Ethical Dilemmas

108 Counseling and Values ■ April 2020 ■ Volume 65

© 2020 by the American Counseling Association. All rights reserved.

Received 06/30/17 Revised 12/21/17

Accepted 03/11/18 DOI: 10.1002/cvj.12125

The Role of Decision-Making Models and Reflection in Navigating Ethical Dilemmas

Jessica Burkholder, David Burkholder, and Martin Gavin

The ACA Code of Ethics (American Counseling Association [ACA], 2014) mandates counselor competency in using ethical decision-making mod- els (EDMs) and mandates that counselors use an EDM when confronted with making ethical decisions. Additionally, researchers have highlighted the importance of counselors continually evaluating and reflecting when faced with ethical dilemmas and working through a decision-making model. Using a phenomenological research design, the authors examined how counselors address ethical dilemmas, including how reflection and EDMs are incorporated into the decision-making process. Emergent themes from data analysis include (a) incomplete following of EDMs, (b) varied dilem- mas, (c) power, and (d) ethics training.

Keywords: ethical decision-making models, counseling, CACREP, counselor education, values

T he ACA Code of Ethics (American Counseling Association [ACA], 2014, Purpose section, p. 3) directs counselors to use a reliable model for mak- ing ethical decisions. Many models are available to counselors (Cottone

& Claus, 2000; Levitt, Farry, & Mazzarella, 2015; Remley & Herlihy, 2010; Sheperis, Henning, & Kocet, 2016), and counselors are expected to be fa- miliar with the process and leverage a model effectively on a case-by-case basis that best serves the client (Kaplan & Martz, 2014). Daily, counselors face complex situations that require a sound decision-making process for navigating those dilemmas (Forester-Miller & Davis, 2016). Kitchener (1984) described an ethical dilemma as “a situation in which there are good rea- sons to take different courses of action” (p. 53). Although some clinicians may expect that their ethical conflicts can be resolved by simply finding the appropriate section of the code of ethics, codes of ethics can be ambiguous and contradictory. Ethics codes are concurrently “too broad in some cases and too narrow in others” (Kitchener, 1984, p. 46).

Addressing the ambiguous and sometimes contradictory nature of codes of ethics, Kitchener (1984) emphasized the importance of considering a

Jessica Burkholder, David Burkholder, and Martin Gavin, Department of Professional Counseling, Monmouth University. Correspondence concerning this article should be addressed to Jessica Burkholder, Department of Professional Counseling, Monmouth University, 400 Cedar Avenue, West Long Branch, NJ 07764 (email: [email protected]).

Counseling and Values ■ April 2020 ■ Volume 65 109

more stable foundation to use than ethics codes when making decisions. She identified the most important principles—autonomy, beneficence, nonmaleficence, justice, and fidelity. These principles are the “foundation for ethical behavior and decision making” (ACA Code of Ethics, Preamble section, p. 3; ACA, 2014) and are infused in the ethical decision-making models (EDMs) most widely used in the counseling profession (Sheperis et al., 2016).

In line with Kitchener ’s (1984) recommendation, the task force for the most recent revision to the ACA Code of Ethics (ACA, 2014) acknowledged that a variety of EDMs exist but stopped short of endorsing a specific model (Kaplan & Martz, 2014). The task force declined to specify a par- ticular EDM because of the potential legal issues if an alternate model was available and valid but not used (Martz & Kaplan, 2014). Several scholars have identified commonalities in the most frequently cited EDMs. For example, Remley and Herlihy (2010) identified eight common elements across EDMs:

1. Identify and define the problem. 2. Consider the principles and virtues. 3. Tune in to your feelings. 4. Consult with colleagues or experts. 5. Involve your client in the decision making process. 6. Identify desired outcomes. 7. Consider possible actions. 8. Choose and act on your choice. (pp. 14–15)

Similarly, Forester-Miller and Davis (2016) found these common directives:

1. Identify the problem. 2. Apply the ACA Code of Ethics. 3. Determine the nature and dimensions of the dilemma. 4. Generate possible courses of action. 5. Consider the potential consequences of all options and determine a

course of action. 6. Evaluate the selected course of action. 7. Implement course of action. (p. 5)

Despite these similarities, Cottone and Claus (2000) found that EDMs exhibited a wide variety of foci and few were grounded in theory. Cottone (2001) noted that most models articulate steps for making an ethical choice but fail to describe how to make that choice. Cottone emphasized that ethical decisions made in a social context are not simply an intrapsychic process. The “how” of decision-making has been connected to the decision maker ’s moral development (Neukrug, Lovell, & Parker, 1996).

