 2007; Neukrug, Milliken, & Waiden, 2001; Saunders, Barros- Bailey, Rudman, Dew, & Garcia, 2007). The freedom and flexibility to determine independent practice conditions, such as seeing no elients before 10:00 a.m., or a practice foeusing solely on the elderly or the young, for example, are what motivate many MHGs to join or start a private practice. As with political freedom, however, this professional freedom comes with added responsibilities.

MHGs in private practice need to attend to the ethical dimensions of their practice with heightened diligence. There is offen no immediate over- sight or system of checks and balances to support ethical practice. Indeed, in private practice no one is looking over your shoulder. That is why private praetitioners need to build their own ethieal support system. This article describes the knowledge needed and the steps that must be taken to ensure ethical practice.

Cécile Brennan is affiliated with John Carroll University Correspondence about this article should be directed to her at John Carroll University. Department of Education & Allied Studies, I John Carroll Boulevard, University Heights, OH 44tl8. Email: cecilebrennant^gmaiicom.

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FOUNDATION OF ETHICAL PRACTICE

The standards of ethical practice are set forth in the codes of profes- sional bodies and in the laws of eaeh state. For licensed counselors, codes include the American Counseling Association Code of Ethics (ACA, 2005) and the American Mental Health Counselors Association Code of Ethics (AMHCA, 2010). Licensed psychologists follow the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2010). Licensed social workers adhere to the National Association of Social Workers (NASW) Code of Ethics (2008). In addition to the mandatory codes, there are also aspirational codes developed for various specialties. For exam- ple, the Assoeiation for Speeialists in Croup Work (Thomas & Pender, 2007) has a detailed aspirational code. While these codes are essential, private practitioners must also follow the ethieal requirements of the state where they practice. If there is ever a conflict between the professional and the state code, the more stringent one is to be followed.

It is not surprising, then, that the first step toward being an ethical private practitioner is to become familiar with the codes and laws. Certain concepts that lie at the heart of the counseling process are equally impor- tant whether MHCs are in agency settings or in private practice. Terms like confidentiality, duty to warn, multiple relationships, and privacy should be familiar to all MHCs. Because these guiding principles are important in all counseling settings, they need not be reviewed here.

Far too many MHCs feel that reviewing the ethical codes and laws is all they need to do to conduct an ethical private practice. It is not. MHCs need to understand the principles that informed the creation of the ethics codes and recognize how principles and laws are translated into the kinds of actions a private practitioner must take.

Ethical Pñnciples The actions of MHCs working with clients should always be informed

by the core ethical principles of autonomy, beneficence, fidelity, justice, and non-maleficence (Beauchamp & Childress, 2001; Kitchener & Anderson, 2010). Derived from the field of medical ethics, these principles underlie the ethics codes and can guide MHCs when a situation arises for which a eode does not provide a clear answer. The principle of autonomy emphasizes the need for MHCs to ensure and respect client autonomy unless the client is at risk of harming self or others. This core principle helps them to keep their personal values and opinions in check as they help clients to achieve their maximum potential. Client goals are to be respected, and the values a client brings to the session need to be understood. Beneficence requires always work- ing in the best interest of the client.

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Fidelity emphasizes the need to honor commitments made to clients when engaging in a professional relafionship. Cancelling appointments at the last minute, showing up late for appointments, not being fully present during a session, not responding to requests for records —all violate the principle of fidelify. The ethical principle ofjustice requires treafing all clients equitably. For example, clients should not be discriminated against because they are on public assistance or, conversely, because they are excepfionally wealthy. Jusfice also requires MHCs to account for each client's unique cultural and personal history. For instance, a long-standing appointment may have to be rescheduled if it falls on a religious holiday. The principle of non-malefi- cence is derived from the medical oath physicians take, the Hippocrafic oath. Basically, its goal is that as pracfifioners we do no harm. Even if treatment does not resolve a client's problems, it should not make them worse.

Foundational Ethical Actions

Ethical principles and codes and state laws set out a number of essenfial actions MHCs need to take when working with clients. The most central and foundafional of these occur when the counseling relafionship begins; some will be revisited throughout the counseling process. Other acfions with ethical implicafions are professional protocols that dictate funcfional aspects of clinical pracfice. In agencies, some of these acfions are the responsibilify ofa paraprofessional office manager or whoever completes the inifial intake. In private pracfice the responsibilify all falls to the MHC.

