Transcript Essential Ethics For Counselors

Ethical Decision
Making: Handling
Real Life Scenarios
By Michele D. Aluoch, MS, LPCC
River of Life Professional Counseling, LLC
Copyright 2014
Defining Counseling
• Not just an occupation but a profession with
responsibilities
Professions:
• Derived from societal needs
• Supported by public trust, respect, recognition
• Addressed needs of health, order, meaning, or security
• Has earned privileges
• Has a leading organization: educational standards,
practice standards, accreditation, ongoing skill
development
Defining Counseling
• Must act in the public good
• Has items it “professes” or acts upon
• Both legal and moral practice
• Those in practice and the governing body are in a
covenant relationship
• Goal: for outlining the nature of helping relationships
between colleagues, clients, employers/employees
surrounding this profession
• Makes judgments under conditions of technical and
ethical uncertainty
“ Codes of ethics do not come to
professions on stone tablets from
high mountains. Rather they are
always a work in progress. They
are developed by committees,
examined by professionals and the
public they serve, and then lived
out by frail humans and adapted to
changing contexts.”
From: Ponton,R.F. & Duba, J.D. (2009)
Limitations of Ethical Codes:
• Profession bound (whereas practice is not)
• Do not include underlying rationale to help the
practitioner make better decisions
• Can never be comprehensive b/c so many situations
• Challenges enforcing codes
• Reactive rather than proactive
• Personal versus field ethics
• Must be adapted to various cultural and other contexts
• Some situations not easily handled by ethical codes
Law Versus Ethics
Law- minimal ethical
standards of society
Ethics- standards set by
profession
Ethics Vs. Legality:
(from Thompson, A., 1990)
1) Ethical & Legal
2) Ethical & Illegal
3) Ethical & Alegal
4) Unethical & Legal
5) Unethical & Illegal
6) Unethical & Alegal
Making Ethical Rules:
1) Utilitarianism- judging on the basis of clearly forseeable
consequences, not behavior itself but outcomes of
behavior (J. Bentham)
2) Moral Institutionalism- consequences are important but
not separate from certain mandatory duties (W.D. Ross)
Making Ethical Rules:
a) Fidelity
b) Reparation
c) Gratitude
d) Justice
e) Beneficence
f) Nonmaleficence
Nine Values of Master Therapists
(Jennings etc.-Jan.2005)
Category I: Building and Maintaining Interpersonal Attachments
1) Relational connection- supervision and collegial supportformally or informally
2) Autonomy- ability to individually and independently determine
the timing and direction for counseling
3)Beneficence- promote well being of clients
4) Nonmaleficence- avoid damage to clients
Nine Values of Master Therapists
(Jennings etc.-Jan.2005)
Category Two: Building and Maintaining Expertise
5) Competence- maintaining skills that are useful and current
6) Humility-knowing what you don’t know
7) Professional growth-willingness to reach out to develop
cognitive an clinical abilities both through CEUs and personal
development
8) Openness to complexity and ambiguity-see intricate
counseling situations in context
9) Self awareness- understanding personal needs
Benefits of Ethical
Standards
• Gives some specific guidance
• Helps professionals keep their colleagues
accountable
• Gives the public outlines regarding hat
should be expected for the welfare of clients
Ethics: The
Issues
Scenarios: Sex and
Relationships With
Clients
Scenarios: Sex/Relationships With Clients
• A gentleman arrives before his wife for their scheduled
marriage counseling session. The wife calls and states
she is on her way just a few minutes behind at a traffic
light. The husband begins joking with you about
relationship matters- and telling you some jokes about
males versus females. How do you respond?
• A client of the opposite sex winks at you and comments,
“you look so nice in that color. You should wear it more
often.” How do you respond?
Ethical Dilemmas: Sex with Clients
• A client comes into your office dressed in a very revealing
way. It is making it difficult to focus on the issues at hand.
It seems like each session the behaviors get a little more
provocative an the way the client sits and mannerisms
become more difficult for you to maintain your focus. How
do you handle that? Do you say anything?
Ethical Dilemmas: Sex with Clients
• You have counseled a single person regarding stresses and
depression associated with being single and alone.. You
can really empathize and understand because you have felt
that way yourself. Later you are at a local community
based singles event when you realize that the client is
there. After some group activities the client approaches
you saying that it must have been destiny since you
understand each other so well and maybe the two of you
can go out after the singles group.
Ethical Dilemmas: Sex with Clients
• A client comes in sitting a bit close to you
and acting flirtatious throughout the session.
The client makes advances and begins joking
about sexual things finally making the
commet, “Life would be so much better if I
could just be with someone like you.” How
do you handle this?
Scenarios: Sex/Relationships With Clients
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You recently lost some weight and are wearing somewhat
more form fitting clothes. You notice certain clients looking
more intently at parts of your body when you wear these
clothes. How do you handle this?
It has been over 10 years since you last assessed and treated a
past client. You are both single. You run into each other in the
community and the past client asks you for a lunch date “since
you are not in the relationship any more.” You felt as if you
really connected before and you understood the past client
well. In your opinion, the person did not have major life issues
besides some small life adjustment issues. It has been over 10
years since you counseled the past client. How do you
respond?
Scenarios: Sex/Relationships With Clients
• A teenage client wants to demonstrate the new bump
and grind dance moves they do. How do you handle this?
• A client begins undressing in the office during a
counseling session. How do you handle this?
Ethical Issues: Sex With Clients
• No sexual relationship allowed: “including kissing, sexual
intercourse and or touching by the client or therapist of the
others breasts or genitals”, also “no physical advances or
verbal or nonverbal conduct that is sexual in nature.”
• Considerations: vulnerability, power differential, and trust
issues
• “ a therapist who is choosing to engage in a sexual
relationship with a current or former patient is effectively
choosing to discard his or her career.”
Key Questions to Evaluate Ethics
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What are my internal perceptions about this case?
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What goals need to happen here?
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What is our treatment plan?
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What would other counselors do in this situation?
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Is there anyone with whom I could consult- colleagues, board, liability
insurance company?
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Any precedents of similar cases I could look to?
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Who am I as a person? As counselor?
Scenarios: Education
Scenarios: Education
• A potential client shares that he/she
“wants a seasoned counselor”
regarding the issues they called in for
as the presenting problem. You have
10 years of experience including some
limited experience on this presenting
issue. How do you respond to this
inquiry from the potential new client?
Scenarios: Education
• A friend of yours shares that he/she “was
born to help people.” The friend reports
numerous examples of ways in which
he/she has helped others who comes for
advice. The friends then says he/she has
completed a 10 course series in helping
people heal from emotional wounds so
he/she can be a counselor. What do you
say?
Ethical Issues: Education
• Do not promote a degree from a school not accredited
by the US Dept. of Education
• “No person may claim, either orally or in writing, to
possess an academic degree… or title associated with
said degree, unless the person has in fact, been
awarded said degree from an institution that is
accredited by a regional or professional accrediting
agency recognized by the United States Department of
Education at the Commission on Recognition of
Postsecondary Accredidation.”