110 Counseling and Values ■ April 2020 ■ Volume 65

Moral Development

EDMs were developed to assist helping professionals facing ethical decisions. As counselors grow in their knowledge of ethics and moral development, they continue to need a sound ethical decision-making process. Neukrug et al. (1996) found that how a person uses the ethics code and EDMs, also known as the person’s decision-making style, was connected to his or her moral development and that counseling students needed to move beyond rote memorization and learn to reason ethically. When facing an ethical dilemma, the mature counselor continues to evaluate and reflect on their chosen course of action, whereas an immature helper is likely to be impetu- ous or overly confident.

Sheperis et al. (2016) noted the tendency for counselors to take decision- making shortcuts and act on the basis of what seems to be common sense or what feels right. As a result, counselors frequently end up making decisions that are based on their own personal values, not the values of the profession or the laws that govern clinical practice (Sheperis et al., 2016). Sheperis et al. emphasized that counselors must follow an EDM to ensure that their values are consistent with those of the counseling profession. Neukrug et al. (1996) asserted that education must attend to the character of the decision makers and “attempt to stimulate cognitive development in the moral domain” (p. 104), so that helpers become skilled at integrating ethical guidelines with their personal and professional values. For the developmentally mature counselor, the ethics codes and decision-making models are tools used in their deeply reflective decision-making process.

Kitchener (1984) offered a similar caution and directed counselors to pursue a greater understanding of their ethical decision-making process by considering two levels of moral reasoning: intuitive and critical-evaluative. The intuitive level of moral reasoning is associated with a person’s immedi- ate, prereflective response to dilemmas based on her or his own historical knowledge and experience. Because this level cannot always be expected to result in good ethical decisions being reached, the ethically mature counselor displays critical-evaluative-level reasoning by taking into consideration ad- ditional aspects, including ethical rules, which are often contradictory and ambiguous, and ethical principles, such as autonomy, justice, and beneficence.

Counselor Training and Decision-Making Practices

Those in the helping professions are first exposed to ethics training in their programs of study, ideally including both EDMs and cognitive development in the moral domain. There is an almost universally recognized need to in- clude ethics training (Neukrug & Milliken, 2011), but there is some debate about how to do so. Much of this debate has focused on whether to infuse ethics training across the entire curriculum or to concentrate it in one course. Pack-Brown, Thomas, and Seymour (2008) argued for an infusion of ethics

Counseling and Values ■ April 2020 ■ Volume 65 111

training, as did Corey, Corey, and Callahan (2005). Sanders and Hoffman (2010) researched ethics training, contrasting two distinct methods: (a) infusion across the curriculum and (b) two types of distinct ethics courses (common morality model and mixed model). Sanders and Hoffman discovered that using a common morality model led to students possessing better moral judgment and sensitivity. McGee (2005) and McCarron and Stewart (2011) have argued for specific coursework in ethics training, with both promoting the use of vignettes so students can consider ethics issues in the context of real-life applications.

Other researchers have examined ethics training in counseling programs. Jordan and Stevens (2001) found that students in programs accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP) may perceive their ethics courses as uninteresting and risk low information retention. The authors asserted that using multiple delivery mediums and a variety of classroom engagement activities may increase the likelihood of student engagement and information retention. Ethical decision-making is complex and represents a long-term learning process, which needs to be integrated throughout the counseling curriculum.

Ametrano (2014) taught an ethics class alongside clinical experiences under supervision. The goal was to help students progress from their initial ethics code awareness toward a more in-depth appreciation for the intricacies of the process of ethical decision-making. Early in their training, students relied on one decision-making component, such as the ACA Code of Ethics (ACA, 2005) or their own personal values. Providing multiple opportunities for working through ethical dilemmas with peer interaction increased students’ awareness of how their values affected their decision-making process.