Professional disclosure statement and scope of practice. A counselor needs to begin private pracfice by wrifing a Professional Disclosure Statement (PDS), which is required by most state licensing boards. This statement should be displayed in the office along with a copy of the license. It is also recommended that the PDS be given to clients. PDS examples can offen be found on the websites of state boards. Basically, the PDS should contain the M H C s name, address, and professional license number; a summary of edu- cation; whether the MHC is operafing under supervision or independently, and if sfill under supervision, the name of the supervisor; the fee schedule; a statement of the scope of pracfice; the name and address of the licensing board; and where complaints can be filed (Ohio Counselor, Social Worker & Marriage and Family Therapist Board [Ohio Board], 2012).

The item on the PDS that has the most ethical implicafions is the scope of pracfice. It is important that what is stated there correlates with the M H C s training (Wheeler & Bertram, 2008). MHCs need to recognize that a weekend CEU workshop on PTSD or sexual addicfion does not qualify them to work with clients who have those problems. A counselor who wishes to establish a new area of pracfice must first complete addifional coursework under the supervision of someone with the necessary experfise.

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MHGs are sometimes tempted to accept new clients even though they are not experts in the client's areas of concern. That is not appropriate, though if the MHG has had some training and is willing to seek supervision while working with the client, it might be acceptable to see the client. This is particularly true —even advisable —if the client cannot otherwise find assistance. In this situation the MHG needs to inform the client that he or she does not usually deal with the presenting issues and will be seeking supervision. This should also be written out and placed in the client folder.

In creating a PDS and adhering to a stipulated scope of practice an MHG is demonstrating professional responsibility. The PDS makes it clear that all clients are being charged according to a set scale (justice), and are being informed about the counselor's education and credentials so that a considered decision can be made about working with this particular coun- selor (autonomy). Stipulating the scope of practice ensures that the private practitioner is competent to treat the presenting concerns (beneficence, non-maleficence).

Informed consent. Eliciting informed consent continuously is also very important (Herlihy & Gorey, 2006; Sommers-Flanagan, R., & Sommers- Flanagan, J., 2007). Informed consent is both a legal and an ethical principle that requires counselors to explain fully to the client and, if a minor, to the legal guardian benefits, risks, and alternatives to the proposed counseling (Glosoff & Pate, 2002). The explanation should be geared to the individual's developmental level and intellectual ability. Often the process is managed by having the client, and if necessary a guardian, sign an informed consent state- ment. This is a good practice, but it is not sufficient. The informed consent process needs to continue throughout the counseling relationship (Barnett (Si- Johnson, 2010; Glosofi&- Pate, 2002). Gounselors need to be orally checking in with the client regularly to update informed consent. These check-ins should be documented in the client folder.

Many MHGs in private practice elect to use or adapt a standard informed consent form; samples can be found online and in a number of books for private practitioners (Hedberg, 2010; Wiger, 2010; Zuckerman, 2008). A standardized form offers assurance that the document contains all the information considered necessary for informed consent In engaging in a continuous process of informed consent, the counselor is ensuring adherence to the ethical principle of autonomy.

Privacy statement/HIPAA. As everyone who has visited a medical facil- ity knows, it is usual to be given a statement explaining its privacy practices. Examples of these forms abound; they can be reviewed and adapted to private practice (Hedberg, 2010; Wiger, 2010; Zuckerman, 2008). The forms, and the policies and actions they describe, indicate that the MHG is aware of the federal regulations governing storage and sharing of client information. In

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thoroughly explaining the policy and having clients acknowledge in writing that they have been issued a privacy statement, the counselor is demonstrat- ing adherence to the ethical principles of beneficence, non-maleficence and fidelity.

Billing and insurance companies. A private practice is a business. If the practice is large, with several MHCs, an administrative assistant may manage much of the business, but even so, the counselors are ethically, and some- times legally, responsible. That means clients must be fully informed about the practice's billing policies. Will they be charged for missed appointments? Is there a sliding scale that all clients can review? What is the procedure if clients cannot afford to continue treatment? Is payment required at the time ofthe appointment? Are any concessions made for a client who is temporarily unable to afford the co-pay? Prospective clients should be given a form that details the business aspects ofthe counseling relationship (Hedberg, 2010; Wiger, 2010; Zuckerman, 2008), spelling out in clear language the financial policies ofthe practice.