Scenarios: Diagnosis
Scenarios: Diagnosis
• A couple has been coming on for marital
counseling. When a session is scheduled
the husband is running a little late so the
wife says, “since it is our session time- can
you tell me what you really think
diagnostically of my husband so I know
how to deal with him?”
Scenarios: Diagnosis
• A gentleman comes in through EAP insurance plan
regarding how his depression is affecting his job. You
have given him a diagnosis of 300.4- Dysthymiarealizing that he has had some long term low level
depression for years that has been exacerbated by
some recent stressors. You get a call from the
employer who says he “knows that the client is in
counseling and that due to a recent yelling outburst
and some refusal to comply with his supervisor’s
authority the employer is contacting you for
diagnostic and prognostic information for this
organization “to decide what to do with him (the
client).”
Scenarios: Diagnosis
• An adult male comes in for individual counseling.
You are aware and have received specific, measurable
documentation of symptoms which substantiate an
diagnosis of OCD. He says he “has been reading
information and knows that a lesser diagnosis can be
given” because he may not be allowed to stay on his
job if he has an OCD diagnosis and has to take meds.
He says that “he is going through adjustments after all
and can just be diagnosed as adjustment disorder with
depression or anxiety from his research” so he won’t
lose his job. What do you say?
Scenarios: Diagnosis
• A family contacts you, an LPCC therapist, with a request
to “meet with them for assessment and counseling
regarding family issues.” During the course of the
diagnostic assessment you realize that the adults are
hoping to use your diagnosis and recommendations to
support or dispute each of their abilities to potentially care
for their children during a custody dispute.
Scenarios: Diagnosis
• Mary, an adult female, has been to numerous
counselors before and as complained early on when
asked about her treatment history that “none of
them know what they are talking about regarding
what is wrong with her.” She says she recalls words
like “borderline”, “bipolar”, and “something about
traumatic stress.” Then after five sessions with you
she directly asks you, “so now that you have started
to know me what do you say? What ‘ lovely’ words
do you want to put on me now?” she asks
sarcastically.
Scenarios: Diagnosis
• A client clearly only fits criteria for
adjustment disorder but when insurance
comes back as rejected and unpaid you
learn that a more serious diagnosis is
required- even an NOS diagnosis may be
paid. How do you handle this?
Scenarios: Diagnosis
• A parent brings in his or her 6 year old child for
evaluation for possible ADHD after some
behavioral issues have arisen in the school. The
parent says he really does not want his son to have
a bad reputation if anything is found out
(diagnostically) through the counseling process
but he wants his son to get the help needed.
Scenarios: Diagnosis
• You feel creeped out by this big, bulky guy. He looks to
you like someone from “America’s most wanted.” You
think that your instincts are usually right. He must be
antisocial personality, delusional, or something serious.
You can just feel it. Is your feeling accurate for diagnostic
purposes? Why or why not?
Scenarios: Diagnosis
• A client presents some interesting facts related to
practices in his culture about trace states and ritualized
behaviors. Taking into consideration this person’s culture,
would you still diagnose this behavior you find bizarre as
schizophrenic?
Ethical Issues: Diagnosis
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Unethical- therapist as moral agent, client no longer autonomous
person coming for help
Ethical- based on observation of concrete, observable or clients self
reported behaviors compared to “norms” and researched and studies
standards
with respect to client perspectives and worldview
with full information and informed consent
under a specific “contract” outlining terms of the clinical relationship
Scenarios: Licensure
Scenarios: Licensure
• You are moving from another state to Ohio. You have
been practicing as an independently licensed mental
health professional for over 20 years and are well
respectd in the field. If you move to Ohio can you expect
that you will transition easily into another independent
license? Will your years of experience and licensure and
training qualify you for a similar independent license in
Ohio? What about if you are leaving Ohio with
independent licensure and going to another state?
Ethical Issues: Licensure
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Citizenship, residency- OH will consider those from other states
and even out of US after review of packet
Education- Accredited educational institution, specifically
counseling, 90 quarter hours min. (including 30 quarter hours in
certain areas)
Exam- pass standard set by board on national counseling exam
Experience- supervised, pre-approved
Scenarios: Supervision
Scenarios: Supervision
• A supervisee comes in very excited and proud about the
way he handled a case. He tells you how well he
challenged and confronted a client and set boundaries with
him. He shares how he taught him techniques to “just be
tougher in the trauma.” You are aware that the way the
supervisee handled this particular client was not
appropriate for the situation and that the client is now at
risk for additional issues. The supervisee really thinks he
did a great thing but you are certain that worse problems
have been created.
Scenarios: Supervision
• A supervisee comes to you saying, “I know one of your
areas of competence is not substance abuse treatment but
in my counseling session with Mr. Smith I just found out
that he has been using drugs. What do I do?”
Scenarios: Supervision
• A supervisee is scheduled to be present for a joint session
you have with a married couple. A half hour beforehand
you receive a message on your home phone from the
supervisee that he or she “needs to stay home and take care
of himself and herself” and won’t be there
Scenarios: Supervision
• A supervisee begins to cry excessively and talk about
problems in her life regarding her marriage, family, and
juggling too many things at once. You see it is affecting
her ability to get to counseling sessions on time, to be fully
present for clients, and that she may have developed some
mental health issues herself. How do you handle this?
Scenarios: Supervision
• A supervisee comes in very excited and proud about the
way he handled a case. He tells you how well he
challenged and confronted a client and set boundaries with
him. He shares how he taught him techniques to “just be
tougher in the trauma.” You are aware that the way the
supervisee handled this particular client was not
appropriate for the situation and that the client is now at
risk for additional issues. The supervisee really thinks he
did a great thing but you are certain that worse problems
have been created.
Scenarios: Supervision
• A client calls you and asks to speak to you as your
supervisee’s supervisor. This client (of your supervisee)
says that while the supervisee “was a nice person and got
them thinking” and “gave them some new ideas” nothing
really helped. The client asks you, “can we meet with you
or another therapist?”
Scenarios: Supervision
• A supervisee is a bit more lenient with clients giving
theme 60 minute sessions instead of the insurance
covered 45 minute sessions and not being so specific
about boundaries. It is resulting in this supervisee’s
clients getting different care than other clients at your
agency and having different expectations. How do you
handle this before it gets too out of hand?