Only one study was found that sought to understand the way in which counselors engage in moral reasoning. Levitt et al. (2015) provided participants with a brief case and asked them to “think-aloud” about their decision-making process. The results revealed four themes that guided decision-making, including “personal values, clients’ best interest, transparency in decision- making and perceptions of formal training and practice” (p. 88). Levitt et al. reported that the decision-making process participants used was far more complex than linear EDM models. They noted the need to further explore the application of decision-making models post formal education.

Although much literature exists describing the theory of ethical decision- making, the importance of ethics training, and the examination of the best way to deliver such training, a gap exists in the research literature examining how ethical decision-making is made. Similar to Levitt et al. (2015), in the current study we aimed to describe the practices that counselors used when facing ethi- cal dilemmas. In contrast to the dilemmas used by Levitt et al., in this study the participants described their real-life experiences and were prompted to discuss EDMs and how their training prepared them to navigate ethical dilemmas. Guided by the work of Kitchener (1984) and Neukrug et al. (1996), we focused on how reflection was used in conjunction with EDMs by the participants.

112 Counseling and Values ■ April 2020 ■ Volume 65

Method

Our primary research question was as follows:

Research Question 1: How do counselors address ethical dilemmas?

The second research question, focused on the decision-making tools that counselors use to aid them in that process, was as follows:

Research Question 2: How do counselors incorporate reflection and EDMs into their decision-making process?

A phenomenological research design was used to better understand the decision-making process of practicing counselors. Phenomenology attempts to describe both the meaning and the essential structures of the lived experi- ences of the participants by describing what they have in common (Creswell, 2007; Moustakas, 1994). In this study, we were concerned with both the specifics of the ethical dilemmas faced by the participants and the meaning they attached to their decision-making process.

Participants

Upon receiving institutional review board approval, we solicited participants through an email sent to the graduate students in the counselor education electronic mailing list COUNSGRADS and the ACA Connect discussion board. Purposeful sampling was used to increase learning about the is- sues central to the purpose of this study (Merriam, 2009). Only licensed counselors who had graduated from CACREP-accredited programs were considered to increase homogeneity in graduate training experiences. Those interested in the study were provided with an informed consent and demographic questionnaire. Nine participants met the previously stated criteria and participated.

Seven participants were women, and two were men. The participants ranged in age from 28 to 55 years old (M = 39, SD = 8.4). Years of experi- ence practicing ranged from 4 to 26 years (M = 8.7, SD = 7.5). Six of the participants worked in mental health agencies, two had private practices, and one worked at a hospital.

Data Collection

The primary researcher collected data through recorded telephone individual interviews that ranged from 50 to 90 minutes in length. Prior to the interview, the participants were asked to identify two ethical dilemmas they have faced in their clinical practice. An ethical dilemma was described as when two or more ethical values are in conflict, so that both values cannot be equally and necessarily upheld.

Counseling and Values ■ April 2020 ■ Volume 65 113

A semistructured interview protocol was used to provide opportunities for elaboration, correction, and clarification (Creswell, 2007; Maxwell, 2005). The research questions informed the development of the interview protocol. The questions used in the interview were as follows: (a) Describe an ethical dilemma you have encountered in your work as a professional counselor. (b) What were the key ethical concerns? (c) What steps did you take to resolve this dilemma? (d) What was the outcome? And (e) What would you have done differently? These questions were repeated for each dilemma. Next, counselors were asked (a) What was your training for resolving ethical di- lemmas? (b) How helpful was it to you in these situations? and (c) Do you use a specific ethical decision-making model?

Data Analysis

We used an abridged version of Moustakas’s (1994) data analysis method. Upon completion of the interviews, the recorded interviews were tran- scribed. We repeatedly reviewed the transcripts separately and took reflective notes. Moustakas referred to this process as horizonalizing, in which researchers regard “every horizon or statement relevant to the topic and question as having equal value” (p. 118). We continued separately to identify meaning units relevant to the phenomena being studied and clustered them into tentative themes. We came together to discuss these tentative themes and reached an agreement on the organization of the data. The data were used to develop textual-structural descriptions that included what was common in the experience of the participants. These descriptions were supported by verbatim quotes that reflected the tone of the participants’ experiences.

