Unit 2 Written Assignment: Applying the Ethical Decision-Making Model

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ETHICS IN COUNSELING AND PSYCHOTHERAPY: STANDARDS, RESEARCH AND EMERGING ISSUES

6th edition

Elizabeth Reynolds Welfel, Ph.D.

Chapter 1

Introduction to Professional Ethics A Psychology and Philosophy for Ethical Practice

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

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Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Counseling and psychotherapy are effective methods for relieving distress: 80% of those who receive services are better off than those who do not attend (Wampold, 2010).

Still, some services are harmful, at least 5% of clients deteriorate (Lambert 2010).

Much of that deterioration is related to unethical and incompetent practice

Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Dimensions of professional ethics

• Having sufficient knowledge, skill, and judgment to use efficacious interventions

• Respecting the human dignity and freedom of the client(s)

• Using the power inherent in the professional’s role responsibly

• Acting in ways that promote public confidence in the profession

• Placing the welfare of the client(s) as the professional’s highest priority

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Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Resource 1: Developmental psychology

Rest’s model of moral development applied to ethical practice

• Ethical Sensitivity

• Ethical Reasoning

• Ethical Motivation

reserved.

Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Resource 2: Codes of Ethics

American Counseling Association: Code of Ethics and Standards of Practice (2014)

American Psychological Association: Ethical Principles and Code of Conduct for Psychologists (2010)

American School Counselor Association: Ethical Standards for School Counselors (2010)

Association of Marriage and Family Therapists: Code of Ethics(2012)

National Association of Social Workers: Code of Ethics (2008)

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Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

These codes represent the official statements of the professions about what is expected of members, and all members are held accountable for actions that violate the code.

Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Advantages of Codes

• They support the professional faced with an ethical question

• They demonstrate that mental health professionals take seriously their responsibility to protect the public welfare

• They furnish members with a definition of what their colleagues consider the fundamental ethical values

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Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Limitations of a code

• Application to any one setting is limited. • Codes do not uniformly address cutting‐edge issues

• Codes sometimes represent what the board of directors can agree to, rather an ethical ideal

• Codes of ethics are not cookbooks for responsible behavior and do not always offer specific guidance

Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Resource 3: Literature from Philosophy

This scholarship defines the ethical principles, virtues, and theories that form the rationale for the specific statements in the codes.

It clarifies the values and virtues underlying the actions of responsible professionals and highlights that ethical practice always requires value judgments

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Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Ethical principles: respect for autonomy, beneficence (the obligation to do good), nonmaleficence (the avoidance of harm), fidelity to promises made, and justice.

Ethical theories: the most fundamental definitions of what defines ethical behavior

reserved.

Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Feminist theory: emphasizes systemic variables such as the power of the participants within the system and the impact of race, class, and oppression

Social constructivist model of ethical decision making: an ethical choice is viewed as primarily a socially interactive process

Positive ethics perspective: an approach to ethics that encourages practitioners to frame ethical action according to ethical ideals

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Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Resource 4: Literature from Neuroscience

This research offers some intriguing and controversial findings; it suggests that moral functioning may be affected by changes in the brain caused by early experience, and it supports the deep connection between emotions and moral judgments.

It also highlights the relationship between some forms of brain damage and misbehavior, especially damage to the prefrontal cortex (Damasio, 2007).

Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Research Findings on Professional Ethics

Sexual contact with clients is a frequent violation for which counselors and psychologists are disciplined. More males than females are in this category

Other kinds of multiple relationships that compromise objectivity occur repeatedly. Incompetent practice, violations of confidentiality, negligent responses to suicidal clients, and inappropriate fees are recurrent problems.

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Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Law and Ethics

Codes of ethics and laws related overlap substantially, but some conflicts arise. Laws seek to eliminate problematic behaviors, whereas codes also define good and desirable behaviors.

Professionals should focus on ethics not avoiding lawsuits or discipline as the best form of risk management

Chapter 1: A Framework for Understanding Professional Ethical Values and Standards

Creating a Positive Ethical Identity:

Professional ethics is not a matter of minimal compliance with codes and laws; it represents a deep personal commitment o be a virtuous clinician who strives for the ethical ideal.

The task is to integrate the values of the profession into one’s personal values

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Chapter 2

A Model for Ethical Practice Using Resources to Enhance Individual Judgment and Ethical Resolve

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

Chapter 2: A Model for Ethical Practice

Why a model is important

• Useful when ethical questions arise • Has substantial value in identifying the broader ethical issues

• Can identify likely issues to emerge in a setting before they happen

• Use is required by ACA and strongly recommended by APA and licensing boards

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Chapter 2: A Model for Ethical Practice

Forms of Ethical Reasoning (Kitchener, 1984)

Intuitive judgments: spontaneous ethical judgments motivated by emotion or by a person’s ordinary moral sense.

Critical evaluative judgments: a deliberate process in which professionals justify ethical decisions based on consideration of the facts involved, and consistency with professional values, virtues, and accepted standards for practice

Chapter 2: A Model for Ethical Practice

Welfel’s 10‐Step Model of Ethical Decision Making

Step 1: Becoming sensitive to the moral dimensions of practice

Step 2: Identify all the relevant facts, sociocultural context, and stakeholders

Step 3: Define the central issues in the dilemma and the available options

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Chapter 2: A Model for Ethical Practice

Welfel’s 10‐Step Model of Ethical Decision Making

Step 4: Refer to professional ethical standards and relevant laws and regulations

Step 5: Search out the relevant ethics literature

Step 6: Apply fundamental ethical principles and theories to the situation

Chapter 2: A Model for Ethical Practice

Welfel’s 10‐Step Model of Ethical Decision Making

Step 7: Consult with colleagues about the dilemma

Step 8: Deliberate independently and decide

Step 9: Inform appropriate people and implement the decision

Step 10: Reflect on the actions taken

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Chapter 2: A Model for Ethical Practice

Notes on the model

• Not all issues require all 10 steps

• Some are resolved with reference to codes and guidelines

• Prior experience with an issue can quicken the analysis

Chapter 3

Ethical Practice in a Multicultural Society The Promise of Justice

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Introduction

American society has never been culturally homogeneous, but changes in population demographics will render it truly heterogeneous.

In fact, by middle of the twenty‐first century, ethnic groups that have long been labeled minorities will collectively outnumber the majority population. This has already occurred in many states in the US.

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Attention to diversity has become so intense that some have called this movement psychology’s “fourth force” (Pedersen, 1991a)

These changes mean that mental health professionals will need multicultural competencies that equip them for providing effective service to diverse clients.

Competencies include (1) self‐awareness , understanding of one’s own cultural heritage and the impact of racism and discrimination on self and others (2) knowledge of other cultures and the impact of culture on human behavior, (3) skills in transcultural interventions and in adapting counseling interventions to meet the needs of a diverse clientele.

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Ethics Codes and Multiculturalism

• Codes place extensive emphasis on cultural competence.

• Other guidelines enhance responsible practice with diverse clients (e.g., the APA’s Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (2003); the Guidelines for Assessment and Intervention with Persons with Disabilities (2010); and ACA’s Competencies for Counseling Transgender Clients (2009) .

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Language of Multiculturalism

Culture is the “set of shared meanings that make social life possible” (Fowers & Richardson, 1996, p. 610).

Ethnicity is a shared identity derived from shared ancestry, nationality, religion, and race (Lum, 1992).

Multiculturalism is a “social‐intellectual movement that promotes the value of diversity as a core principle and insists that all cultural groups be treated with respect and as equals” (Fowers & richardson, 1996, p. 609). ©2016. Cengage Learning. All rights reserved.

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Language of Multiculturalism

Culture‐centered practice is a term endorsed by psychology to refer to the “cultural lens” psychologists should use as a central focus in their work.

A minority has long been identified as a group that has suffered discrimination or been oppressed.

Culturally diverse clients are clients from any group that is represented in the preceding definition of minority or are otherwise of a different cultural tradition from the professional or from those who hold a more dominant position in society.

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Language of Multiculturalism

Multicultural counseling or multicultural psychotherapy is any service in which the cultures of the client and the professional differ in ways that are likely to influence communication and therapeutic content and progress.

Prejudice is “the positive or negative evaluation of social groups and their members” (Sherman, Stroessner, Conrey, & Azam, 2005, p. 1)

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

The Foundation of Ethical Practice in a Diverse Society

Empathy is not possible without awareness of the sociocultural context in which a client is describing the reasons for seeking help.

Gallardo, “…to be culturally responsive is not a concept at which one arrives, but more a process that is life‐long and ever evolving” (2009, p. 428).

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

The Context of the Current Ethical Standards

Professionals are not immune from the prejudicial attitudes and can inadvertently perpetuate oppression and discrimination even if they want to practice sensitively.

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Sue, Bucceri, Lin, Nadal, and Torino (2007) refer to acts that are unintentionally prejudicial as racial microaggressions and define them as “brief and commonplace daily verbal, behavioral, and environmental indignities … that communicate hostile, derogatory, or negative racial slights and insults to the target person or group” (p. 72).