Ethical Issues: Supervision
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*NOTE: New 2008 Ohio codes on this*
General Board Rules Re. Supervisors
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Supervisor/supervisee relationship must be board approved in
advance
Roles and scope of practice are specifically delineated
Start and end dates are delineated
Supervisor/supervisee only have supervision in areas of
specified competence
“Not a family member or relative”
Requires documentation of supervisor/supervisee interactions
Reports co-signed by the supervisor
No more than 6 supervisees per clinical supervisor
Ethical Issues: Supervision
General Board Rules Re. Supervisees
• Clients of supervisee can pay but only to the agency
• Supervisee
openly acknowledges with clients the rules and limits of
supervision
• Disclosure to clients of supervisee status
• No
reports, forms, or paperwork disseminated without review of
supervisor and his/her signature
• Filling in of training agreements is the supervisee’s responsibility
• 30
day board notice of changes of supervisors or any other changes in
agreement
• Only
counting hours of supervision by a designated supervising
counselor
Interviewing Potential Supervisees
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Career Goals and Expectations
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Counseling Goals and Expectations
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Supervision Goals and Expectations
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Experiences to This Point/Desired Experiences/Outcomes
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Areas For Further Training
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Theoretical Orientations Preferred
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Special Populations or Issues Preferred
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Supervision Experiences to this Point- Pros/Cons
Boundaries With Supervisees
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Adhere to general, professional, ethical standards
Reduce likelihood of exploitation
Never- sexual relationships or sexual harassment
Honest credit/citation to sources
No supervision by a relative
Honest evaluation to board, even if it means a person is not
necessarily recommended for licensure
Regular follow-ups initiated and evaluations: two way
Ethical Considerations in
Supervision
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Vicarious responsibility
Due process afforded supervisee
Receiving informed consent (both supervision relationship and
trainee/client relationship)
Avoiding dual relationships
Competency areas of supervisor and supervisee
Confidentiality of client issues and supervision issues
Scenarios: Competency
Scenarios: Competency
• A client comes in “for depression.”
Through the use
of cognitive-behavioral treatment as depressive
symptoms are being dealt with other issues arise. It
becomes clear that the client not only has an alcoholic
family system but also has some binge drinking and
alcohol abuse issues. When you initially agreed to
meet with the client you did so knowing that “mood
disorders” and “family of origin issues” were
competency areas of yours as specified by your
disclosure statement. However, substance abuse is not
a competency area of yours. How do you handle this?
Scenarios: Competency
• You have training dealing with abuse and trauma victims
using behavioral relaxation, cognitive and behavioral
therapies, mindfulness, and EMDR. However, you have
not received specialized training in dealing with
traumatized people who dissociate. During one of your
sessions a client begins to manifest dissociative
symptoms. How do you handle this in terms of your
competency?
Scenarios: Competency
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A colleague of yours has filled in for you at your practice when you
have been on vacation, overseeing the business and supervision of
therapy. She has similar competencies to you. She asks if you could
return the favor since she will be going on a vacation the next month.
She would like you to oversee the management of the sexual
offenders and mandated clients groups as well as treatment for
behavior problem children. You have dealt with behavioral disorders
routinely and list this as one of your areas on your disclosure
statement. However you have never counseled a sexual offender
regarding their sexual offenses or run any such groups. Your
experience has also been primarily limited to voluntary clients, not
mandated or court ordered ones. How do you respond to her request
to cover supervision functions for just one week?
Ethical Issues: Competency
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Provide reliable evidence of competence- education, specialized
training, licensure
Practice only within competency areas
Based on standards of care- reasonable practice
Protection from harm
Only accept referrals in competency areas
Use proven, appropriate techniques
Scenarios: Confidentiality
Scenarios: Confidentiality
• A spouse calls in to ask for dates and time of their spouses
next (individual) counseling session and to reschedule on
behalf of the client. The counseling has never been set up
as marriage counseling and you do not have release of
consent to speak with this spouse. When the spouse says,
“I’d like to reschedule for your client” and “by the way,
how are things going? I am very concerned because I want
my spouse back” how do you respond?
Scenarios: Confidentiality
• Some parents comes back after their teenage child’s
session stating that they want a summary of exactly what
has been said to the counselor by the child. ‘After all,
“they state, “we are the ones paying for this counseling.”
How do you handle this?
Scenarios: Confidentiality
• After you call your client back from the waiting room to
your office the client mentions that it was interesting to see
his next door neighbor there too and to catch up with him
in the waiting room. “So I guess you know the scoop on
the whole neighborhood now,” the client says. What do
you say?
Scenarios: Confidentiality
• You have met with a couple for marriage counseling. After
one of them withdraws from marriage counseling the other
wants to continue with you for individual counseling.
What do you think?
Scenarios: Confidentiality
• A disability organization faxes a letter to request copies
of records on a particular client. They would like you to
send notes, prognosis, and treatment summaries. This is
for the purpose of seeing whether or not the client
qualifies and will be approved for long term disability.
How do you respond?
Scenarios: Confidentiality
• You are treating a high profile individual in the news. You
wish they knew the real story of the client’s life- all the
abuse, trauma, pain and wounds. Do you respond to the
inquiries of the past of the news media regarding whether
you know about this person’s treatment?
Scenarios: Confidentiality
• If a lawyer sends you a request for records for one of his
clients are you mandated to send the records?
• A client requests to see his or her own chart and to have
copies of the entire chart. How do you handle this?
Scenarios: Confidentiality
• You have received a subpeona requesting you to come to
court and bring all the records on a particular patient. Do
you bring the records? Can you break confidentiality with
a subpeona?
Ethical Issues: Confidentiality
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Has to do with private information being protected through reasonable
expectation that it will not be further disclosed except for the purpose for which it
was provided
Areas Protected:
• Whether or not a person has been a client
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The frequency and intervals of appointments
Types of treatment or services received
Reasons for treatment
Specific words, behaviors or observations during treatment
Client diagnosis
Course and prognosis of treatment
Summaries and recommendations
Ethical Issues: Confidentiality
Disclosure:
• Requires informed consent- specifying what consenting to,
with discussion to client about advantages and
disadvantages and potential limitations of disclosure
• Should be in your policies and procedures about
confidentiality, possible breaks of confidentiality and how
this is should be handled
• Should be in writing and signed by all parties
Ethical Issues: Confidentiality
• Information
cannot be disclosed in court proceedings
unless both: 1) a subpeona has been issued 2) a court order
has disclosure. Then court must find that the need for
information outweighs the public policy for confidentiality
(42 CFR 2.61-2.65 and 45 CFR 164,512 (e) (1) (ii)
• By
law confidentiality continues even after the death of the
patient, death of the therapist of sale of the practice to
others
• “When in doubt don’t give it out.”
Scenarios: Practical
Privacy Considerations
Scenarios: Practical Privacy
Considerations
• People in the assessment rooms hear each
other’s assessments. This can’t be helped. The
walls are too thin and the building is old. What
do you say? Is this okay?
Scenarios: Practical Privacy
Considerations
• Some patients like to talk to you as you leave the
office to go to the hall to get your next patient.
They don’t take the signal that their time is up.
Patients in the waiting room and those coming in
the building can all hear all that this patient is
saying. Is there anything you can do?
Scenarios: Practical Privacy
Considerations
• Volunteers whoa re interested in working in the
mental health field often pass through the
records department where yet to be field charts
are laid out, lists of daily activity logs with
patient’s names and ID numbers are sitting, and
sign in sheets for psychiatric patients are visible.
Anything you should do or say?
Scenarios: Practical Privacy
Considerations
• One of your counselors at your agency is
currently with a client while he is with that client
an important call comes in from another client
that was scheduled for later that day. How do
you pass the urgent message to the counselor so
as to protect privacy for both clients?