Billing can become very complicated when an insurance company is involved. When an insurer accepts a counselor as a provider, the counselor agrees to the company's fee structure. This means the counselor cannot charge the client any more than the company has stipulated. Even if the fee is quite low, say less than $40 an hour, and even if the client volunteers to pay more, it is unethical to accept. Most insurance companies also do not allow private practitioners to charge for no-shows, no matter what the policy ofthe practice may be. Operating ethically requires honoring the commitments made to each insurance company.

When the reimbursement rate is very low, MHCs need to be alert for any temptation to give a client less attention than if the client were paying the counselor's stated fee. Allowing the fee structure to influence the quality of counseling, and therefore ofthe counseling relationship, undermines several ofthe guiding ethical principles, particularly non-malfeasance, beneficence, and justice. If low fees are going to result in less attention and a lessened commitment to the client, MHCs in private practice should choose not to participate in those insurance programs.

Submitting bills to insurance companies requires a formal diagnosis. A particular insurance policy may award more sessions for certain diagnoses, or not cover some diagnoses at all (National Conference of State Legislators, 2011). To maximize the number of sessions a client can receive, and not incidentally increase the number of sessions that can be billed, an inaccurate or inflated diagnosis is sometimes given (Danzinger & Welfel, 2001; Kress, Hoffman, & Eriksen, 2010). While this may seem beneficial in that the client can receive more sessions, it is not appropriate for several reasons:

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1. A diagnosis of severe mental disorder goes on the client's permanent medical records. That may pose serious problems for clients later and may inaccurately skew future psychological evaluations or be consid- ered a pre-existing condition by an the insurer.

2. MHGs and insurance companies need to operate in an environment of mutual trust. Lying about a diagnosis undermines that trust.

3. Finally, lying about a client, however well intentioned, is unprofes- sional and unethical; it violates the principle of veracity or truthful- ness and accuracy.

Recordkeeping. MHGs are trained to empathize with their clients, to develop a therapeutic relationship, and to assist in their clients' struggles with emotions. \Vhat often does not get much emphasis is the importance of documentation. Maintaining good records is important for the client as well as often a matter of contractual obligation to insurers. A consistent approach to record-keeping and report-writing is necessary, and there are numerous resources to support it (see, e.g., Hedberg, 2010; Luepker, 2012; Wiger, 2010; Zuckerman, 2008). From an ethical perspective, what is important is that the records summarize what has occurred and document any actions of the counselor that may have ethical implications. For instance, if a MHG decides to accept a gift or, say, attend a client's graduation, the reason should be thor- oughly documented. If a counselor needs to report actions of the client to an outside agency or to another individual, for instance a legal guardian, the reasons for this, too, need to be documented, in a HIPM-compliant manner.

Professional will. The AGA Code of Ethics {AGA, 2005; Kaplan, 2008) and some state boards (e.g., Ohio Board, 2012) require counselors to have a transfer plan, also referred to as a professional will, in case the counselor becomes incapacitated or dies. This is particularly important for those in pri- vate practice who are the sole custodians of client records. In a professional will the counselor names a professional executor and sets out the process to be followed in terms of how clients will be notified and client records maintained. The executor will also meet with clients to offer assistance with referrals. Gther instructions should cover office procedures, access to files (keys, passwords, etc.) and software where client records may be stored, liability insurance policy information, coding information, tax identification numbers, passwords to voicemail, etc. An article by Bradley, Hendrieks, and Kabell (2012) contains an excellent description ofthe professional will.