Two subtypes of this phenomenon are termed microinsults and microinvalidations (Sue etal., 2007).

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Codes of ethics include both aspirational principles and specific standards related to responsible practice in a diverse society throughout the codes, all emphasizing competent, respectful, and adaptive services.

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Sue and Sue (2007) laid out three components of multicultural competency: (1) self‐ awareness of one’s values, biases, personal beliefs, and assumptions about human nature; (2) an understanding without negative judgments of the worldviews and assumptions of culturally diverse clients; and (3) skill in using and developing counseling interventions appropriate with diverse clients.

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Multicultural Counseling Competencies and Standards (Arrendondo et. al., 1996).

4 components:

1. Awareness of the influence of one’s own cultural heritage on his or her experiences, attitudes, values, and behaviors and the ways in which that culture limits or enhances effectiveness with diverse clients.

2. Comfort with cultural differences and with clients from diverse cultures, and an attitude that values and appreciates cultural difference.

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Multicultural Counseling Competencies and Standards (Arrendondo et. al., 1996).

3. Honesty negative emotional reactions and preconceived notions about other cultures, recognition of their harmful effects on clients, and commitment to changing such attitudes.

4. Respect and appreciation for culturally different beliefs and attitudes.

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

APA’s Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (2003b) echo the same themes, with greater emphasis on the impact of bias on diagnosis and assessment.

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Measures to help professionals assess their level of multicultural competency

Multicultural Counseling Inventory by Sodowsky, Taffe, Gutlin, and Wise (1994)

See Hays (2008), Pope‐Davis and Coleman (1998), or Suzuki, Ponterotto, and Miller (2008) for additional measures

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Research findings

Recent research on the beliefs of professionals about the importance of multicultural competencies of mental health professionals show promising results: professionals perceive themselves as competent and view multicultural competency as important

Negative results: professionals believe themselves more competent than they seem to be

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

A critique of the ethics codes

• The ethical principles that underlie their tenets are not universally endorsed by all cultures.

• The emphasis on respect for individual autonomy in Western societies and in the codes is much less dominant in some Eastern and African cultures.

• Some claim they fail to help practitioners deal responsibly with cultural conflicts in fundamental ethical values.

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

A critique of the ethics codes

• LaFromboise, Foster, and James (1996) suggest that professionals must avoid both ethical absolutism (a rigid, dogmatic adherence to a particular set of ethical values) and ethical relativism (an equal acceptance of all ethical values).

• Fischer, Jome, and Atkinson (1998) echo discuss multicultural counseling as a “universal healing process that takes place in a culturally sensitive context” (p. 525).

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Other Recommendations

James and Foster (2006) encourage mental health professionals to be aware of the difference between rights‐oriented societies and duty‐oriented societies. They recommend that professionals develop what Aristotle referred to as practical wisdom, which is the capacity to use rules, norms, and standards in a contextual way.

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Misinterpretations of Multicultural Competence

1. Failure to take culture into account in the therapeutic process.

2. Failure to acknowledge intra‐cultural variations and individual differences.

3. Failure to see overlap in cultural groups

4. Failure to remember each interpersonal encounter is a multicultural encounter (Pedersen, 1991)

5. Thinking that attention to issues of cultural diversity is limited to professionals from European backgrounds or others in privileged groups

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Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

When Clients Express Prejudicial Ideas

Professionals must be respectful but cannot endorse actions in direct opposition to professional values and standards. They must not impose their values, but must stand by them.

Sometimes educating clients can be useful, if done respectfully.

Chapter 3: ETHICAL PRACTICE IN A MULTICULTURAL SOCIETY

Fundamental attitudes and background

• Openness • Inclusive Cultural Empathy • Specific Cultural Knowledge • Openness to Involvement of Support of Members of the Client Community

• Willingness to Adapt Interventions to the Individual

• Tolerance for Ambiguity

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Chapter 4

Competence to Practice Building and Maintaining a Foundation for Doing Good and Avoiding Harm

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

Chapter 4: Competence to Practice

Essential Components:

Knowledge: Comprehension of a body of information about theory and research in the field, the judgment to make an informed choice about what knowledge and interventions apply in a given situation, and a set of objective criteria for evaluating new theory and research (Spruill et al., 2004).

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Chapter 4: Competence to Practice

Components of Competent Practice

Skill: Successfully applying interventions with clients. Norman (1985) and Overholser and Fine (1990) divide this component into two kinds of skills: Clinical skill is the competent use of basic interviewing skills, and technical skill concerns effective use of specific therapeutic interventions in an evidence‐based context.

Scope of Practice: The boundaries of competent practice within which a professional must operate.

Chapter 4: Competence to Practice

Components of Competent Practice

Diligence: Consistent attentiveness to the client’s needs that takes priority over other concerns, including appropriate assessment and intervention for a client’s problem and maintenance of that care until services are completed. Diligence also encompasses emotional competence, the capacity of the individual “for self awareness and respect for ourselves as unique, fallible human beings” (Pope & Vasquez, 2010, p. 62).

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Chapter 4: Competence to Practice

Achievement of Competence

One is competent when one’s knowledge and skills are as well developed as those of other professionals previously demonstrated to be competent in the specified area. In other words, if, after education and supervised practice, one can carry out an intervention at least as well as supervisors or colleagues.

Also measured by attainment of the standards established by a professional association for a particular type of practice.

Chapter 4: Competence to Practice

Performance not Capacity as Central Feature

One may have the ability (i.e. capacity) to perform competently, but competence is judged in the performance of the task itself (Jensen, 1979).

Environmental circumstances, unpredictable events, mental health problems, or personal distress can compromise competent performance in someone with the capacity to be competent.

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Chapter 4: Competence to Practice

Competent performance probably varies from client to client and day to day. A realistic standard is a set threshold level for competent practice, which is not crossed. This threshold level should be defined as service that provides the client with the likelihood of benefit.

Chapter 4: Competence to Practice

Codes on Competence

ACA and APA and ASCA codes all identify extensive criteria for professional competence and for education of students and supervisees.

Licensing boards have similar standards to obtain a license and usually to renew one.

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Chapter 4: Competence to Practice

Advanced Credentials

Professional organizations have been formed to provide more stringent measures of competence and more direct assessment of therapeutic judgment and skills.

One organization is the American Board of Professional Psychology (ABPP). Practitioners may apply to this body to be certified as “diplomats” in their field.

The National Board of Certified Counselors (NBCC) provides the same service for counselors.

Chapter 4: Competence to Practice

Other Credentials

Woody (1997) describes dubious and bogus” credentials that have emerged because of increased competition in the marketplace for clients and reimbursement (p. 337). Practitioners “earn” these credentials when they pay the requisite fees and are often required to provide little additional verification of their training or qualifications.

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Chapter 4: Competence to Practice

Procedures for Developing New Areas of Competence

1. Obtain formal training of a length and depth needed for the activity

2. Engage in supervised experience

3. Demonstrate competence equal to professional standards for that activity

Chapter 4: Competence to Practice

Continuing Education: Criteria for Identifying Acceptable Training

The proposed training (1) is based on scientific evidence, objectively obtained; (2) includes sufficient classroom time to absorb the new material; (3) is offered by a professional with expertise in the area, and (4) provides opportunities for supervised practice and/or recommendations for obtaining additional supervised experience.

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Chapter 4: Competence to Practice

Competence with New Populations

Professionals need to evaluate readiness to work with different populations if training and experience in an intervention has been limited to another population.

Chapter 4: Competence to Practice

Competence in Rural Settings and Small Communities

Limiting scope of practice is difficult for these practitioners, given limited alternative access to care.

Practitioners should consider: risk of harm to client, opportunity to help, difficulty of access to alternative care, availability of supervision when needed, and willingness to monitor client progress very carefully when working with clients at the boundaries of their competence.

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Chapter 4: Competence to Practice

Other Criteria for Evaluating Competence:

1. Am I emotionally able to help? Also referred to as emotional competence (Pope and Vasquez, 2010).

2. Could you justify your decision to take on a client to a group of your peers? This is the “clean well‐lit room standard” Haas and Malouf (2005).

Chapter 4: Competence to Practice

Distress, Burnout, and other Problems of Competence

Given the emotional and cognitive demands of the profession, counselors and therapists must carefully monitor their ability to provide competent service, especially in setting where caseloads are high or financial pressures are great.

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Chapter 4: Competence to Practice

Distress, Burnout, and other Problems of Competence

Components of Burnout:

• Emotional Exhaustion (most common)

• Loss of a Sense of Accomplishment

• Depersonalization

Chapter 4: Competence to Practice

Stress in Crisis Counseling

Crisis work carries additional risks of emotional distress termed compassion fatigue or vicarious traumatization.

The primary manifestations of compassion fatigue include withdrawal and isolation from others, inappropriate emotionality, loss of pleasure, loss of boundaries with the client, and a sense of being overwhelmed or pressured.