Scenarios: Practical Privacy
Considerations
• You work for an agency that has someone clean after
hours. You and a colleague are still needing to pull charts
and do paperwork while the cleaning help is there. How
do you handle that?
• A client comes in regarding dealing with grief from having
an affair with am married man who she says “is the love of
her life but she knows she can’t have.” Simultaneously,
you are counseling a woman and her child who you later
understand are the wife of the “affair man” and his
daughter who don’t know about the affair. How do you
handle this?
Scenarios: Practical Privacy
Considerations
• You are counseling a teacher regarding marital difficulties
she is having . During her session she mentions the name
of the school she teaches at which happens to be the
school where your next child client attends. How do you
handle this ?
• You call a home number to speak to a client regarding
scheduling. The client’s family member answers and asks
who you are and to take a message. What do you say?
Practical Privacy Considerations:
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Respecting those in waiting room from hearing sessions or
session or client related information
Telephone calls in reception area should not be overheard by
clients
Messages regarding client information should not be given in
ways that violate privacy
Training support staff regarding confidentiality (e.g. sign a
pledge)
Scenarios: Informed Consent
Scenarios: Informed Consent
• A parent lets you know that his or her attorney will be
asking your expert opinion regarding custody decisions,
especially which house the child belongs at. What do you
say regarding your role as a therapist?
• A shy, withdrawn codependent woman seeks therapy “to
set boundaries and be more assertive.” How do you
present assertiveness therapy to her?
Scenarios: Informed Consent
• What do you do or say if a new client comes in for your
psychotherapy but keeps calling you “doctor” (when you
do not have an MD and are not a Ph.D.)?
• A diagnosis is required for insurances to cover treatment.
However, diagnosis may stay with people for some time
so some clients do not want that. If no diagnosis is given
and insurance is not used this means that the person is
essentially self pay. What do you say to the client?
Scenarios: Informed Consent
• When a client comes in for an initial assessment after
signing paperwork you realize that the client is illiterate
and can’t read. How do you get informed consent?
Ethical Issues: Informed Consent
• Extent and nature of services
• Pros and cons (counseling in general, electronic
counseling, phone counseling, techniques used, setting)
• Limitations
• In clear, understandable, non-technical language
• Specified provider name
• Therapist’s responsibility to make sure the client
understands (e.g. if cannot read, blind, etc.)
Ethical Issues: Informed Consent
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Defines role of counselor (versus mediator, court guardian,
expert witness)
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Expectations of both therapist and client behaviors
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Risks/benefits of therapy
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Qualifications of the therapist
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Financial considerations and responsibilities
Ethical Issues: Informed Consent
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Time per session
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Confidentiality and its limitations
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Releases of info.- when required, specifications (provider, what
information, to whom, 1 or 2 way, time frame, nature of release and
intended use)
Signature of individual or someone authorized to sign on their behalf
Scenarios: Responding
To Records Requests
Scenarios: Responding To Records
Requests
• An employer requests information to determine whether
or not they will be keeping an employee on the job.
Because of the client’s behavioral reactions on the job
recently they want your recommendations about
whether or not the employee should be fired. Can you
give this recommendation without a release? With
release?
Scenarios: Responding To Records
Requests
• You receive a phone call from a guardian ad litem asking
for copies of records on a child client the guardian for the
child in court oversees. Do you have to send records or
call this person back based on the phone message?
Scenarios: Responding To Records Requests
• You receive a faxed copy of a release of consent but there
is no end date and no specific words regarding the types
of things from the record requested. Is this release
appropriate? Why or why not?
Scenarios: Responding To Records
Requests
• A client has signed several releases of consent requesting
that you talk with certain collateral sources. You do not
believe the information being out is in the client’s best
interest and may even be damaging to the client. Do you
have to release information on any client if he or she has
signed a release of consent? Can you refuse requests for
information when a release has been sent?
Responding to Records Requests
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What does the client want?
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Anything potentially harmful?
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What parts should or should not be revealed?
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Is discussion beforehand advisable?
Scenarios: Record Keeping
Scenarios: Record Keeping
• You have several different pieces of information in a case
from courts, law enforcement, and various social service
agencies. The client presents certain ways which are
consistent with some of the input from other collateral
sources and inconsistent with other information from
collateral sources. How do you document clinical
impressions, diagnosis, and treatment information in this
instance?
Scenarios: Record Keeping
• A child of divorced parent domes in for counseling,
usually brought by his biological mother. The child
mentions some harsh and critical tendencies of his father
throughout sessions. You want to document thoroughly
the client’s self report on things but are concerned that if
dad requests records the child may be punished for his
comments and opinions about the severe harshness of
dad. How do you document the client’s input?
Ethical Dilemmas: Record Keeping
What would you correct or change if anything about
this note a clinician put in a client’s file?
• Susie returned to counseling after a two week break.
Upon
entering the room it was apparent that her depression had become
worse. We talked about the struggles she had in the past two
weeks because she has not been to counseling. Then we processed
her struggles regarding family members she lives with. It was
clear to me that her dad is in fact an abusive man as she said
before. Used grief counseling techniques to assist her in grieving
and expressing anger she would have liked to express to add in
session. I told her it would be good for her to bring the dad with
her next session We will meet in one week instead of two weeks.
Next session we will aim at confronting dad’s abuse and the
consequences it has on Susie.
Scenarios: Record Keeping
• You notice in reviewing a colleague’s notes on a client
that she has written in the client notes comments like,
“Client’s appearance was overweight and disgusting
looking- needs to lose weight. Disheveled and unclean,
filthy to be around. I felt afraid of catching a disease
being near this person.” How do you handle this?
Scenarios: Record Keeping
• You receive via responses to releases of information
copies of information from other agencies. Can you rerelease to third parties faxed info. from other agencies if
they request copies of the chart?
Ethical Issues: Record Keeping
•
•
•
•
•
•
•
Diagnostic assessment
Psycho-social history
Specific, concrete behavioral symptoms
Tx plan- service goals and outcomes (justifiable, research based standard of
practice)
Measurable clinical outcomes
Direct quotes from clients (in quotation marks)
Monitor progress, re-evaluate goals periodically
Ethical Issues: Record Keeping
NOT
• Opinions
•
•
•
•
Assumptions based on behaviors
Questions and investigations
Second hand judgments of clients or others in the client’s life
Diagnosis of people who are non-clients
Scenarios: Privileged
Communication
Ethical Issues: Privileged
Communication
•
•
•
•
Privilege: a legal term, legal protection against breaking
confidentiality in legal proceedings
The client holds the privilege
Must have clearly been in context in which specified “not be
disclosed” ahead of time
Would cause injury if shared
Ethical Issues: Privileged
Communication
•
Exceptions: judicial discretion, nature of the violation (e.g. harm
to others- abuse, homicide, likelihood to commit future crimes)
3 Automatic Waivers of Privilege
•
•
•
1. If requires immediate hospitalization
2. If court ordered
3. If specifying info. on the emotional condition of the patient is
part of the client’s defense in a court case
Scenarios: Client Dependency
Scenarios: Client Dependency
• It is nice to have a cooperative client who arrives early to
sessions, listens and seems to apply what is taught. It
feels refreshing because especially now it seems like your
other clients are having one crisis after another. Your
client would like to stay because she says she just doesn’t
have the support systems like you out there and that she
has found a “best friend and confidant” in you. How do
you handle this since her treatment goals have been met?