Researchers and Trustworthiness Procedures

The first author is a female counselor educator who has been a professor in two clinical mental health counseling programs for a total of 7 years. The second author is a male counselor educator who has been a professor in a clinical mental health counseling program for 8 years. The third author is a male graduate student in a clinical mental health counseling program. The first and second authors have published research on ethics in counseling (Burkholder, Hall, & Burkholder, 2014) and have worked with students facing ethical dilemmas. Both are interested in the present research because their previous research and experiences with students have shown that students rarely use an EDM. The third author is motivated to explore this topic because of his interest in ethics and counseling.

We recognized that our prior research and experiences with students had the potential to affect our data analysis, so we took multiple measures to ensure the trustworthiness and dependability of this study. These measures served as a protection against events or processes that could result in in- valid conclusions (Maxwell, 2005). We used bracketing, identifying our own

114 Counseling and Values ■ April 2020 ■ Volume 65

personal backgrounds and beliefs in relation to ethical decision-making and setting them aside so that the research process was rooted on the topic in question (Moustakas, 1994). The format of the semistructured interviews also allowed for member checks. Participants were encouraged to elaborate, clarify, and correct the interviewer ’s interpretations. Member checks are considered one of the most important elements of establishing credibility in qualitative research (Maxwell, 2005). We used triangulation by analyzing the data independently and then comparing our findings (Merriam, 2009). Finally, we developed thick descriptions to allow the readers to make their own judgments regarding the transferability of the study findings to their own unique situations (Creswell, 2007).

Results

Analysis of the participant interviews yielded four themes: (a) incomplete following of EDMs, (b) varied dilemmas, (c) power, and (d) ethics training. Textual-structural descriptions that rely heavily on the participants’ own words are provided for each theme to retain the “situated character” of the results (Polkinghorne, 1989, p. 54).

Incomplete Following of EDMs

Only two participants could name a specific EDM that they used, and most participants did not follow an EDM in a systematic way. All participants could describe isolated steps they took to resolve their dilemmas, but what emerged was a pattern of favoring specific parts of EDMs. This was exem- plified by a participant who stated, “Nothing specific. It’s more about being self-aware and consulting when I need to consult.”

The most frequently described action participants used to resolve a dilemma was consulting with peers, supervisors, and treatment teams. Other individual examples of consulting included contacting agency ethics committees, boards of behavioral health, and the ACA ethics hotline. One participant stated, “I was pretty much, if something’s unethical, report it to your supervisor. That is about it.” Another stated, “I went to my supervisor because I had no idea what to do in this kind of situation.” Although consulting with supervisors and peers was often helpful, the participants did not describe being directed toward using an EDM. One participant stated that “it hasn’t been my experi- ence that supervisors use a model.” But others described a good supervisor as a “blessing” and “critical.” A good relationship with a supervisor allowed participants to “feel comfortable saying, ‘I’m faced with this dilemma right now and don’t know what to do about it.’” Consulting with others was described as “invaluable” to helping participants feel less “alone.”

This reliance on consultation and supervisors created problems when the supervisor was the one behaving in an unethical manner. In these cases, the participants often described themselves as being in a tenuous position and insecure about the next step to take. One participant stated, “I have to follow

Counseling and Values ■ April 2020 ■ Volume 65 115

orders of my supervisor because what if I am wrong?” Another participant described being labeled “resistant” and “insubordinate” for disagreeing with a supervisor on ethical grounds.

The participant with the second highest length of clinical experience was the only one to specifically mention reading the ACA Code of Ethics (ACA, 2014) or state regulations when facing an ethical dilemma. This participant also reported a high level of confidence in her ethical decisions. Many par- ticipants echoed elements of “the code,” but were often referring to larger ethical concepts such as confidentiality, dual relationships, or nonmaleficence. Participants described relying on their acquired knowledge of the topics, as opposed to reading the specific sections in the ethics code or regulations amid their ethical dilemma.

Five participants described a process of “weighing pros and cons.” For some, this was done by “writing a lot” and “documentation,” but for others the pros and cons were discussed in consultation with others. In most cases, the primary focus of this “weighing” was reducing harm to the client or the therapeutic relationship.

Finally, six participants relied on their firm belief that they themselves were ethical and thus could trust their own knowledge and intuition. One participant stated, “You can learn the ethics code, but . . . you’re either an ethical person or you’re not.” Other comments included, “I tried internal” and “I think with my ethical decision-making it is about being self-aware.” One participant acknowledged that a pattern of relying on intuition creates additional dilemmas, stating, “It’s tough because it kind of depends on what you see as unethical.” Like supervision, “instinct” or “gut” feelings were prioritized and valued over other elements of EDMs.