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Avoiding Harm to Clients from Distress and Emotional Exhaustion

1. Recognize risks of mental health practice and celebrate its rewards.

2. Set clear limits about how much help you can humanly give. 3. Use the advice you give clients about self‐care. 4. Recognize your vulnerability and seek support when

overwhelmed. 5. Consider counseling or psychotherapy for personal problems,

even if not overwhelmed by them. 6. Prepare for possible symptoms of secondary post‐traumatic stress

when crisis intervention is predominant mode of service and take full advantage of support services.

7. Work to develop quality assurance programs in your work setting to reduce errors and thereby improve overall effectiveness of service.

Chapter 4: Competence to Practice

Good news about work stress

No counselor is doomed to experience any of these problems with appropriate self care, consultation, supervision, and professional networking.

Most therapists see their work as a healing environment not only for their clients but for themselves when they relieve the distress of their clients.

Professional associations and state boards often provide colleague assistance services.

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Chapter 4: Competence to Practice

Legal Ramifications of Incompetent Practice

4 Conditions for a successful liability action:

1. Existing professional relationship – duty to client

2. Substandard practice – breach of the duty

3. Harm to the client must have occurred

4. Therapist’s actions must have caused the harm

Chapter 5

Confidentiality Supporting the Client’s Dignity and Right to Privacy

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

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Chapter 5: Confidentiality

Confidentiality in the Professional Relationship: A Sacred Covenant (Driscoll, 1992)

Distinguished from personal confidences: • Very high client expectations of confidentiality • Clients’ statements are often even secret from

family/friends • Both content and contact with client are confidential • Professional faces real penalties for violation of

confidentiality • Even death does not release the professional from

confidentiality

Chapter 5: Confidentiality

Ethical Principles Underlying Confidentiality

• Respect for Autonomy. Newton (1989) argues that privacy is an essential component of individuality and selfhood

• Fidelity to promises made

• Beneficence

• Nonmaleficence

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Chapter 5: Confidentiality

Virtues Underlying Confidentiality

• Integrity

• Trustworthiness

• Respectfulness

• Compassion

Chapter 5: Confidentiality

Codes of Ethics

• All professionals codes highlight the importance of client confidentiality and the need for clear communication to clients about it and its limitation

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Chapter 5: Confidentiality

Interprofessional Communication

• Sharing client information with other professionals can be valuable and is sometimes essential, but clients must understand that their disclosures will be shared and consent to that communication if identifying information is revealed.

Chapter 5: Confidentiality

Office Staff and Confidentiality

• Office staff who need access to client data must agree to confidentiality and must be appropriately trained and monitored.

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Chapter 5: Confidentiality

Sharing client data with loved ones:

Simply put: prohibited unless information is so vague that there is no possibility that any individual client could be identified.

This standard is commonly violated.

Chapter 5: Confidentiality

Confidentiality and Privilege

Confidentiality refers to an ethical duty to keep client identity and disclosures secret and a legal duty to honor the fiduciary relationship with the client.

It is primarily a moral obligation rooted in the ethics code, the ethical principles, and the virtues that the profession attempts to foster.

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Chapter 5: Confidentiality

Confidentiality and Privilege

The legal term privileged communication refers to the client’s right to prevent a court from demanding that a mental health professional reveal material disclosed in a confidential professional relationship (Younggren & Harris, 2008) as part of evidence in a legal proceeding.

Chapter 5: Confidentiality

Confidentiality and Privilege

Confidentiality deals with the prevention of voluntary disclosure of inappropriate material by mental health professionals, the term privilege refers to the rules for preventing involuntary disclosures requested by parties in a legal action (Roback, Ochoa, Bloch, & Purdon, 1992). Privilege belongs to the client, not the professional.

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Chapter 5: Confidentiality

Subpoenas and Court Orders

• Subpoena, a legal demand to appear in court to give testimony.

• Subpoena duces tecum, a command to appear in court and bring along specific documents.

• A court order , a demand to provide either documents or testimony, or both. In contrast to a subpoena, a court order is issued by a judge who has evaluated the legal merits of the demand and has ruled that it is properly executed and consistent with current law.

Chapter 5: Confidentiality

In states where privileged communication statutes have been passed, counselors, social workers, and psychologists may not disclose material even if subpoenaed by an attorney unless they have client authorization to release that information.

APA has published Strategies for Private Practitioners Coping with Subpoenas or Compelled Testimony for Client Records or Test Data (APA, 2006).

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Chapter 5: Confidentiality

9 Limits of Confidentiality

1. Client requests to release information to a third party – most common when clients ask for insurance reimbursement for services

2. Court Orders for confidential information – most famous court case: Jaffee v. Redmond, U.S. Supreme Court, 1996 extended privilege to Federal Courts for psychotherapists but with exceptions

Chapter 5: Confidentiality

Limits of Confidentiality

3. Litigation against mental health professionals by clients releases the professional from confidentiality regarding the matter brought to court.

4. Litigation in which the client voluntarily discloses mental health treatment as part of the case also limits confidentiality.

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Chapter 5: Confidentiality

Limitations of Confidentiality

5. Mandated reporting required by Federal and state statues

• Child abuse and neglect

• Elder abuse and neglect (in most jurisdictions)

• Vulnerable adult abuse and neglect (in most jurisdictions)

reserved.

Chapter 5: Confidentiality

Limitations of Confidentiality

6. Clients dangerous to others: In many states (but not all) mental health professionals have a duty to protect or warn a third party at risk of serious harm from a client. Laws vary greatly so knowledge of statutes and case law in each jurisdiction is crucial.

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Chapter 5: Confidentiality

Limitations of Confidentiality

7. In some jurisdictions if a client is planning a future crime a mental health professional may be required to respond to police questioning about a client.

8. When clients with HIV spectrum disorders maliciously intend to infect others, that may be a limit. Otherwise, disclosure of client HIV status by mental health professionals is probably not allowed in most jurisdictions.

Chapter 5: Confidentiality

Limitations of Confidentiality

9. When clients with terminal illnesses are seriously considering hastening their death, confidentiality may be limited by law and is limited when the person is simultaneously diagnosable with a mental illness or has cognitive impairments.

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Chapter 5: Confidentiality

Confidentiality with Children and Adolescents

Codes offer general guidance but few specifics, so professionals must also rely on fundamental principles and virtues and legal requirements.

Unless otherwise specified by law, minors have no rights to secrets from parents/guardians, but some laws have given minors this right.

Whether minors can be granted any confidentiality in therapy also depends on their age and maturity level.

Chapter 5: Confidentiality Confidentiality with Children and Adolescents

• Fundudis (2003) identifies four factors to determine a minor’s competence: 1. Chronological age (including developmental history

and maturational progress)

2. Cognitive level (including language, memory, reasoning ability and logic)

3. Emotional maturity (including temperament, stability of mood, attachment, educational adjustment, and attitudinal style)

4. Socio‐cultural factors such as family values and religious beliefs

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Chapter 5: Confidentiality

Confidentiality with Children and Adolescents

Laws typically specify 4 exceptions to parents’ rights to consent to minors’ care

1. Mature minor

2. Emancipated minor

3. Emergency treatment

4. Court orders

Chapter 5: Confidentiality

Confidentiality with Children and Adolescents

Specific state and federal statutes allow for minors to consent to treatment in many cases for:

• Short term psychological care

• Some types of medical care, especially reproductive health care

reserved.

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Chapter 5: Confidentiality

Confidentiality with Children and Adolescents

Important, regardless of law, to attempt to involve parents in care as they have responsibility for minors. At the same time, the best interest of the minor takes priority over parental involvement.

Chapter 5: Confidentiality

Group and Family Counseling

Responsibility is to encourage members to keep disclosures confidential, to discuss limits with them at the initiation of treatment, and to monitor members’ compliance.

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Chapter 5: Confidentiality

Confidentiality and Diverse Populations

Cultural norms regarding individual rights to privacy from loved ones vary significantly and professionals need to be sensitive to cultural issues when discussing confidentiality with clients.

Chapter 5: Confidentiality

Confidentiality and Managed Care

Most clients are in managed care plans so to obtain payment for services requires disclosure of confidential information re diagnosis and treatment and preauthorization of services. Insurers may also reserve the right to audit records.

Clients must be informed of these disclosures and alternative forms of payment available.

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Chapter 5: Confidentiality

Technology and Client Records

When keeping records on a computer, tablet, or other mobile devices they must be kept secure during both storage and transmittal to another professional or third party payor. Theft or damage to mobile devices is common and back up for these records should also be a routine practice.

The responsibility lies with the professional to ensure that faxes, text messages, data stored on tablets, laptops, home computers, and other media are kept secure and not put at risk of hackers or of theft.

Chapter 5: Confidentiality

Technology and Online Client Contact

Ethical issues: Highlighted in ACA Code Section A. 12

Promising but innovative form of service

Client rights and privacy must be protected and clients must be informed of the limits of technology, confidentiality and issues related to informed consent

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Chapter 5: Confidentiality

Threats of Suicide‐Homicide

A rare but possible event especially when there is a history of domestic violence, when an older adult caregiver is depressed. Workplace violence happens also but it is the least common type.