THE COUNSELOR AS THE AGENT OF ETHICAL BEHAVIOR

Once counselors have ensured adherence to ethical codes, laws govern- ing counseling practice, guiding ethical principles, and actions that establish

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an ethical climate for counseling, the next step is to examine their own fitness to perform as an MHC (Burke, Harper, Rudnick, & Kruger, 2007; Tjeltveit & Cottlieb, 2010). The goal of this self-examination is to identify areas of ethical vulnerability. Doing so greatly reduces the chance that such areas of vulnerability will disrupt the counseling process. This process, introspective ethics, moves ethical preparedness from being just about rules, laws, and guidelines to being about the person of the counselor (Brennan, 2009). An MHC may commit an ethical violation by convincing him- or herself that it is the right action to take or may be in denial about some aspect of his or her own clinical functioning (Brennan, 2009; Burke et al., 2007; Tenbrunsel & Messick, 2004; Tjeltveit & Cottlieb, 2010). The process of introspection brings to the surface personal issues that could undermine ethical practice.

While this process is important for all MHCs, it is especially so for those who do not have a support system immediately available. Working interpersonally with people about pressing emotional issues, empathizing while listening to a depressed client talk, and mediating between couples and families in eonflict can all be very emotionally draining (Trippany, White Kress, & Wilcoxon, 2004). This reaction may be exacerbated if a sole prac- titioner is operating in an environment with considerable isolation, without the camaraderie, coUeagueship, and support found in an agency. The sense of isolation may foster an environment where the counselor's own unfmished emotional business ean surfaee unchecked.

The process of coming to an enhanced state of self-awareness to antic- ipate areas of potential ethical lapse has three steps, which Brennan (2012) calls the three windows of introspection. At each step the counselor must think deeply about a particular area. Three possible windows are personal history, emotional-temperamental, and conventional-functional.

Personal History Window

In reviewing one's own personal history particular attention should be paid to any circumstances that have especially powerful emotional content, whether positive or negative. The important factor is the strength of the emotional valence because that may result in countertransference (Celso & Hayes, 2007; Haidt, 2001). For instance, a counselor who had a particularly pleasant childhood in a small town with a large loving religious family may incorrectly read her adolescent client's circumstances, when they are similar, according to her own experience. As a result of this unconscious bias, the counselor may miss warning signs of abuse or neglect, or even deny evidence of it that the client presents. Conversely, an MHC who was bullied by ath- letes in high school may be unconsciously biased against a football-playing client. In both cases the situation is primed for an ethical violation. In the first case, not responding appropriately to circumstances of abuse or neglect

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violates the ethical principles of non-maleficence and fidelity as well as per- haps a reporting mandate. In the second case, the counselor's unconscious judgment is a violation of beneficence and fidelity.

These are just two of many possible examples. Only a systematic review of their past can provide the knowledge and insight counselors need to manage emotional carry-overs from the past. The review should begin by applying an adjective or phrase to each developmental period: childhood, adolescence, and adulthood. After this, each period should be examined for emotionally laden circumstances. Finally, by reviewing both the labels assigned and the specific situations that have emerged, it is possible to begin to identify the kinds of clients and circumstances that might trigger emo- tions that eould place a counselor at risk of committing an ethical violation. Once these circumstances and clients have been identified, it is possible to proactively adopt a mechanism to manage these situations appropriately. For instance, if an MHC knows that his or her own abusive childhood makes it difficult to keep appropriate boundaries when working with children and families where there is abuse, the MHC will be prepared to seek extra super- vision or consultation and engage in a strict ethical decision-making process when evaluating possible actions. By examining tbe past, counselors are bet- ter prepared to avoid bringing it into the present unconsciously.

Temperamental-EmoHonal Window In addition to becoming aware of how the past may be influencing coun-

seling, it is equally important to consider how the counselor's temperamental disposition and present emotional state may do so (Celso & Hayes, 2007). An extroverted, goal-oriented counselor may overly control the counseling process. Unchecked, this could lead to a loss of client autonomy. A coun- selor temperamentally predisposed to avoid conflict may hesitate to confront a client's pattern even when it is in the best interest of the client to do so. This becomes a violation of the principles of beneficence and fidelity. In some cases, a need to avoid conflict could even result in harm to the client, or the client's friends and family, if dangerous or threatening behavior is not responded to appropriately.

To avoid ethical lapses, counselors need to be thoroughly aware of the temperamental predisposition they bring into the counseling session. Equally important is for them to be aware of what is presently affecting their emo- tional state. A counselor going through an emotional divorce may be feeling abandoned and emotionally vulnerable. This could translate into feeling flattered by the attention of an attractive client, and perhaps even lead the counselor to breach professional boundaries and participate in a personal relationship with the client. Obviously, this would be a serious breach of ethics. Another example is the MHC who is experiencing serious financial

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difficulties and therefore cannot empathize with a client who has had to downsize from a large estate to a more modest home.