Varied Dilemmas

The participants reported a wide variety of ethical dilemmas, which varied in scope and complexity. Participants frequently noted the contrast between the complexities of the ethical dilemmas they encountered compared with the brief ethical training they received at the graduate level.

The most frequently noted ethical dilemma was being directed to do something by a supervisor or administrator that the participant deemed unethical. Participants described being told to “falsify records”; participate in insurance fraud; operate in unsafe work environments; practice outside of their competence level; maintain high caseloads, leading to inadequate service; and disregard their duty to report. One participant expressed sur- prise, stating “I never dreamed in a million years entering the profession that people would not support good ethics. I thought you would run into one or two people . . . but it just seems so widespread.” In many cases, participants reported the motivating factor to be money. They described supervisors saying things such as “Don’t you see how many specific ways you can bill this specific code?” or instructing them to get “butts in the chairs.” Many

116 Counseling and Values ■ April 2020 ■ Volume 65

shared a general feeling that administration and supervisors were not concerned with them being a good counselor as much as “asking people to make them money.” When participants felt “mandated by a higher author- ity” to provide inadequate or unethical care, they expressed feeling that ultimately clients were being harmed. As one participant shared, services offered to clients were “not accurately representing the field of counseling . . . clients are looking for care and we’re actually doing harm.” In addition, three participants shared concerns of peers engaging in illegal or unethical practices. They wrestled with whether to report them to state counseling boards. These ethical concerns involving supervisors and peers, coupled with a reliance on consultation to resolve ethical dilemmas, contributed to participants feeling insecure in their work environments.

The next most frequently cited ethical dilemma was dual relationships. Participants expressed concerns that dual relationships could compro- mise confidentiality or cause harm to clients. Participants also described regional and location-specific conditions that resulted in an increased likelihood of encountering clients in public. Dual relationships were the ethical dilemma in which participants were most likely to use a “weigh- ing of pros and cons.”

Other ethical dilemmas that were shared related to the duty to report and treatment interventions that reduced client autonomy. Paired with the pattern of participants relying on their gut or intuition, it should be noted that only one participant expressed a concern about imposing their values on a client.

Power

Participants frequently reported feeling that they did not have power in their places of employment to disagree with supervisors or administrators regarding ethics. One participant stated, “You don’t feel like you can do what is necessary,” and another shared, “This was the tipping point. I realized I had no rights at the company at all to try to work ethically.” Participants often described the environments themselves as unethical, commenting that “there was so much bad stuff going on.” This was also illustrated when a participant expressed, “We were given a clear message that it was unethical, but it was just that as a subordinate employee you have very little power.”

Their feelings of powerlessness intensified when they feared losing their jobs. One participant stated, “My dilemma was ‘Oh my God, I got to keep my job.’” Others felt that they had to ignore ethical issues because “if I want to keep my employment, I have to.” Interestingly, all participants who expressed feeling that they had little power in their workplace eventually left their place of employment. One stated, “I just looked for another job, because I realized it was just going to be untenable.” Another shared a similar sentiment, “I realized in order for me to do the right thing, that may include leaving.” Another participant shared the experience of “watch[ing] everyone leave and find their own path.”

Counseling and Values ■ April 2020 ■ Volume 65 117

Many participants who secured new jobs with improved work environ- ments reflected that they could have “pushed back even harder” or ques- tioned, “Why didn’t I say that?” but at the time felt they had little power or few options. Having chosen to leave unethical work environments, they reported increased confidence that they themselves were ethical. One par- ticipant stated, “In my practice, I have control, and can be ethical and make ethical decisions.”

Although many participants did use steps found in EDMs, only two par- ticipants explicitly followed an EDM. As a result, these two reported higher levels of confidence and empowerment when navigating ethical dilemmas. One seasoned clinician stated, “I think that the choices that I made at the time were probably the best choices.” She stated, “I’m at a different place where I don’t feel intimidated by anyone.” She compared this with earlier in her career when she did not use an EDM and frequently felt “like I was navigating the waters all by myself.” The other participant who used an EDM stated, “What’s sort of stunning to me is that more people don’t use a decision-making model or they don’t seem to go with anything other than their gut, which is not a good idea.”