Clients at risk tend to look depressed and not have a history of violence or acting out.

Chapter 6: Informed Consent

Rationale for its importance:

Clients have no other way to gain information about the service.

Consent expresses respect for client and can facilitate client engagement in the process.

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Chapter 6

Informed Consent Affirming the Client’s Freedom of Choice

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

Chapter 6: Informed Consent

Components of Informed Consent

1. Disclosure of relevant information the client needs to make a reasoned decision about whether to participate.

2. Free consent which means that the decision to engage in an activity is made without coercion or undue pressure.

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Chapter 6: Informed Consent

History of Informed Consent as a legal duty

First major case: Schloendorff v. Society of New York Hospital ruled that “every human being of adult years and sound mind has a right to determine what shall be done with his own body “(p. 93).

Second case: Canterbury v. Spence (1972, p. 783) concluded that, “The duty to disclose is more than a call to speak merely on the patient’s request, or merely to answer the patient’s questions; it is the duty to volunteer, if necessary, information a patient needs for an intelligent decision.”

Chapter 6: Informed Consent

Truman v. Thomas (1980) initiated the duty regarding informed refusal of care

Natanson v. Kline (1960) clarified that disclosure should include the nature of the illness, the treatment(s) available, their risks and the probability of their success, and alternatives to treatment and their risks

Osheroff v. Chestnut Lodge (1990) required disclosure of alternatives to proposed treatment

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Chapter 6: Informed Consent

Underlying Ethical Principles

• Respect for autonomy and the client’s right to self determination

• Nonmaleficence so that clients know risks • Justice so that clients (or their adult guardians) are

treated as equals

Nagy (2000) recommends that clinicians “consider telling [clients] what you would want a good friend to know … if he or she were consulting a psychologist for the first time” (p. 89).

Chapter 6: Informed Consent

Codes of Ethics on Informed Consent

Codes of Ethics have codified the requirement of truly informed consent in language that clients can understand and with some direct discussion of services by the professional – not all of consent can be delegated to subordinates.

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Chapter 6: Informed Consent

In addition scholars also recommend disclosure of:

• Logistics of counseling/psychotherapy • Discussion of release of information to third party payors

• Indirect effects of therapy • Alternatives to therapy • Risks and uncertainties of innovative forms of care

• Options for filing grievances

Chapter 6: Informed Consent

Explicit consent for recording of sessions is required by codes.

All standards for informed consent apply to all media in which counseling is conducted – phone, electronic, as well as face to face.

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Chapter 6: Informed Consent

HIPAA Requirements

This federal law covers any professional who uses any type of electronic communication in relation to their work.

Gives clients control of who has access to their private health information.

Includes both civil and criminal penalties for violation.

Chapter 6: Informed Consent

HIPAA’s Notice of Privacy Practices document allows for transmission of information to obtain payment from third parties, to provide treatment, and to keep the ordinary operations of the practice, agency, or institution proceeding in an orderly fashion. HIPAA requires all community‐ based mental health professionals to have clients read and sign the Notice of Privacy Practices so that clients understand what information will be released without explicit consent.

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Chapter 6: Informed Consent

Approaches to Informed Consent

Codes require BOTH written and oral review of consent issues.

Verbal discussion allows personalization of consent and avoids some of the bureaucracy.

Written documents give clients a chance to review consent components whenever they wish.

Important that documents be at a reading level clients can understand.

Chapter 6: Informed Consent

Formats for consent documents:

• Client information brochure • Frequently asked questions list • Declaration of client rights • Counseling/psychotherapy contract • Consent to treatment form • Web based materials, videos, etc.

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Chapter 6: Informed Consent

Consent is a process, not an event, an activity for client benefit, not therapist protection, or a formality. Counselors must keep this frame of reference in order to conduct consent responsibly.

Counselors must adapt process to crisis situations, must take into account social and cultural variables.

Chapter 6: Informed Consent

When serving adults not competent to consent (either temporarily or permanently) professionals must obtain substitute consent from a guardian or have legal authority to treat without consent.

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Chapter 6: Informed Consent

Consent with Minors

In most situations a parent or guardian must consent. However, client assent to services is also essential for treatment to be effective.

In some states teens as young as 12 are allowed by law to consent for short term services and parents need not be informed.

Chapter 6: Informed Consent

Court Mandated Counseling

Typically consent involves 3 conditions: 1. Voluntariness: Free consent

2. Capacity: Fundamental ability to understand

3. Comprehension: Ability to comprehend the language in which consent is discussed

In mandated counseling voluntariness comes into question.

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Chapter 6: Informed Consent

Court Mandated Counseling

The task is to weigh the deficiency in consent against the possible good that counseling might do for a particular person.

In essence, one engages in a kind of risk–benefit analysis, asking oneself, Would service without free consent be likely to do harm? Would the failure to provide treatment, even under these compromised circumstances, be likely to cause more harm than providing it? Do I have the skills, compassion, and attitude to help the client overcome the distrust inherent in mandated services?

Chapter 6: Informed Consent

Informed Consent to Assessment

All the legal duties and responsibilities for consent to therapy apply to testing and other assessment tools.

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Chapter 6: Informed Consent

Research Findings

Clients who have experienced a responsible informed consent process view self‐disclosure more positively and have more optimistic expectations for counseling outcome (Goodyear, Coleman, & Brunson, 1986).

Also, evidence suggests that adult clients view therapists who carefully develop informed consent as more trustworthy and expert than those who do not (Sullivan, Martin, & Handelsman, 1993).

Similarly, parents of children appreciate informed consent information (Jensen, McNamara, & Gustafson, 1991) and expect that mental health professionals will provide that information to them.

Chapter 6: Informed Consent

Compliance with ethical standards and licensing board rules for consent is inconsistent in both face to face and electronic services.

Claiborn et al. (1994) found that only 6% of the clients surveyed indicated that their therapists had given them information on the limits of confidentiality.

Especially problematic is waiting to disclose what cannot be held as confidential after the client reveals such information.

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Chapter 6: Informed Consent

Informed consent and social networking

Is it ethical for therapists to view clients’ Facebook pages without their consent?

Most scholars suggest that it is not consistent with standards or with ethical principles, unless there is a compelling risk of harm.

Chapter 7

Sexualized Relationships with Clients, Students, Supervisees, and Research Participants: Violations of Power and Trust

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

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Chapter 7: Sexual Misconduct

A Universal Prohibition

All health care professions explicitly and categorically state that sexual contact with current clients is unethical.

All licensing boards have the same standards.

Some states have criminalized sexual contact with clients.

Chapter 7: Sexual Misconduct

Still, the behavior continues at a slightly lower rate than previously, but has not been eliminated.

Why? • Intimacy of the counseling interaction • Mental health or character flaws in the professional

• Client misunderstanding of the nature of the therapeutic relationship that sets the stage for exploitation by someone they regard as an expert helper whom they need

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Chapter 7: Sexual Misconduct

History of the problem

For decades client claims of sexual exploitation were viewed as fantasies of mentally ill women, but that changed with of Roy v. Hartogs (1975). Currently, such allegations are taken very seriously. False claims happen, but are rare.

Chapter 7: Sexual Misconduct

When counselors make sexual overtures clients typically feel trapped, too dependent on the therapist to refuse.

Sometimes, they confuse the therapist’s kind empathic approach for interest in a personal relationship.

At other times they have a history of exploitation by those claiming to help, so they mistakenly think this is the price they must pay for help.

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Chapter 7: Sexual Misconduct

• Damage from sexual misconduct is extensive. Pope and Vasquez (2010) list 10 categories of distress:

1. Ambivalence 2. Guilt 3. A sense of emptiness and isolation 4. Sexual confusion 5. Impaired ability to trust 6. Confused roles and boundaries, 7. Emotional liability 8. Suppressed rage 9. Increased suicidal risk 10. Cognitive dysfunction

Chapter 7: Sexual Misconduct

Effects on the Professional and the Profession

Professionals often lose licenses, pay high malpractice claims, receive public as well as professional censure, and experience loss of their profession. Sometimes criminal charges ensue.

Since sexual exploitation is not the only ethical problem, they face other ethics charges.

The reputation of the profession is also damaged by such behavior.

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Chapter 7: Sexual Misconduct

Research on the Scope of the Problem

No age limit to client abuse exists either for clients or therapists

Male therapists and female clients are most commonly involved

No other demographic or professional competency correlate exists

More common in supervisory and teaching relationships than in therapy relationships but up to 5% of professional relationships may be involved sometimes

Chapter 7: Sexual Misconduct

Sexual Contact with Former Clients

Usually unethical or in violation of regulations, but is allowed under rare circumstances, after 5 years (for counselors) and 2 years for psychologists. Consultation with peers is crucial even when the time constraints have been reached.