Scenarios: Client Dependency
• You have been counseling a family for almost two years.
This
nontraditional family of four young children stay with the
grandmother since the children’s parents are all not
consistently in the picture. During the counseling you have
worked with each child individually as well as the family
through numerous adjustments. Now, in your clinical
judgment, it seems as though things have stabilized for months
and you have taught all the skills and techniques you know to
do. But when you share with the grandmother about phasing
out counseling she says that “the kids look forward to
meetings” and she “likes to know she has the support she needs
to fall back on because raising the grandkids is not easy stuff.”
Scenarios: Client Dependency
• A borderline seems to always be “in crisis” according to
her self report. She says that once per week counseling “is
not enough” yet when she comes in for her weekly
counseling sessions she repeatedly has not done homework
and just wants to complain about problem people in her
life. She says that she has “lost everyone she has known
and loved,” that “you are the only one who has given me
the time of day and taken time to understand me.”
Ethical Issues: Client Dependency:
•
Issues such as when to introduce topics, how long to talk about
topics, and when to keep a client on a topic he or she may feel
uncomfortable about
•
Ask client regarding his or her comfort level
•
Client as equal partner in therapeutic process
•
•
•
Avoid high ambiguity situations- promoted dependency (ex:
high usage of sessions, more time with the therapist)
Use balance in giving homework assignments
Avoid judgments like, “you are doing much better now.”
(Instead, stick to concrete behavioral outcomes)
Solutions to Dependency
Promoting Autonomy
•
•
Avoid doing what clients can do for themselves
Let the clients be active in their treatment (e.g. cognitivebehavioral treatment of noting thought and behavior patterns)
•
Adjusting frequency of sessions
•
Termination plan and closure sessions
Scenarios: Termination
Scenarios: Termination
• You have met with a client a few times and devised a
detailed treatment plan which the client consented to.
The suddenly the client withdrew from counseling after
he calls and said that he has gotten the meds he needs
from a psychiatrist “he wanted” and does not need your
help anymore. What do you do about this case?
Scenarios: Termination
• You periodically evaluate counseling goals with your
clients. During a recent review of counseling goals a client
agrees that the goals have been met. However, she does
not want to consider lessening the frequency of treatment
or termination. You notice the comments in her sessions
appear to be shifting more towards personal things in her
life as opposed to the clinical presenting concerns. How
do you handle this?
Scenarios: Termination
• You are just beginning with a diagnostic assessment with
a client. You have never met this person before but you
are aware from his initial phone conversation that he has
had over a dozen therapist’s in the past year. Do you do
any preventative work or have any discussion the first
session knowing that this person has a pattern of only
remaining in counseling for no more than a few sessions
with each of his past therapists in this past year?
Scenarios: Termination
• You have seen many people suddenly leave counseling
when they believe they have gotten better or have no
need for counseling anymore. How do you create a plan
for generalizing skills taught in counseling so that clients
do not suddenly leave when they obtain some gains
before the ideal course of therapy?
Ethical Issues: Termination
•
Pros/cons discussed with client
•
How to apply techniques on an ongoing basis and generalization
•
Options of referrals
•
When a therapist leaves the practice
Scenarios: Multiple or
Dual Relationships
Scenarios: Multiple/Dual
Relationships
• You get a call from a friend who is having a challenging
situation. She begins by apologizing: “I am sorry to bug
you but I do not know where to turn.” Even though she
had a counselor the counselor is now out of network so a
few months ago your friend stopped seeing the
counselor. “ I know I am not your client but maybe since
you are a counselor you can just help me get through this
rough time until I can find someone in my insurance
network.”
Scenarios: Multiple/Dual
Relationships
• An adult woman has been with you in treatment for a few
months and has already established rapport and is on the
right track prognostically. She states she can no longer
afford treatment and asks if she can help clean the office in
the meantime to make up for it because she does not “want
to lose you.”
Scenarios: Multiple/Dual
Relationships
• You have been counseling a health professional who has
some borderline features and is one of your more
challenging clients. You decide to start attending a grief
support group for yourself after the death of your mother
at one of the local community organizations. When you
arrive at the grief group excited about having found a
group that really sounds like it pertains to you, you
discover that the group is actually led by your very own
borderline health professional client. What do you do?
Scenarios: Multiple/Dual
Relationships
• Years ago you counseled dually diagnosed persons. One
person you counseled in the past was Mary, a substance
user and sporadic abuser who had some past criminal
history. After years of a successful treatment regimen
Mary was terminated. One of your tasks for a mental
health agency is to work with the court programs.
Ironically, the program director is Mary your former client
who now assists other young people with drug and
alcohol and criminal problems to overcome what she had
successfully gotten through herself.
Ethical Issues: Multiple
Relationships
•
Definition- relationships which have the potential to dilute or diminish the
therapeutic relationship, reciprocal relationships, bartering relationships
•
Not in general a good idea
•
All alternatives discussed
•
Must be outlined and documented as to how/why beneficial
•
Should not have room for exploitation
•
*NOTE: New 2008 Ohio codes on this*
Scenarios: Family
Counseling
Scenarios: Family Counseling
• You began counseling a woman for her marriage
relationship issues. With her consent eventually she and
her husband had a few sessions together about her
concerns to practice the skills she had been taught in her
individual sessions about the marriage. After one year
the two of them got a divorce and you receive a call from
the ex husband. He said he felt like what you said in past
was beneficial to both of them and though they are
divorced wondered if he could be your client now. Do you
accept him as a client?
Scenarios: Family Counseling
• You are already counseling a man about how he can no
longer bear the stress in his relationship. He wants to
learn assertiveness and boundary setting to end what he
considers a toxic relationship. Unbeknownst to him his
partner separately calls in asking for individual counseling
to work on dealing with the fact that her boyfriend has
cold feet and lack of commitment issues. You do not
realize they are in a relationship with each other and both
separately are your clients until after you have begun
with each. How do you handle this when you realize it?
Scenarios: Family Counseling
• A young girl has been coming in for anxiety and panic
issues. After a few months of meeting with her you
realize that this is not really her problem but that the
issue is actually her overhearing the parents domestic
issues. Do you do anything with this realization? How do
you address this in treatment?