Ethics Training

Most participants expressed thinking that their ethics training was incom- plete. Most reported being introduced to the ethics code in one of their first classes, but the focus was primarily identifying ethical issues. Two partici- pants expressed that they did not have any ethics training and “there were no models.” Two more participants used the exact phrasing of “Do this, don’t do this” to describe their ethics training. Case studies were used to “identify certain ethical issues, but not work through them.” A participant expressed, “I guess it was helpful, but it wasn’t sufficient.”

Following that early coursework, many participants reported a long gap in their ethics training until they arrived at their clinical coursework. One participant shared, “I don’t feel like it is infused.” One participant wished there had been an “ongoing discussion” to keep ethics “fresh in your mind and prepare you for internship.” Another participant’s experience was sum- marized as follows: “I understand having the ethics course as one of the first courses, but what I can say for myself was by the time I was in my practi- cum and internship, I had forgotten the class.” A participant who currently teaches internship described requesting students “whip out that ethics code,” but the students acted as if “they had forgotten that document even exists.”

In addition, participants shared that they got little training in problem- solving and decision-making. One participant stated, “If you only take one ethics class, it’s hard to really figure out a model,” and another shared, “You really need to practice and apply it.” Another emphasized the importance of repetition, emphasizing the importance of having “case vignettes to really problem solve.”

118 Counseling and Values ■ April 2020 ■ Volume 65

For those whose education did include case studies, they found their introduction to ethical dilemmas shared little in common with the ethical dilemmas they faced in practice. One participant stated, “The ethical cases that I encountered in graduate school were much different than what I encountered working there.” Similarly, a participant shared, “I would pres- ent more realistic case studies because I think that it’s not uncommon to encounter those types of situations in certain work places. . . . As much as we don’t want to admit this, you have people who want to make money at the cost of ethics.”

Multiple participants shared a perspective that one participant described by saying “my training began once I was approached with this dilemma and had to go through it.” This participant expressed that until he was in his field placement class and faced with clinical situations requiring problem-solving, he did not learn how to make a clinically ethical decision. He stated, “It was very black and white to me. The windows started opening to some flexibility in internship.”

One participant had returned to doctoral studies and reported getting additional ethics training. As a result, the participant consistently uses an EDM. The participant shared how previously she had believed she would “know if something was unethical,” but upon reflection she concluded that “there were some things I probably didn’t even realize were unethical.” She stated that had she been using an EDM, her process would have been “more objective as opposed to subjectively just guessing my way through it.”

Connections Between Themes

The foregoing themes are clearly interrelated. Participants described feeling that their ethics training was insufficient. They reported little practice work- ing through complex ethical dilemmas. Thus, when they entered clinical experiences, they frequently relied on their intuition and supervisors. This pattern of relying on consultation and gut feelings, but not ethics and legal documents, likely increased feelings of powerlessness and insecurity. How- ever, as participants gained experience working through ethical dilemmas, many grew in their skills and confidence.

Discussion

The themes found in this study are consistent with priorities articulated by previous researchers in the ethics literature. Kitchener (1984) noted the need for clinicians to have a strong ethics foundation and understanding of their own ethical decision-making process. Cottone (2001) emphasized the impor- tance of training clinicians in how to make an ethical decision. Sheperis et al. (2016) expressed concerns that clinicians who made decisions based on their intuition were doing so based on their own personal values, not the values of the counseling profession. Ametrano (2014) found that students early in their ethics training tended to rely on one decision-making component.

Counseling and Values ■ April 2020 ■ Volume 65 119

Neukrug et al. (1996) emphasized the skill of integrating ethical guidelines with personal and professional values. They noted that using the ethics code and decision-making models was a sign of counselor maturity. Jordan and Stevens (2001) noted low information retention from ethics courses and the importance of ethics being integrated throughout the counseling curriculum. This study adds the element of powerlessness or insecurity that counselors may feel when they do not have an established and balanced decision-making process. The findings of this study confirm the importance of ethics curricula that are applied, integrated, and connected to clinical practice.