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Chapter 7: Sexual Misconduct

Sexual Contact in Online, Educational, Consultation, and Employment Settings

The ACA and APA standards extend the prohibition of sexual intimacies with current clients to people in other kinds of professional relationships including students, supervisees and indicate that exploitation of anyone over whom the professional has authority is prohibited.

Chapter 7: Sexual Misconduct

Sexual Attraction vs. Sexual Misconduct

Most therapists sometimes feel attraction – a normal human response. Feeling attraction is not unethical, but acting on it is.

Most scholars also agree that disclosing attraction to clients is irresponsible.

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Chapter 7: Sexual Misconduct

The Place of Nonerotic Touch

The question of when a hug or a touch on the shoulder is ethical in the absence of any sexual intent depends on several variables: • Theoretical orientation of the therapist • Client culture and religious identification • Client history and diagnosis • Client transference and attraction to therapist or therapist attraction to client

Chapter 7: Sexual Misconduct

Providing Subsequent Therapy for Clients Victimized by other Therapists

Important to believe the client, not minimize the seriousness, explain client rights to file a complaint, assist with the complaint process as needed, keep client disclosures confidential unless a mandated reporting law exists (rare event).

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Chapter 8

Nonsexual Multiple Relationships and Boundary Issues Risking Objectivity and Client Welfare

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

CHAPTER 8: BOUNDARY ISSUES

Counselors usually maintain clear boundaries around a professional relationship to maintain objectivity and avoid exploitation. Boundaries around non sexual contacts need not always be rigid and extending them can sometimes be therapeutically beneficial.

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CHAPTER 8: BOUNDARY ISSUES

Definition of Terms

• Multiple relationship or boundary extension: A connection with a client beyond the professional relationship, e.g., buying groceries at a market where a client works. Formerly called dual relationships.

• Boundary crossing: an acceptable additional client contact.

• Boundary violation or boundary break: an unethical additional client contact, e.g., hiring a client as a office manager.

CHAPTER 8: BOUNDARY ISSUES

Types of Multiple Relationships

Circumstantial: e.g., Buying gasoline at a service station and seeing a client doing the same

Concurrent: Providing therapy to a neighbor

Consecutive: Providing services either before or after another connection with a client, e.g., treating someone with whom the therapist had served on the PTA board

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CHAPTER 8: BOUNDARY ISSUES

Scholars and ethics standards disagree on what constitutes an ethical or unethical boundary crossing

Some worry about a slippery slope to exploitation

Others argue that crossings can confuse clients

Others argue that they compromise objectivity in ways therapists do not always realize

CHAPTER 8: BOUNDARY ISSUES

Kitchener refers to the question of ethics of boundaries as an issue of social roles. The greater the divergence between roles, the greater is the risk of an unsatisfactory therapeutic outcome.

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CHAPTER 8: BOUNDARY ISSUES

Culture and boundaries

Client cultural background influences decision making. Not all groups appreciate or accept the fine distinctions Westerners make between professional and personal relationships.

CHAPTER 8: BOUNDARY ISSUES

Benefit vs. Risk

ACA emphasizes potential benefit as a major consideration in evaluating ethics.

APA emphasizes objectivity and avoidance of the risk of exploitation in their codes.

Neither code provides a blueprint for practice, so the burden of assessing the ethics of any given prospective multiple relationship falls largely on the individual practitioner.

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CHAPTER 8: BOUNDARY ISSUES

Sonne (1994) advises professionals to take a risk‐preventive stance neither code provides a blueprint for practice, so the burden of assessing the ethics of any given prospective multiple relationship falls largely on the individual practitioner.

CHAPTER 8: BOUNDARY ISSUES

Application to other professional relationships

Not limited to counseling/therapy relationships

Apply also the supervisory, employment, and teaching relationships

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CHAPTER 8: BOUNDARY ISSUES

Underlying Dynamics

1. Fiduciary relationship between professional and client. This means that the professional’s primary obligation is to promote the client’s well‐being.

2. Duty to abstinence from gratifying self interest

3. Duty to neutrality to enhance client autonomy and independence

CHAPTER 8: BOUNDARY ISSUES

Additional dynamics

Client emotional involvement with the therapist. The therapist becomes an important person in the life of the client, at least during their professional contact. When a professional has another role in a client’s life, trust may be endangered, the rules for interaction may be obscured, and expectations may diverge.

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CHAPTER 8: BOUNDARY ISSUES

Additional dynamics

Multiple roles may make the client unsure about when therapy begins and ends and what kinds of conversation are appropriate in which setting.

The third dynamic, the power differential between professional and client, may make clients acquiesce to the therapist’s wishes or suggestions even when doing so is at odds with their own desires.

CHAPTER 8: BOUNDARY ISSUES

Final dynamic

The confidentiality of services may be endangered by accidental disclosures by the therapists in the other contact.

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CHAPTER 8: BOUNDARY ISSUES

Questions to consider in decision making about boundary crossings:

1. How divergent are the 2 counselor roles?

2. Is promoting the client’s welfare the exclusive motivation of the professional?

3. Does the sociocultural context of the client make the boundary crossing more important to therapeutic process?

CHAPTER 8: BOUNDARY ISSUES

Questions to consider in decision making about boundary crossings:

4. Can the professional attain the same degree of objectivity and competent practice as is achieved in other professional relationships?

5. Is misuse of the professional’s power a plausible occurrence?

6. Is the professional reasonably certain that the crossing will not negatively affect the client’s emotional involvement or capacity to achieve the therapeutic goal?

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CHAPTER 8: BOUNDARY ISSUES

Questions to consider in decision making about boundary crossings:

7. Is the multiple relationship truly unavoidable?

8. Has an informed consent procedure been undertaken so that the client understands the its risks and the necessary arrangements?

9. Have both parties evaluated the changes that may result in their other relationships because of the professional contact?

CHAPTER 8: BOUNDARY ISSUES

Questions to consider in decision making about boundary crossings:

10. If the decision were presented to the practitioner’s colleagues (using the clear‐ light‐of‐day standard), is it likely that they would support the decision?

11. Is the professional willing to document the nonprofessional contact in case notes?

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CHAPTER 8: BOUNDARY ISSUES

Questions to consider in decision making about boundary crossings:

12. Have provisions been made for consultation and/or supervision to monitor risks

13. Have the client and professional developed an alternative plan

14. Is the professional committed to diligently following up

CHAPTER 8: BOUNDARY ISSUES

Practitioner views

Because of the changes in standards regarding boundaries and the role of individual judgment professionals have not generally agreed on what is ethical and unethical and have not always followed professional standards.

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CHAPTER 8: BOUNDARY ISSUES

Gifts in Therapy

What is a professional’s responsibility when a client offers a gift?

Codes do not prohibit gifts; ethics of accepting depends on the circumstances under which it was offered.

CHAPTER 8: BOUNDARY ISSUES

Gifts in Therapy

Professionals should take into account:

• Cultural factors

• Monetary value

• Nature and status of the professional relationship – is this a token of gratitude at the end of service or a recurring event during treatment

reserved.

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CHAPTER 8: BOUNDARY ISSUES

Other considerations in accepting gifts

• It promotes rather than endangers the client’s welfare

• It does not compromise the therapist’s objectivity or capacity to provide competent service in the future

• It is a token of appreciation consistent with the client’s cultural norms and with a small monetary value

reserved.

CHAPTER 8: BOUNDARY ISSUES

Boundary Considerations in Rural Settings and Small and Shared Communities

Client access to alternative services is limited

Therapists are more likely to know potential clients or their family members

Cultural norms in rural communities are more accepting of multiple relationships and circumstantial contacts are more frequent

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CHAPTER 8: BOUNDARY ISSUES

Recommendations for Small Community Practitioners

• Careful informed consent and ongoing monitoring of possible complications from a boundary crossing

• Frequent consultation/supervision • Keeping client welfare as highest priority • Keeping limits to boundary crossings – rural settings to not automatically justify them

CHAPTER 8: BOUNDARY ISSUES

Bartering for services

A rare event, not prohibited by the code, but one that should be used cautiously to avoid client exploitation.

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Chapter 9

Interventions with Groups, Couples, and Families Unique Ethical Responsibilities

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

Chapter 9: Group and Family Services

In addition to ethical responsibilities already mentioned, multiple person therapies involved unique responsibilities in regard to:

• Confidentiality

• Privilege

• Consent

• Competence

• Boundaries

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Chapter 9: Group and Family Services

Competence

Therapist power is increased in multiple person settings – training and supervision to learn group leadership skills is essential

Client vulnerability is greater, so screening of clients before group is also essential

Chapter 9: Group and Family Services

Confidentiality is limited because no legal sanctions exist for group or family members who violate it. Encouraging member commitment to confidentiality and monitoring it throughout group/family is an ethical duty.

Privilege may also be limited for the professional depending on state law.