Ethical Issues: Family Counseling
• Be clear who the client is
• (individual, couple, family)
• Refer when potential conflicts
Disclosure of Records to Family
Members:
(ORC 5122.31 (a) (7) )
• Limited circumstances
• The
family member is involved directly in planning,
providing, and monitoring services to the client
• Client
notifications and informed consent without
objection
• Only
information with intention of supporting client’s
mental health
Disclosure of Records to Family
Members:
(ORC 5122.31 (a) (7) )
• Under 18 years old- patients have right to disclosure of
records except SA whereby only child can give consent
• Emancipated child under 18 - full control of all records
and parent- none
Scenarios: Duty To Warn
Scenario: Duty To Warn
• You meet with a teenager who says to you two months
prior to school getting out that she “hates a girl at her
school so much that she knows how to beat the crap out of
her.” The teenage client tells you of a plan the last day of
school or the following day for her and her gang “to find
the girl outside of school and beat her until she is as close
to dead but not kill her.” The client has a habit of really
running her mouth but this time she has verbalized a
specific plan to physically injure severely a girl she does
not like at school. You know the name of the school and
the girl’s name. What do you do if anything?
Scenario: Duty To Warn
• A woman tells of how she is sick and tired of abuse by her
husband although in session the example she gives points
to two way emotional abuse by both her and her husband.
She says she “wishes he wasn’t there” and “would not be
offended if he just died.” She makes a general comment
of, “I just wish I could kill him. It would be so much
easier.” She laughs as she speaks and offers no specific
plan for how she would do anything but just says she
wants the problems to get over. She also says she “is just
plain tired of the attention his girlfriend’s get that she
should get as his wife.” How do you respond?
Scenario: Duty To Warn
• A gentleman comes to you for counseling regarding some
work issues and anger with his supervisor at the job. He
has been placed on leave during the rime of counseling.
During this past session you and the client are planning to
talk about the transition of his return to work this
upcoming week. During this discussion the client
comments, “my supervisor will pay. He’ll get what’s
coming to him. He better not be around me when I return
that day. You know I’m a shooting man and a pretty good
one at that and he’s the type of target I’d be sure not to
miss. He better not even think of pissing me off the day I
return or he won’t live to see many more days.”
Scenario: Duty To Warn
• An angry employee tells you in a counseling session
about a co-worker, “he will wish that he never met me. I
will be their worst enemy. He better be watching his back
because if he doesn’t straighten up I will be on him like a
leech. I will be following him like a shadow if he gets on
my nerves.” Anything you need to do when you hear this?
What should your response be?
Ethical Issues: Duty to Warn
• Therapist to use professional knowledge, client judgment
• Burden to prevent harm
• Consideration of alternatives: tx programs, decrease access
to weapons, referral to MD’s for meds, voluntary or
involuntary hospitalization, warnings to intended victims,
notifying authorities
Ethical Issues: Duty to Warn
 Clinicians- protected against liability when a clear,
credible, explicit threat of imminent and serious harm or
identifiable potential threat (if client attempts to
hospitalize, tx plan supported by reasonable standard of
care of other professionals, likelihood of that threatserious, and warning to intended victims and law
enforcement w/ specific reference to the nature of the
threat)
Scenarios: Advertising
Your Practice
Scenarios: Advertising Your Practice
Correct or change anything you think needs adjusted in the
following scenarios:
1) Our practice specializes in stress management
techniques geared toward managing depression, anxiety,
and overwhelming feelings Because we have been in
business over 25 years we certainly know what works and
what does not. Our practice only uses tried and true
methods. And our stress management methods have been
used by people in some of the most stressful jobs. If you
have a stressful life, try our stress management program of
six sessions to the new, improved healthier you.
Scenarios: Advertising Your Practice
• 2) Dr. Mia Ethical is consultant to many in the counseling
field. Her individual, couples, and group sessions with
adults with traumas have assisted over 500 clients n
learning skills to manage flashbacks, relax their bodies in
stressful situations, and counteract negative thought and
behavior patterns.
Scenarios: Advertising Your Practice
• 3) Dr. Ison Me is a leading expert in addiction recovery.
He is a worldwide author of articles on addiction and a
known, reputable colleague to many in this field of
addiction recovery. For many people the addictions that
used to be a struggle for them are now subdued or
eliminated entirely due to Dr. Ison Me’s techniques.
Scenarios: Advertising Your Practice
• 4) Mike Quickfix, LPCC can assist you in developing
assertiveness skills. While others offer assertiveness
programs for the equivalent of over $1,000 most of Mr.
Quickfix’s clinical clients are bolder, more direct, and
more highly assertive in less than half the cost and less
time.
Ethical Issues:
Advertising Your Practice
•
•
•
•
Must be accurate statements of qualifications, affiliations,
functions (NOTE: if limited time or space does not mean
everything has to be included but that that which is included is
true)
Must give general information so consumer can make an
informed decisions o whether or not to use the service
NO- statements that are predictive
NO-statements that play on client fears to get a
person to come in
Ethical Issues:
Advertising Your Practice
•
•
•
•
•
•
“professional, scientifically acceptable, and factually
accurate informative manner.”
Should not use extra-ordinary methods, sensationalism or exaggeration
Research participants: tell pros/cons
Do NOT promise, “this will guarantee ____ result.”
You can say something about techniques used, outcomes, or
populations served but make sure you can substantiate or document it.
Dangers- testimonials and radio shows
Advertising Versus Marketing
• Focus on your specialties on your disclosure statement
• Follow up with EAPs, lawyers, ministers, guidance
counselors, physicians
• Provide clinical information to clients on issues of
concern which apply to their counseling
• Speak to community groups, churches, businesses,
organizations, etc.
• Avoid personality descriptions
• Avoid clinical jargon
• Know trends in your field
Scenarios: Multicultural
Counseling
Scenarios: Multicultural Counseling
• A Mexican couple have been having marital difficulties.
During their first few sessions they share that one of the
approaches they have used to try and work through their
problems has been to involve the extended family and
friends in their marital debates. This is a cultural norm for
them but it also appears (from their self report) to make the
arguments worse.
Scenarios: Multicultural Counseling
• An adult male of African decent talks about the frustrations
of being in America and being trapped between family of
origin who are native born Africans and their values versus
some mixture of differing values he may have. How do
you approach counseling goals with him?
Scenarios: Multicultural Counseling
• A young Asian female comes into counseling very quiet
and reserved slow to open up. After three sessions she
speaks up a little more but not like your other clients. Do
you confront her regarding the “necessity” of speaking
more or not? If so, how?
Scenarios: Multicultural Counseling
•
A young lady comes to you with panic anxiety. While treating her for
the anxiety with behavioral relaxation and some cognitive behavioral
the therapy you also realize that she may benefit from some antianxiety medication. However you are aware that having counseled
her for over four months now that she has some strong religious
beliefs about seeing and hearing from God which are consistent with
her Pentecostal background. You are concerned that the psychiatrist
who is not of a Pentecostal Christian religious background will
possibly medicate her for psychosis when she describes having
spiritual dreams or hearing from God in prayer. How do you
approach the psychiatrist and do collateral consultation on this case
if at all?
Scenarios: Multicultural Counseling
• An inner city youth comes to counseling wanting to share
his music with you, draw pictures, and make art as
opposed to sitting and talking about problems. Is this
resistance? How do you know?
• An elderly woman likes to bring in examples of her
handmade crafts and tell folk stories from the town. How
do you determine if she is just wasting your and her time?
Is there any way you can use this in therapy?