Unique to this research was the illumination of how practicing counselors approach making ethical decisions and the impact of using an EDM. Our research has shown that counselors feel more confident when using ethics and EDMs and feel an increased amount of worry and insecurity when they do not. Underscoring these unique findings is the indication that few counselors use EDMs, even though using an EDM has been required by the ACA Code of Ethics (ACA, 2014) since 2014.

Implications for Counselor Education

Programs may consider an additional ethics course that students take concurrent with clinical coursework. This approach may be similar to the model proposed by Ametrano (2014) that taught decision-making models and emphasized small-group discussions. Such an approach would allow for real ethical dilemmas that arise in clinical coursework to be worked through systematically and with guidance. If programs choose not to add a course, they may consider adopting a model to intentionally teach students. Faculty could use this model in each course to work through class-specific dilemmas. This would allow for students to be taught a model and practice using it throughout the counseling curriculum.

Faculty members may consider requiring students to bring their ethics code and state regulations to practicum or internship class. It can be assumed that students will face ethical dilemmas in their clinical coursework. Requiring students to follow an EDM is a powerful way to model how they should ap- proach ethical dilemmas in their clinical practice. Programs may also consider offering training to their supervisors regarding ethical decision-making. By training and encouraging supervisors to use EDMs as a tool in their supervi- sion, they can increase continuity between coursework and clinical training experiences. CACREP (2015) encourages programs to provide supervision training to site supervisors, and training in ethical decision-making could benefit supervisors, agencies, students, and the community.

Finally, programs may also provide career guidance for students and recent graduates as they choose their first work environment. Many participants lamented the unethical environments in which they found themselves. Help- ing students to identify signs of an ethical work environment could aid them as they transition from student to practitioner.

120 Counseling and Values ■ April 2020 ■ Volume 65

Limitations

A discussion of the limitations of this study will assist the reader in deciding whether to accept the credibility of these findings. The goal of this study was to understand the decision-making process of practicing counselors, but of the nine counselors who participated in the study, only two were men. This may be representative of the counseling profession, but it does not provide adequate data to understand the decision-making process of male counselors or to discuss variations across gender. Similarly, greater diversity across years of clinical practice and place of employment might yield meaningful findings regarding environmental conditions that influence decision-making. The goal of qualitative research is not generalizability but transferability, so additional research in this area will continue to grow confidence in this knowledge base.

Areas for Future Research

This study highlights many areas for future study. Qualitative research typically uses small samples, but it may be helpful to replicate this study with a larger sample size. The themes found in this study could be used to develop a quantitative instrument that could be more widely disseminated. Another area for study could be examining the kinds of ethical dilemmas that counselors are facing and whether there is a relationship to the type of clinical environment. Many participants suggested that money or lack of resources contributed to the ethically questionable situations in which they found themselves; future research could explore whether these types of di- lemmas may be more frequent in certain clinical environments. It may also be helpful for programs to apply some of the recommendations provided in this article and examine whether the training increases the likelihood of those counselors using an EDM in clinical practice. Finally, it may be valuable for researchers to evaluate whether the use of an EDM improves the quality of the ethical decision. Although the ACA Code of Ethics (ACA, 2014) mandates the use of EDMs, few empirical studies exist that validate or compare the utility of specific EDMs (Cottone & Claus, 2000).

Conclusion

EDMs are mandated by the ACA Code of Ethics (ACA, 2014), and researchers have pointed out the value of using EDMs, such as ensuring that clinicians are basing decisions on the values of the counseling profession and not their own personal values. Despite this, the present research illustrates that practicing counselors may be unfamiliar with EDMs and navigate ethical dilemmas either by using their intuition or by relying solely on a supervisor. In light of the mandate from the ACA Code of Ethics, previous research, and our finding that clinicians report higher levels of confidence when using an EDM, it is hoped that the present study highlights the importance of train- ing students in using EDMs and encourages more research on this topic.