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Chapter 9: Group and Family Services

Informed consent also involves:

• Disclosure of the limits of confidentiality and privilege

• Discussion of the power of multiple person therapies

• Disclosure of the “ownership” of the records of multiple person therapies

• Disclosure of policies regarding drop‐outs and/or non‐participation of family members

Chapter 9: Group and Family Services

Compliance with consent standards is uneven and many therapists fail to discuss unique limits of confidentiality in groups. Such omissions can have serious implications.

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Chapter 9: Group and Family Services

Groups with Minors and in the Schools

An effective and efficient mode of intervention, but more attention to confidentiality issues is needed because of the developmental levels of participants

Parental consent is also needed in most cases

Chapter 9: Group and Family Services

Boundary Issues

All the same duties apply in group and family

Concurrent Group/family and individual counseling – not unethical but tricky and can cause problems with group cohesion and confidentiality. Material disclosed in individual sessions cannot be disclosed in group or family without explicit permission.

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Chapter 9: Group and Family Services

Involuntary Group Participation

Those mandated to groups have the same rights as those mandated to individual therapy.

Professionals have the same informed consent responsibilities.

Chapter 9: Group and Family Services

Multicultural Issues

Most groups are multicultural. Professionals leading groups need to be sensitive not only to their own cultural awareness but also to that of the group members.

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Chapter 9: Group and Family Services

Families and Couples

Therapist values play a more central role in family therapy – because families come in many varieties, professionals need to be aware of their own beliefs about the definition of a healthy family and good parenting.

Insensitivity to cultural differences serious compromises quality and effectiveness.

Chapter 10

The Ethics of Assessment Using Fair Procedures in Responsible Ways

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

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Chapter 10: The Ethics of Assessment

Clients seek the professional help of counselors and therapists with two major goals in mind— (1) to find solutions to their problems and (2) to gain a better understanding of themselves.

The procedures that professionals use to achieve the first goal are collectively called assessment. The first step in helping is to accurately diagnose the problems and personal psychosocial resources of the client.

Chapter 10: The Ethics of Assessment

Assessment is conducted as a collaborative process between a professional and a client.

Competent assessments include judgments about client prognosis, strengths, and social supports along with determinations of the scope and severity of problems.

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Chapter 10: The Ethics of Assessment

Two aspects of assessment are especially vulnerable to abuse— (1) the use of diagnostic categories to describe client problems and (2) the use of psychological and educational tests.

To diagnose means to define in professional terms the nature, limits, and intensity of a problem a client brings to counseling (Welfel & Patterson, 2004).

Chapter 10: The Ethics of Assessment

Because of its association with naming and specifying problems, diagnosis has been pejoratively called “labeling” by some professionals.

Reliance on the DSM with its overlapping categories and issues with reliability in some diagnoses adds to the distrust of a medical approach to diagnosis.

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Chapter 10: The Ethics of Assessment

The limits of the DSM do not mean that diagnosis is inherently unethical or problematic if:

Professionals use this or any other system diligently and with training. Accurate diagnosis of a problem leads to more effective treatment and more hope for clients.

Chapter 10: The Ethics of Assessment

Power of Diagnosis

Diagnosis with a mental illness can limit some job options, life insurance options, and new self‐definitions, even if accurate, but it is necessary to be helpful ultimately.

Inaccurate diagnosis leads to improper treatment, client distress, and other problems.

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Chapter 10: The Ethics of Assessment

Problematic influences on diagnosis

• Method of payment – when insurance covers only certain diagnoses practitioners are more likely to use them even when not fully accurate

• Pressure to diagnose quickly • Confirmation biases and other heuristics misused by professionals

• Client reluctance to fully disclose symptoms in a new therapeutic relationship

reserved.

Chapter 10: The Ethics of Assessment

Ethics of Testing

Two groups with ethical duties:

• Test developers and marketers

• Test users who have responsibilities to developers and test‐takers

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Chapter 10: The Ethics of Assessment

Ethics for Test Developers

The fundamental ethical directives for test developers are (a) to prepare instruments with substantial evidence to support their validity and reliability, with appropriate test norms, and with a comprehensive (and up‐do‐ date) test manual; and (b) to keep the welfare of the consumer as a higher priority than profit.

Chapter 10: The Ethics of Assessment

Ethics for Test Developers

Developers must truthfully represent the test and restrict sales to professionals who can show they are qualified users. Most test developers require that users disclose their degrees, licenses, graduate courses, and training in psychological testing.

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Chapter 10: The Ethics of Assessment

Ethics for Test Users

1. To maintain test security to protect the rights of test publishers and the future usefulness of the measure

2. To use only tests for which they have been trained and deemed competent to administer independently and use them with sensitivity to sociocultural factors

Chapter 10: The Ethics of Assessment

Ethics for Test Users

3. To protect the rights of test takers, using only measures with appropriate psychometric properties in controlled conditions

4. To select and interpret results accurately and in context

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Chapter 10: The Ethics of Assessment

Legal obligations of test users

Test Takers have rights to see their results, to have their results explained, and usually to have copies of test reports under HIPAA.

Test takers may have access to test data but not to the test materials, those materials that are copyrighted by the publisher.

Chapter 10: The Ethics of Assessment

Definition of Qualified Test User

Differs from state to state, but is fundamentally governed by competence to understand when to use a test and how to interpret it accurately.

Tests should be relevant to the client, should be used as part of multiple criteria for decision making about diagnosis and treatment , and the inferences derived should be limited.

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Chapter 10: The Ethics of Assessment

Client rights in testing

• Understandable explanation of the reasons for testing

• Feedback about results in understandable language

• Confidentiality of results • Clear and comprehensive informed consent prior to testing

Chapter 10: The Ethics of Assessment

Characteristics of sufficient feedback

• The client’s satisfaction that he or she understands the meaning and implications of the test results

• The professional’s assessment that the feedback has clarified any confusion in the test findings

• Their agreement about the ways in which test results should influence treatment planning

• The implications of the release of these findings to others if the client agreed to the release prior to the testing

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Chapter 10: The Ethics of Assessment

Other ethical duties

Test data becomes obsolete – it is the duty of the professional not to use obsolete data

Test interpretation services should be used as a second opinion, not a substitute for competence

Be alert to the ways in which gender, age, race, ethnicity, national origin, religion, sexual orientation, disability, language, or socioeconomic status may affect the appropriate administration or interpretation of assessment tools.

Chapter 11

Maximizing the Opportunity to Prevent Misconduct and Minimizing the Damage when Prevention Fails

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

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Chapter 11: When Prevention Fails

Clients frequently tell their counselors and therapists about unethical behaviors by other mental health professionals.

According to Pope (1994), approximately half of all American mental health professionals have had at least one client who revealed sexual involvement with a prior therapist.

Chapter 11: When Prevention Fails

Information about ethics violations also may come from co‐workers and from one’s own observations of others’ behavior in the workplace.

Reports from practicing professionals show that between 15 and 28% of practicing psychologists had personal knowledge of an incompetent or unethical colleague (Floyd, Myszka, & Orr, 1999).

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Chapter 11: When Prevention Fails

When professionals act unethically, they may be disciplined by employers, the state or provincial licensing boards, and all national and state professional associations to which they belong. Interstate communication among licensing boards also occurs through the National Practitioner Data Bank.

Counselors and therapists who violate standards are also accountable to the courts in civil lawsuits for negligence, malpractice, or breach of contract, or in criminal court.

Counselors can utilize a model like Crowley and Gottlieb’s (2012) primary risk‐management model for more resources and for higher probability of responsible action.

The fundamental value of a model for primary prevention of ethical misconduct is that it attends to the practitioner and focuses on ways in which the “non‐rational” factors can affect ethical decision making.

Chapter 11: When Prevention Fails

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Crowley and Gottlieb’s (2012) model contains five stages:

1. Resource accumulation

2. Attention and detection of risk

3. Initial appraisal of potential risk

4. Preliminary risk management efforts

5. Elicitation and use of feedback

Chapter 11: When Prevention Fails

Procedures for dealing with unethical behavior by professionals

• Informal remedies recommended between colleagues for minor violations as a first step in most jurisdictions and in the ethics code. Some jurisdictions for some professions mandate reporting all violations to a licensing board.

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Chapter 11: When Prevention Fails

Formal Remedies

• Employer Complaint • Licensing Board Complaint • Professional Ethics Committee Complaint • Negligence/Malpractice Claim

All REQUIRE client agreement to release information related to any client interaction. Without client release, the suspected violation must be kept confidential.

Chapter 11: When Prevention Fails

If a complaint is received with proper releases, Boards and Ethics Committees first determine whether they have jurisdiction, then begin an investigation. Due process rights of the professional and the person filing the complaint are protected in the process.

If found guilty, professionals are sanctioned at different levels depending on the seriousness of the violation.

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Chapter 11: When Prevention Fails

Supporting the client through the complaint process

Professionals need to: • Avoid minimizing the suspected violation a client reports

• Explain complaint procedures and lengthiness of the process and give client full autonomy

• Explore client’s emotional reaction to filing a complaint and dealing with the process

Chapter 11: When Prevention Fails

Responding to an ethics complaint if filed against you

The risk of an ethics complaint happening to an individual counselor or therapist is extremely low (Van Horne, 2004). In 2009 complaints were received by APA for only .07% of the membership (APA, 2010).