Scenarios: Multicultural Counseling
• A southern woman talks a lot about being a victim to
oppression, a single parent home, physical and sexual
abuses, and natural disasters. She describes how she has
barely survived so many things in here life. Does this
victim talk mean that for sure she is avoiding the real
issues of therapy? Could there be any usefulness of this
victim narrative and historical survival story in treatment?
Ethical Issues: Multicultural
Contexts
WESTERN
•
•
•
•
•
•
•
Individuality
Democratic
Nuclear Family Focus
Youth Emphasized
Independence
Assertiveness
Non-conformity
EASTERN
•
•
•
•
•
•
•
Relationship
Authoritarianism
Extended Family Focus
Maturity Emphasized
Interdependence
Compliance
Conformity
Ethical Issues: Multicultural
Contexts
EASTERN
WESTERN
Competition
Cooperation
Conflict
Harmony
Freedom
Security
Individual needs
Collective goals
Responsibility within individual
Responsibility within society
Express Feelings
Control Feelings
Ethical Issues: Multicultural
Contexts
WESTERN
Uniqueness of each person
Self actualization
Future focus
Innovation
Morality-internal, individual
“Change is very good”
EASTERN
Uniformity of each person
Collective actualization
Traditionalism
Conservativism
Morality-relational
“Support is very good”
Dealing With Cultural Differences
• Counselor and Client Perspectives: Do you share same cultural
perspective or not? Is this important or central to the
counseling?
• What do you wish to do about differences of approach?
• Defining Value systems/Cultural Context- “teach me”
Ethical Guidelines for Multicultural
Counseling
(D.W. Sue & D. Sue, 1990)
•
•
•
•
•
•
Therapist awareness of own beliefs, values, feelings and biases
Ability to accept, value, and integrate client culture
Not threatened with referrals or consultations when appropriate
Judge client reactions of treatment approaches within cultural
context rather than personally
Therapist learns /allows self to be educated on that culture
(Same guidelines apply to all “special populations”)
Scenarios: Boundary Setting
Scenarios: Boundary Setting
• You are assisting in teaching a class at the university to
counselor education interns. During a break you hear
three students discussing some challenging cases in
detail outside the restroom. They discuss the names of
the clients, their reputations on campus, and other
personal and clinical details. Others can overhear them.
How do you react?
Scenarios: Boundary Setting
• During a staff lunch another therapist brings up in a joking
manner how he had to deal with “John,” a client that
everyone at the mental health center knows of who is a
routine substance abuser and known around the
community. The therapist jokes about how “John” is so
stupid that he used his pocket knife when drunk sitting in a
tree to cut the rope he was going to hang himself with.
Clinical staff, secretarial staff, and various workers at this
lunch joke about how John acted and that “dumb people
like this keep our business going.”
Scenarios: Boundary Setting
• A parent of a college-aged (over 18 year old) adult says,
“since I will be paying for my college-aged son to see you
I am hoping we can at least spend a few minutes at the end
of each session or on the phone so I know how it is going?
I am the parent after all and I really care for him because
he still lives with us and his behaviors affect us all.”
Scenarios: Boundary Setting
• A potential client calls in stating, “I just read that
cognitive-behavioral therapy is good for the issue I am
having and my insurance lists you as doing that so can I set
up an appointment?”
• During a phone consultation before initial appointment a
potential client says, “I am not tying to be hard on you but
you know there are so many people to pick from out thereI saw on my insurance list so many but how do I know you
are the best one for me?”
Scenarios: Boundary Setting
• During a first session a client says, “so I realize that by
your license and length of time owning the practice that
you have been around over 15 years. So how do you
approach situations? And I saw some of your specialtiesthey sound interesting- so I think maybe the Christian
counseling can be good for me- so what do you think?”
Scenarios: Boundary Setting
• Client says: “I have been to counseling a few times before
but I have a feeling that this time I am really ready for
change. What do you think?
• At scheduling time a client comments, “I am so glad your
office has so many days and hours open- I can only come
on Wednesday evenings at like 6 or 7 pm because my life
is so busy.”
Scenarios: Boundary Setting
• A client states to you, “I know you plan to go on vacation
but I don’t feel comfortable talking to anyone else but you.
I have never felt so comfortable with anyone and I have
been through lots of people before.”
Boundary Setting
•
•
•
•
•
Know your clients’ beliefs/expectations (clients most/least comfortable with, values
and belief systems, theoretical approaches preferred)
Know the standards of your agency (policies and procedures, mission/goals,
methods of dealing with things)
Know/keep up with the latest board rules and regulations
Be familiar with the social, multicultural, and interpersonal qualities of who you
serve, where you are situated
How will you communicate these?
•
•
•
Verbally
Written policies & procedures
Other
Scenarios: Personal
Stress Management
Scenarios: Personal Stress Management
• After 5 years in the mental health field you begin to find
yourself looking at the clock through client’s sessions,
getting more easily frustrated with things in the field, and
wondering if you can really “help everyone.” The
enthusiasm you had at the beginning to seemingly help
the whole world has waned to where you are not sure if
you should even be in the field. How do you handle this?
Scenarios: Personal Stress Management
• You notice yourself having increasingly negative
conversations about your organization, colleagues, lack
of pay, and dissatisfaction with the field. What do you do
next?
Scenarios: Personal Stress Management
• When you begin assessing particularly traumatic clients it
reminds you of when you survived abuse as a child
yourself. You picture yourself actively in your client’s
situations, like your empathy is on overdrive. Their story
becomes your story. What might be a useful suggestion
so you can best be present for your client?
Scenarios: Personal Stress Management
• In cognitive behavioral therapy we teach clients to be
aware of the shoulds, absolutes, have tos, and concrete
self critical thoughts. You notice that you are having
many of these types of thoughts with regard to working
in the field. Some of them are: “If I am not completely
successful with every client I should not have been in the
field”, “I have to be accessible and emotionally present
100% of the time for all types of clients and all situations
or I am a personal failure,” “Every stress reaction is just
evidence that I should have never gone into the field.”
How do you process these negative, irrational beliefs of
burnout prone therapists?
Ethical Issues: Personal Stress Management
& Burnout Prevention
Warnings: irritability, exhaustion,
abuse of alcohol/drugs,
reduced personal effectiveness,
compulsive working,
drastic behavior changes,
isolation from other professionals,
lack of balance- empathy and
professional distance,
taking work concerns with you
Irrational Beliefs of Burnout Prone Therapists
(Deutsch, 1984)
•
“I should always work at my peak level of enthusiasm and competence.”
•
“I should be able to cope with any client emergency.”
•
“ I should be able to help every client.”
•
“Client lack of progress is my fault.”
•
“I should always be available when clients need me.”
•
“I should be able to work with all types of clients.”
•
“I should be on call always.”
•
“Client needs come before my own needs.”
•
“I am responsible for my client’s behaviors.”
•
“I have power to help, control, or fix a client.”
Scenarios: Receiving
Gifts From Clients
Scenarios: Gift Giving
• As you approach termination of
counseling a clients asks if he can give
you a free gym membership to his
gym because he was unable to pay all
copays. How do you handle this?