Counseling and Values ■ April 2020 ■ Volume 65 121

References

American Counseling Association. (2005). ACA code of ethics. Alexandria, VA: Author. American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author. Ametrano, I. M. (2014). Teaching ethical decision making: Helping students reconcile personal

and professional values. Journal of Counseling & Development, 92, 154–161. doi:10.1002/j.1556- 6676.2014.00143.x

Burkholder, D., Hall, S. F., & Burkholder, J. (2014). Ward v. Wilbanks: Counselor educators re- spond. Counselor Education and Supervision, 53, 267–283. doi:10.1002/j.1556-6978.2014.00062.x

Corey, G., Corey, M. S., & Callahan, P. (2005). An approach to teaching ethics courses in human services and counseling. Counseling and Values, 49, 193–207. doi:10.1002/j.2161-007X.2005. tb01022.x

Cottone, R. R. (2001). A social constructivism model of ethical decision making in counseling. Journal of Counseling & Development, 79, 39–45. doi:10.1002/j.1556-6676.2001.tb01941.x

Cottone, R. R., & Claus, R. E. (2000). Ethical decision-making models: A review of the literature. Journal of Counseling & Development, 78, 275–283. doi:10.1002/j.1556-6676.2000.tb01908.x

Council for Accreditation of Counseling and Related Educational Programs. (2015). 2016 CACREP standards. Alexandria, VA: Author.

Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among five approaches (2nd ed.). Thousand Oaks, CA: Sage.

Forester-Miller, H., & Davis, T. (2016). A practitioner’s guide to ethical decision making. Alexandria, VA: American Counseling Association.

Jordan, K., & Stevens, P. (2001). Teaching ethics to graduate students: A course model. The Family Journal, 9, 178–184.

Kaplan, D., & Martz, E. (2014, July). New concepts in the ACA code of ethics: An overview of the revised ACA code of ethics. Counseling Today, 57, 20–21.

Kitchener, K. S. (1984). Intuition, critical evaluation, and ethical principles: The foundation for ethical decisions in counseling psychology. The Counseling Psychologist, 12, 43–55.

Levitt, D. H., Farry, T. J., & Mazzarella, J. R. (2015). Counselor ethical reasoning: Decision-making practice versus theory. Counseling and Values, 60, 84–99. doi:10.1002/j.2161-007X.2015.00062.x

Martz, E., & Kaplan, D. (2014, December). New concepts in the ACA code of ethics: Legally speaking. Counseling Today, 57, 28–29.

Maxwell, J. A. (2005). Qualitative research design: An interactive approach (2nd ed.). Thousand Oaks, CA: Sage.

McCarron, M. C. E., & Stewart, D. W. (2011). A Canadian perspective on using vignettes to teach ethics in psychology. Canadian Psychology, 52, 185–191. doi:10.1037/a0024504

McGee, T. (2005). Ethics and legal considerations in the training of mental health profession- als. Journal of Aggression, Maltreatment, and Trauma, 11, 271–285. doi:10.1300/J146v11n03_01

Merriam, S. B. (2009). Qualitative research: A guide to design and implementation. San Francisco, CA: Jossey-Bass.

Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage. Neukrug, E., Lovell, C., & Parker, R. J. (1996). Employing ethical codes and decision-making

models: A developmental process. Counseling and Values, 40, 98–106. doi:10.1002/j.2161- 007X.1996.tb00843.x

Neukrug, E., & Milliken, T. (2011). Counselors’ perceptions of ethical behaviors. Journal of Counseling & Development, 89, 206–216. doi:10.1002/j.1556-6678.2011.tb00079.x

Pack-Brown, S. P., Thomas, T. L., & Seymour, J. M. (2008). Infusing professional ethics into counselor education programs: A multicultural/social justice perspective. Journal of Counsel- ing & Development, 86, 296–302. doi:10.1002/j.1556-6678.2008.tb00512.x

Polkinghorne, D. E. (1989). Phenomenological research methods. In R. S. Valle & S. Halling (Eds.), Existential-phenomenological perspectives in psychology: Exploring the breadth of human experience (pp. 41–60). New York, NY: Plenum Press.

Remley, T. P., Jr., & Herlihy, B. (2010). Ethical, legal and professional issues in counseling (3rd ed.). Upper Saddle River, NJ: Merrill.

Sanders, S., & Hoffman, K. (2010). Ethics education in social work: Comparing outcomes of graduate social work students. Journal of Social Work Education, 46, 7–22.

Sheperis, D. S., Henning, S. L., & Kocet, M. M. (2016). Ethical decision making for the 21st century counselor. Thousand Oaks, CA: Sage.

Copyright of Counseling & Values is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.