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Chapter 11: When Prevention Fails

Responding to an ethics complaint if filed against you

Professionals need to: • Cooperate with formal requests • Get legal and emotional support • Avoid personal contact with the person filing the complaint

• Admit wrongdoing if it occurred, show the context, and demonstrate remorse and a plan for change

Chapter 11: When Prevention Fails

Self‐Monitoring: Taking responsibility for ethical missteps in the absence of any outside complaint

The typical mental health professional spends 30 to 40 years in practice. In that span of time ethical mistakes of varying seriousness will almost certainly occur. Many mental health practitioners admit both intentional and unintentional violations of ethical standards (Pope et al., 1987). Most never get reported or identified by others.

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Chapter 11: When Prevention Fails

Professionals who fail to acknowledge their vulnerability to misconduct are naive at best, and frightening at worst. One of the truest tests of a professional’s commitment to ethical practice is the way that person reacts when he or she deviates from ethical path and when colleagues, clients or disciplinary bodies are not likely to discover that deviation.

Chapter 11: When Prevention Fails

A Three Step Model of Recovery

Step 1: Acknowledging the violation

• The first task in self‐monitoring is to fully acknowledge the ethical lapse and understand its nature and scope without catastrophizing about it. This task requires careful reflection and tolerance for the emotional discomfort accompanying such reflection and is grounded in ethical sensitivity.

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Chapter 11: When Prevention Fails

A Three Step Model of Recovery

Step 2: Addressing and Responding to the Damage • Assessing harm to the client is the top priority, followed by damage to colleagues, others in the community, and to the reputation of the profession. Consulting with a trusted colleague who is objective, knowledgeable, and able to identify unconscious biases is often helpful. Then the professional should develop a strategy that will ameliorate that harm.

Chapter 11: When Prevention Fails

A Three Step Model of Recovery

Step 3: Rehabilitating the Professional

• A professional who has erred begins the process of recovery with an honest self‐evaluation that unflinchingly recognizes the mistakes made and seeks out the causes so that they will be less likely to recur. The goal here is not to engender guilt or shame, but rather to gather energy for the process of change.

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Chapter 11: When Prevention Fails

Compassion and Empathy

Personal accountability also involves compassion.

It reminds professionals that we are all vulnerable to ethical missteps and deters us from adopting an attitude of moral superiority toward professionals who have been accused of misconduct.

Chapter 12

Ethics in Community, College, Addiction, and Forensic Settings Avoiding Conflicts of Interest

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

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Chapter 12: Community, College, Addiction, and Forensic Settings

Counseling and Psychotherapy in Community‐Based Settings

Primary Ethical Issue: Conflict of Interest

Professionals must balance their own right to a fair profit from their work against clients’ rights to services and their roles as professional helpers. In addition, outside parties, especially those who provide payment for professional services, often affect the relationship between counselor and client. ©2016. Cengage Learning. All rights

reserved.

Chapter 12: Community, College, Addiction, and Forensic Settings

Counseling and Psychotherapy in Community‐ Based Settings

Responsibility 1:

• To set fair, clearly communicated fees sensitive to the financial status of the client. Professionals have a right to a fair income, but they are not allowed to place their own financial gain ahead of the welfare of clients.

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Responsibility 2:

• if service must be interrupted, mental health professionals ought to have in place mechanisms for alternate care so that clients’ therapeutic progress will be minimally disrupted by the interruption. If a referral is needed, specific and multiple options must be provided to the client.

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Counseling and Psychotherapy in Community‐Based Settings

Responsibility 3: • Records of services must be up‐to‐date, accurate, and confidential so that competent service can be provided and privacy can be protected. Records should be maintained for sufficient time for follow‐up care to be provided, and disposed of in ways that guarantee client privacy and follow the law.

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Responsibility 4:

• To recruit clients with fair, complete, and honest descriptions of their capabilities and credentials and to avoid direct solicitation of potential clients.

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Counseling and Psychotherapy in Community‐Based Settings

Responsibility 5:

• To interact ethically and responsibly with the media or when asked to give public testimony about matters before the legislature or to comment about social problems. Conducted ethically, such interactions educate the public and bring credit to the profession.

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Responsibility 6:

• If clients need to be hospitalized against their wishes, the procedures used should be respectful to clients and minimally restrict their freedom.

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Ethical Relationships with Colleagues

Relationships with colleagues in the community are built on respect, honesty, and fairness. Turf wars, private judgments about competencies, and disagreements among professional disciplines ought not to be carried into the consulting room.

Financial arrangements between colleagues should be open to client inspection and free from fee splitting or other forms of kickbacks.

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Dealing with Outside Payors

Professionals must advocate for their clients for needed services and for limited intrusion into their clients’ privacy.

They must assess appropriate diagnosis and treatment separately from insurance and financial considerations (i.e., avoid “upcoding”).

The frustrations with insurers that mental health professionals commonly experience do not excuse misrepresentations in diagnosis and treatment to those payors.

Chapter 12: Community, College, Addiction, and Forensic Settings

Ethics in College Counseling

Not just developmental issues:

In a 2013 survey of 97,000 college students, American College Health Association found that 11% of students reported a depressive disorder, 12.9% reported anxiety problems, 1.8% identified a substance abuse problem, and 6% listed experiences of panic attacks. Nearly one third (31.3%) reported feeling so depressed it was difficult to function at times, and 7.4% indicated that they had seriously considered suicide in the last 12 months.

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Ethics in College Counseling

College mental health professionals are also affected by increasing concerns about liability for student suicides and acts of violence.

They are part of the threat assessment team and have a role to play. However, they are still bound by confidentiality standards and privilege laws and are obliged to honor regulations governing their duties with clients at risk for violence to others in their jurisdictions.

Chapter 12: Community, College, Addiction, and Forensic Settings

Ethics in College Counseling

College mental health professionals need to keep abreast of laws in their state or province regarding privilege and the duty to protect and to fully explain the limits of confidentiality that apply to their clients.

They also have a responsibility to collaborate with college administrators to develop policies regarding threat assessment that protect student privacy as much as possible.

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Finally, professionals need to familiarize themselves with recent federal legislation, including clarification of FERPA applications to college students, the application of the Americans with Disabilities Act, and the Clery Act.

Chapter 12: Community, College, Addiction, and Forensic Settings

Ethics of Addiction Counseling

Addiction counseling requires professionals who are competent, who use power responsibly, and who honor boundaries.

Competence is crucial since abuse of substances is one of the most common problems clients experience and it occurs in conjunction with other mental health, social, and employment problems.

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Ethics of Addiction Counseling

Training in substance abuse treatment is uneven and general mental health training does not necessarily imply competence with this population. Ethical practice requires some training and supervision do competently do this work.

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Ethics of Addiction Counseling

Since substance abuse clients are typically reluctant or mandated clients, one ethical issues in working with these clients is the degree to which there is some voluntary component to their presence in treatment.

Counselors have an ethical responsibility to use their power wisely and not manipulate or coerce clients, but to educate them about the consequences of their substance use.

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Ethics of Addiction Counseling

The third major ethical issue relates to the appropriate management of professional boundaries since many of those who work with substance abusing clients have a history of abuse themselves.

The final important ethical issue is the tendency for clinicians’ to hold negative biases towards clients with substance use problems.

Chapter 12: Community, College, Addiction, and Forensic Settings

Ethics of Coaching

Coaching as a practice activity for mental health professionals emerged fairly recently, but it has grown dramatically in this brief period.

According to Whybrow (2008) it is an activity in which thousands of mental health practitioners now engage.

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Ethics of Coaching

Definitions of what constitutes good training, and competent practice are emerging and the research base on effectiveness is limited.

The central ethical issues in coaching parallel in many ways the ethical issues in counseling – confidentiality, consent, conflict of interest, and boundaries (Brennan & Wildflower, 2010).

Chapter 12: Community, College, Addiction, and Forensic Settings

Ethics of Coaching

In spite of these advances, it is important to note that no state licenses individuals for the practice of coaching or has requirements for such practice in their jurisdictions.

Consequently, if a person is offering services as a personal coach without reference to his or her credentials as a mental health professional, it is unclear whether a client who feels the coach acted negligently has any legal recourse.

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Ethics of Forensic Activities

The term “forensic mental health work” refers to those professional activities of a psychologist, counselor, or social worker that involve courts of law.

These include activities such as conducting child custody evaluations, assessing a person’s competence to stand trial or acting as an expert witness in a legal case.

Chapter 12: Community, College, Addiction, and Forensic Settings

Ethics of Forensic Activities

When conducted with allegiance to high ethical standards, such activities can bring credit to the profession and can improve the likelihood that the court will make a fair and reasoned evaluation of the questions before it.