These are just two of many possible scenarios. The counselor needs to engage in a continuous personal inventory in order to bring to the surface such areas of emotional vulnerability before they emerge in a counseling ses- sion. Once aware of the possible vulnerabilities, MHCs should put in place mechanisms to manage difficult situations. These might include counselors themselves getting counseling, supervision, or consultation about cases that are triggering an unmanageable emotional reaction, or (if possible) not accepting new clients who are likely to trigger in the counselor feelings that would inhibit the therapeutic process.

Conventional-Functional Window Being a counselor in private practice, even as part of a larger prac-

tice, requires enhanced organizational skills (Crodzki, 2000; Stout, 2012). Counselors in private practice are responsible for many actions that would be performed by support staff in an agency. And even if a private practice has support staff, someone has to manage the staff. For all these reasons it is important for MHCs in private practice to assess their organizational and functional abilities. MHCs who tend to arrive late for appointments, not complete paperwork or complete it haphazardly, lose track of appointments, and not keep client files current are having difficulty managing the day-to-day operations ofa private practice. This failure can quickly become an ethical issue. Counselors who do not keep client appointments have failed in their responsibility to the client. Counselors who do not keep comprehensive cli- ent records have failed the client, violated the ethical code, and often violated agreements with insurance companies.

To prevent ethical breeches caused by inconsistent attention to the mechanics of day-to-day operations, private practitioners need to assess their ability to organize and manage themselves, and possibly an entire office. Forgetting appointments and meetings and procrastinating about completing paperwork often violates the ethical principles of beneficence and fidelity. This type of inattention to detail could also result in a client being over- billed. Any of these problems would be serious. Unfortunately, when some- one is not organized, the problems are usually multiple.

Once problems with daily functioning have been identified, counselors can put in place a structure to manage the practice more efficiently, perhaps by scheduling a time at the beginning or end of every day to complete paper- work; scheduling appointments electronically with an alarm to warn when the next appointment is to begin; and not scheduling appointments at times when the MHC is likely to arrive late. Such counselors might also benefit from a course in personal or small business management.

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ESTABLISHING A DECISION-MAKING PROCESS

MHCs in private practice need a clear procedure for what to do when- ever an ethical issue emerges. To create such a procedure, counselors must adopt an ethical decision-making model, establish an ethics support system, and create a list of resources in case outside assistance is needed.

Adopting a Decision-Making Model Decision-making models are step-by-step guides that lead the user

through the process of considering all facets of an ethical dilemma in order to select a course of action. There are many such models for the mental health profession (Cottone & Claus, 2000; Cottone & Tarvydas, 2006; Sommers- Flanagan, R., & Sommers-Flanagan, J., 2007; Welfel, 2012;). Cottone and Claus (2000) provided an excellent review of the literature of decision-mak- ing models and described several. The model chosen for thorough review here contains the essential steps common to all practice-based ethical deci- sion-making models.

Created under the aegis ofthe ACA, this model is a streamlined version (Forester-Miller & Davis, 1996). It has seven steps:

1. Identify the problem.

2. Consult the ACA Code of Ethics.

3. Determine the nature and dimensions ofthe dilemma.

4. Cenerate potential courses of action.

5. Consider the potential consequences of all options; choose a course of action.

6. Evaluate the selected course of action.

7. Implement the course of action.

Forester-Miller and Davis (1996) thoroughly described actions that need to be taken at each step. An MHC who follows this or another model will not easily fall prey to sloppy thinking or an unconscious bias toward a particular course of action. Use of the model should be explicitly documented in the client record. When an MHC can demonstrate that a chosen course of action is the result of a thorough process, even if the results of the action are not positive for the client, counselor negligence can be ruled out.

Besides applying this model, MHCs need to be aware of any ethical codes (e.g., AMHCA, 2010) or state laws that may apply to the specific situ- ation. Links to state laws can generally be found on the website of the state licensing body.