Central ethical issues parallel other forms of practice: competence, consent, confidentiality, conflict of interest, boundaries, and power.

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Ethics of Forensic Activities

Professionals engaged in child custody evaluations or who are asked to give testimony in such a proceeding should be sure to respect the rights of both parents, be clear about one’s role in the court, and limit comments to direct experience.

Chapter 13

The Professional School Counselor Applying Professional Standards to the Educational Culture

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

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Ethical Issues Unique to School Counseling

1. The conflict between the open communication norms among educators and the confidentiality norm of the counseling profession. • Response needed – education of other school personnel.

2. The obligation to assist students experiencing personal and social difficulties and the potential for parents and community standards to conflict with students’ needs. • Response: Sensitivity to community standards, parental

contact and communication, and allegiance to student rights. Huss, Bryant, and Mullet (2008) advise written policies on confidentiality and written referral procedures which have school board approval.

Ethical Issues Unique to School Counseling

3. The responsibility of the schools related to cyberbullying and other harassing online behaviors. Between 12 and 43% of middle and high school students report that they have been victimized by cyberbullying, typically via email, chat rooms, social networking sites, and instant messaging (Dehue, Bolman, & Vollink, 2008). • Response: School counselors can educate parents and

children about the resources they have available to respond and about the serious implications cyberbullying can have on those who perpetrate it.

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Ethical Issues Unique to School Counseling

4. The confusing state and federal laws about parental rights to educational information about their children. • Response: Learn about applicable laws, especially FERPA and share knowledge with colleagues, students, and parents.

5. The obligations of school counselors with suicidal students. • Response: Counselors must understand suicide risk

assessment, must intervene when risk is high to get the student help and must notify parents.

Chapter 13: Ethics in School Counseling

Ethical Issues Unique to School Counseling

6. The complications of group counseling in schools • Response: Educate participants to confidentiality and

group process, inform parents about student participation (usually), and monitor student compliance.

7. The ethical challenges in post‐secondary planning • Response: Avoid practices that suggest compromises in objectivity and protect student privacy.

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Ethical Issues Unique to School Counseling

8. The ethics of peer counseling and peer mediation with minors.

• Response: Limit peer assistance programs to educational content, select, monitor and supervise carefully.

Chapter 13: Ethics in School Counseling

Chapter 14

The Ethics of Supervision and Consultation Modeling Responsible Behavior

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

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Fundamental Ethical Issues in Supervision

Competence in supervision is distinct from competence as a therapist. Education in models of supervision and research findings complimented by supervised experience in supervision is essential.

Chapter 14: Supervision and Consultation

Fundamental Ethical Issues in Supervision

Commitment to respect the rights of the supervisee: (1) provide appropriate educational experiences and informed consent to supervision, (2) give feedback on supervisee work based on observation or review of recordings of supervisee activity, (3) provide remediation experiences as needed, (4) keep supervision separate from therapy, and (5) respect boundaries to avoid misuse of supervisor power.

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Fundamental Ethical Issues in Supervision

Commitment to respect the rights of the supervisee:

Supervisors must keep written records of supervision and of any evaluative feedback or remediation plan.

Chapter 14: Supervision and Consultation

Fundamental Ethical Issues in Supervision

Appreciation of the need to be sensitive to multicultural issues in supervision.

Supervisors must reject the “myth of sameness” and acknowledge the reality and contributions of cultural diversity.

Supervisors must understand that their own views of the world may not be shared by their supervisees and that this difference does not represent a deficiency in anyone.

Supervisors are encouraged to devote the same energy to appreciating cultural diversity in supervision as they may use in understanding how cultural diversity affects therapy relationships.

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Fundamental Ethical Issues in Supervision

Appreciation of responsibility to clients served by the supervisee.

Clients have a right to competent service even when counseled by a trainee.

Supervisors are responsible to monitor care, and intervene if a client is receiving substandard service.

Clients also have a right to know they are being served by a trainee and to consent to any supervision or recording.

Chapter 14: Supervision and Consultation

Legal Issues in Supervision

Direct Liability: Supervisors can be held liable to any failure to carry out their duties

Vicarious Liability: Supervisors can be held liable for any negligence of their supervisees even if carrying out their own responsibilities in accordance with professional standards

These realities highlight the importance of competent and diligent supervision.

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Work Supervision

Work supervisors are responsible to ensure that clients receive competent care and employees are given appropriate rights and responsibilities.

One challenge is monitoring the work of those whom they oversee when the needs of the organization exert pressure to provide services. Another is managing boundaries effectively since co‐workers can often become friends.

The ethical duties of professionals in these positions parallel those of training supervisors in many ways. They must ensure that clients receive competent care and employees are given appropriate rights and responsibilities. Ethics standards apply here as well as in training supervision.

Chapter 14: Supervision and Consultation

Mandated Supervision

Mandated supervision occurs when a licensing board, employer, or ethics committee of a professional association requires professionals to have all or some portion of their work supervised because of a violation. Its goal is to ensure that the violation does not recur and to rehabilitate the professional.

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Mandated Supervision

The supervisor not only has responsibilities to the clients of the disciplined professionals and to the professional, but also to the board or organization that arranged for the supervision.

It requires substantial skill as a supervisor in order to establish a productive supervisory alliance with the professional that also allows for communication with third parties, set reasonable goals and methods of evaluation of the professional’s work, and be committed to the protection of clients.

Chapter 14: Supervision and Consultation

Consultation

Divided into clinical consultation with peers and organizational consultation

Clinical consultation can be an ongoing process in which the professionals meet regularly or it can be a event that happens only when an urgent client issue emerges

What distinguishes consultation from supervision is the equality of the participants in the process.

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Organizational consultation relationships are triadic rather than dyadic (Brown, Pryzwansky, & Schulte, 2011) and include the consultant, the consultee, and the client.

Newman (1993) cautions consultants to stay aware of all three participant groups in consultation, to be sensitive to the effects of their work on all parties, and to avoid situations in which their work may be used to the detriment of the client system.

Chapter 14: Supervision and Consultation

Managing confidentiality, consent, conflict of interest issues and boundaries is complicated in organizational consulting and to some extent in clinical consulting.

Consultants should have training in the mode of service and comply with their responsibilities to all parties involved.

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Chapter 15

Counselors and Therapists as Teachers and Researchers Integrity, Science, and Care

Welfel, E. R. (2014). Ethics in counseling and psychotherapy: Standards, research and emerging Issues (6th ed.).

Central ethical issues embedded in activities of teaching and science mirror those of direct service:

• Competence

• Responsible use of power

• Promotion of welfare of those in care

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Ethics of Teaching

Competence to teach • Knowledgeable about subject matter, prepared for work, and committed to facilitate student learning

Responsible use of power • Abuse of power can include sexual harassment or exploitation, indiscriminant evaluation of student performance, exploiting student labor for personal gain, or neglecting responsibilities

Chapter 15: Teachers and Researchers

Ethics of Teaching

Management of multiple, and sometimes conflicting, role obligations • Distinguish between mentoring and problematic dual relationships;

pay attention to power imbalance inherent in teacher‐student relationship

Duties to profession, students, and public • Educators have a duty to ensure students have emotional stability

and temperament for the profession and that personal issues that may impede their effectiveness are identified and resolved

• Counseling and psychology educators ought not to sacrifice competent and caring teaching to attend to other responsibilities

• Need for professional relationships of trust and personal responsibility for a psychologist’s actions

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Ethics of Research

Responsibilities of researcher:

1. To develop scientifically acceptable research protocols that are worth participants’ time and have reasonable chance of yielding meaningful findings • Poorly designed and executed research is unethical even

if participants are not at risk for harm or discomfort (Rosenthal, 1994)

• Good science assumes sensitivity to issues of diversity (Fisher & Vacanti‐Shova, 2012; Scott‐Jones, 2000)

Chapter 15: Teachers and Researchers

Ethics of Research

Responsibilities of researcher: 2. Protect the rights and safety of research

participants (both human and animal) • Institutional review boards (IRBs) approve and

oversee conduct of any research that involves risk of harming human subjects.

• Be aware of ethical guidelines for research with animals, e.g., APA’s Guidelines for Ethical Conduct in the Care and Use of Nonhuman Animals (2012).

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Ethics of Research

Responsibilities of researcher:

3. To report results fairly and accurately

• Most basic obligation is not to misrepresent results in any publication or communication of them to participants or colleagues.

Chapter 15: Teachers and Researchers

Ethics of Research

Responsibilities of researcher: 4. To cooperate with colleagues and share research

data • Ultimate goal of clinical research is to add to profession’s and public’s understanding of human behavior.

• Research is cooperative endeavor in which findings are shared with colleagues and peer criticism is conducted in educative rather than punitive fashion.

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Chapter 15: Teachers and Researchers

Special Ethical Concerns for Counseling and Therapy Researchers

1. Experimental design

2. Impact of treatments on participants

3. Accessibility of written information about clients and need for client consent to such activities

4. Provision of feedback