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Establishing an Ethics Support System Besides using an ethical decision-making model, it is very beneficial to

consult with knowledgeable colleagues who can act as ethics mentors. These may be former supervisors, members of a peer consultation group, or notable and respected MHGs. It is important to establish an ethical support system before an issue emerges. Mentors should be attuned to the nuances of the profession, as well as being knowledgeable about the relevant ethical code and laws. Mentors aet as edueated, objective reviewers of the process used to arrive at a decision. In talking with mentors, new concerns may surface; the mentors become both a sounding board and a valued source of second opinions about a decision.

Establish a List of Ethics Resources MHGs in private practice would also benefit from creating a list of

resourees to eonsult when an ethical dilemma emerges. Having sueh a list allows the counselor to reach out immediately for guidance. Sueh consul- tation is more likely to produce a well-reasoned decision. Resources might include the ethics helplines of professional organizations and some state boards, information from an attorney in case of a legal charge or a subpoena, and contact information for the malpractice insurer. Insurers provide pre-in- eident risk management and ethics training as well as legal eonsultation should an incident evolve.

SUSTAINING ETHICAL PRACTICE

Onee an ethical practice has been established, it must be sustained. This requires that MHGs monitor changes to the laws and codes governing the profession, ensure their own health and well-being, and stay abreast of changes within the field. Each of these areas will be reviewed with special attention to changes brought about by increased use of technology.

Monitoring Changes to Ethical Codes and Laws Updates to the law can be found on the websites of state licensing

boards. It is important that MHGs consult these sites regularly to keep infor- mation current. Links to the websites of many state boards can be found at the American Association of State Gounseling Boards: http: www.aaseb.org/ aws/AASGB/pt/sp/home_page. A central website for the social work profes- sion is the Associafion of Social Work Boards: www.aswb.org. The organi- zafion represenfing psychologists is the Association of State and Provincial Psychology Boards: www.asppb.net. Informafion at these sites will allow private pracfifioners to readily locate a parficular state board.

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In addition to staying current with what is happening at the state level, wise MHCs incorporate into their professional development such activities as reading newsletters, magazines, and journals on topics relevant to their prac- tice. Each of the major mental health professions has an aligned professional organization: AMHCA and ACA for eounselors, the APA for psychologists, and the NASW for social workers. Changes in codes of ethics are communi- cated in their publications, at professional meetings, and on their websites. Awareness of any changes, and especially of new interpretations of the code, is essential for sound ethical practice. Often associations and divisions of national groups offer ethics continuing education opportunities. Active participation, such as presenting or leading in appointed, elected or volun- teer service roles in professional associations, is also linked with enhanced professionalism and access to current ethical reasoning. Although private practitioners are necessarily isolated when working with clients, it is essential that they not be isolated from the profession.

Ensuring MHC Health Ö- Well-Being MHCs need to be aware of how their clinical work is affecting their

own health and well-being (Kahili, 1988; Lawson &• Venart, n.d.; Orlinsky & Ronnestad, 2005; Skovholt, 2001). Failure to monitor stress and fatigue can result in counselor impairment and inability to work consistently in the best interest of the client (Lawson & Venart, n.d.; O'Halloran & Linton, 2000). Compassion fatigue, burnout, and vicarious traumatization are terms used to describe MHCs who have become impaired. To avoid impairment arising from lack of self-care, MHCs need a method for routinely monitoring their Wellness.

This can be done using structured inventories, such as the Professional Quality of Life assessment (Stamm, 2002) and the Self-Care Assessment (Saakvitne, Pearlman, & Staff of TSI/CAAP, 1996). The first measures compassion fatigue, compassion satisfaction, vicarious traumatization, and potential for burnout. The second assesses how many Wellness activities a practitioner is using to remain healthy. Taken together, they provide a comprehensive picture of an M H C s professional life in terms of both risk of fatigue and burnout and a sense of what is being done to ensure Wellness. Wellness can also be monitored informally. MHCs who are members of peer support or consultation groups have the eyes of their colleagues on them. Changes in attitude or behavior can be noted and addressed by colleagues offering both support and suggestions for self-care (Catherall, 1995; Munroe etal., 1995)

Strategies for self-care can take many forms. O'Halloran and Linton (2000) provided an extensive list of resources for eounselors. Two more recent works have described new approaches to self-care. Christopher and

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Maris (2010) reviewed the use of mindfulness as a self-care technique. For MHCs who use cognifive behavioral or dialectical behavioral therapy, this approach will be familiar. A study by Patsiopoulos and Buchanan (2011) emphasized the usefulness of the pracfice of self-compassion for alleviafing stress and reducing burnout.

Staying Current: Use of Technology Staying current about changes in the pracfice of counseling and psycho-

therapy is parficularly important when change is occurring rapidly. The use of technology in counseling is a case in point. Ethical standards about the use of technology are changing almost as fast as the technology. Fortunately, the ACA, the National Board for Certified Counselors, and many state boards have already adopted general guidelines (AMHCA, 2012; Kaplan, 2006; Nafional Board for Cerfified Counselors, 2012; Ohio Board, 2012). While these guidelines are helpful, the best practices of today may not be the best practices of tomorrow. MHCs need to roufinely review the literature for new informafion about best pracfices in the use of technology in counseling. The most current information can be found at the websites of professional organi- zafions and in communicafions from them.

Central topics here are the use of email, social media, and video-assisted technology. As a first ethical principle, in the informed consent process and form clients should be advised about how these media may be used in counseling. If email is used only to schedule appointments and not to com- municate personal issues to the counselor, for instance, that should be clearly arficulated (Mulhauser, 2005; Zur, 2012). Clients should be told how offen the MHC checks email and advised about how to make contact directly in an emergency—email should not be used to communicate emergencies or per- sonal matters. Clients should also be informed that standard email services are not encrypted, meaning that informafion communicated is not perfectly confidenfial (Mulhauser, 2005; Zur, 2012).

A counselor who chooses to have a public social media page needs to think through the consequences: How will clients who request "friending" be handled? Some authors (e.g., Shallcross, 2011) feel that having a client as a "friend" consfitutes a dual relafionship to be avoided. Others (e.g., Reidenberg, 2010; Zur, 2012) are more open to the possibilify of having a professional social media page that welcomes clients. Again, during the informed consent process, clients should be told about the M H C s stance regarding social media and "friending" requests. Clients should also be advised that a social networking site is not an appropriate way to share confi- dential information.

Conducting counseling sessions via video conferencing is a growing realify (Lehavot, Powers, & Barnett, 2010; Shaw & Shaw, 2006), and as with

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all other issues related to use of technology, there are divergent opinions about it. Goncerns about online counseling center on the perceived loss of empathie contact and the lessened security of speaking over a network that is not fully HIPAA-compliant (Zur, 2012). Arguments in favor of it center on the increased ease of access and the reduction of disruptions to the coun- seling process (Shaw & Shaw, 2006). For example, a mother can make an appointment for when children are napping, and clients living in rural areas, or those who do not drive, can access services through technology. A client who must travel for work avoids a disruption in the counseling relationship by "meeting" online or by phone.

A counselor thinking of offering online services needs to investigate whether any state laws govern the practice (Zack, 2008). For instance, anyone providing online counseling services to residents of Ohio must be licensed there (Ohio Board, 2012). After ascertaining the legality, MHGs need to investigate current best practices for online counseling. Because technology changes so fast, the best sources for information are those that are kept up-to- date, sources like the professional organizations and those dedicated to the topic (International Society for Mental Health Online, 2000). Once all laws and guidelines have been consulted, counselors need to ensure that their clients understand both the potential risks and the benefits of online coun- seling. A thorough informed consent process can accomplish this.

CONCLUSION

Following these guidelines will enable a counselor to maintain ethical standards. A structure supported by a sound base of knowledge, personal introspection, a decision-making process, and clinical currency allows a counselor to comfortably manage the ethical concerns that inevitably arise.

REFERENCES

American Counseling Association. (2005). ACA code of ethics. Alexandria, VA: Author.

American Mental Health Counselors Association. (2010). Code of ethics. Retrieved from https:// www.amhca.org/assets/news/AMHCA_Code_of_Ethics_2010_w_pagination_exd_51110.pdf

American Mental Health Counselors Association. (2012). Recommendations for the use of technology assisted counseling for clinical mental health counselors. Retrieved from http://www.

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