Scenarios: Gift Giving
• A client gives you a Christmas card with a
$100 gift card to a fancy steak restaurant
for you and your husband enclosed. What
do you do?
• An older woman sews together a blanket
for you with your last name and a flower as
a sign of appreciation. How do you handle
this when she tries to present it to you?
Scenarios: Gift Giving
• A child brings in some drawings he made. He asks, “you
will put them on your wall, won’t you? The child’s full
name is on the front of the picture. How do you respond?
What do you say?
• A low income person requests your service. This person
cannot afford even a basic sliding scale fee but asks if
he/she can give you some fresh farm crops from their
field in exchange for your services or if their spouse a give
you some free haircuts and styles in their shop. Do you
barter? If so, what does the agreement look like?
Ethical Issues: Receiving Gifts From Clients
(Gerig,M.-July 2004)
•
Voluntarily given form one person to another
•
With both natural and symbolic value
•
Recipient sees it as a gift
•
A form of communication
•
Three categories:
1) a “tip” for good service
2) for the client to regain status after something lost
3) as a payment of homage
Ethical Issues: Receiving Gifts From Clients
(Gerig,M.-July 2004)
Questions to Consider Regarding Gift Giving
• What will accepting (or not accepting) this gift do to the
•
•
•
•
dignity and worth of the other person?
Is there potential for exploitation?
Would this be considered boundary crossing?
Do I have any approach-avoidance conflict within me?
What are the meanings behind accepting this gift?
Scenarios: Therapist
Versus Client Values
Scenarios: Therapist Versus Client
Values
• A 40 year old married woman with two young children
comes in stating that she “is ready to transition from
housewife to doing what she wants to do for a change.”
She wants your help with leaving her husband, attending
school and working two jobs and changing her lifestyle
entirely.“ How do you handle this?
Scenarios: Therapist Versus Client
Values
• A client comes in complaining regarding the son’s
engagement to a girl of a different race. This client wishes
to have the counseling goal of receiving assistance in
learning skills for “expressing to the son the concerns that
may arise” and “the reasons this is a bad idea.” What the
client does not know is that you are married to someone of
a different culture yourself.
Scenarios: Therapist Versus Client
Values
• A young adult comes in saying he/she has been “hurt and
burned by relationships” and now realizes that “no
commitment and multiple relationships at once is the way
to go.” You personally believe in monogamy and
commitment only to the relationship at hand and see
dangerous on many levels in dating multiple people.
Scenarios: Therapist Versus Client
Values
•
A mother calls in for therapy because she has had “an awakening”
stating that she no longer wants to be married or be around her kids
and wants to be free to do what she wants. She has decided she
wants to live on here own, go where she wants to go, and not be tied
down with a family. You personally have strong beliefs about the
value of the family unit and are deeply concerned about her sudden
abandonment of her husband and kids. Her stated therapeutic goal
is to receive support and assistance with the transition to her new life
and personal goals. How do you handle the inner struggle about
personally disagreeing with this person’s values?
Reasons for Discipline by the Board:
•
Violation of Board rules
•
Falsification of information regarding licensure & registration
•
Accepting a commission or rebate for referring persons to the board
•
Conviction of a felony in Ohio
•
Impaired ability to practice (drugs/alcohol, physical or mental conditions)
•
Misdemeanors in any state in the course of practice under licensure
•
Practice outside your scope of practice
•
Practice without supervision
Possible Reactions to Ethical
Complaints:
•
Discussing the complaint
•
Sanctioning the member
•
Recommending resignation
•
Recommending the member be dropped
•
Recommending remedial action (ongoing supervision, personal
therapy, additional CEUS)
Ethical Decision Making
(Corey, Corey & Callanan, 1993, 11-12)
• 1. What is the problem or dilemma? Is it an ethical legal or
moral issue?
• 2. Who does it affect?
• 3. What ethical guidelines fit this situation?
• 4. What do colleagues think? (reasonable standard of practice)
• 5. What possible consequences of action can be taken?
• 6. What are the consequences of various decisions?
• 7. What appears to be the best course of action?
Preventative Ethical Guidelines
(Breggin,P.R.-2008)
•
1. Every session welcome he client with kindness, empathic
understanding and genuine care and concern
•
2. Be genuinely caring and show “true empathy.”
•
3. Maintain an atmosphere of trust in the clinical relationship.
•
•
4. Make ethical and professional standards an expected part of your
interactions with each client and convey this to him or her.
5. Comment on behaviors of concern in a timely manner.
Preventative Ethical Guidelines
(Breggin,P.R.-2008)
•
•
•
6. Call attention by asking the client to tell his or her story regarding areas you find unusual or do not
understand.
7. Cultivate the sense that of the entire personhood of the client not just focusing primarily on their
mental health problems. Context and settings are important.
8. Frame as assisting the client in shaping, shaping and making productive decisions about his or her
clinical issues.
•
9. Convey balanced optimism.
•
10. Convey balanced optimism.
•
11. Self evaluate.
Preventative Ethical Guidelines
(Breggin,P.R.-2008)
•
•
•
•
•
•
•
12. Personalize therapeutic techniques to the specific needs of each given client.
13. Focus on the client’s ability to develop life skills.
14. Maintain the voluntary nature of counseling as much as is able.
15. Demonstrate in words and behaviors that appropriate expression of client feelings
can be met with empathy, understanding and potential for behavior change.
16. Make clients aware of your values and the extent to which they may impact
counseling. Redirect them elsewhere when necessary.
17. Be careful not to further facilitate helplessness in extremely vulnerable persons.
18. Offer practical direction and techniques, homework, and applied skills to facilitate
behavior change when appropriate.
Preventative Ethical Guidelines
(Breggin,P.R.-2008)
•
•
•
•
19. Reframe your role as clinician as partner, helper, and facilitator rather
than simply expert .Also, remind the client that you are one option.
20. Do not delay in addressing issues that are important for the client, no
matter how ridiculous they may seem to you.
21. Remain calm ad attentive and professional emergencies. Do not allow
yourself to be emotionally reactive.
22. Share the last resorts and options when needed.
Ethical Decision Making Models
Problem Solving Models:
• 1. Identify the problem.
• 2.Define goals by consulting with various sources.
• 3.Generate possible courses of action.
• 4. Consider possible consequences of each action.
• 5. Evaluate the situation as a whole.
Ethical Decision Making Models
Standards of Care Models
• Judge ethical decisions against socially accepted norms
• Looking at what a counselor in your shoes would do
reasonably- legal, precedent defined
Ethical Decision Making Models
Principle Ethics
• Use the standards (e.g. beneficence, nonmaleficience, etc.)
to judge each situation against
Ethical Evaluation
The Four Quadrant Approach of Foster & Black-2007
• All quadrants exist simultaneously
• What is good and what is right
Quadrant One: Ethics & Justice
• What we typically think of as “ethics”
• Standards of he ethics committee
• The principles of counselor/client interactions
• Counselor education, supervision, training, accredidation
Ethical Evaluation
The Four Quadrant Approach of Foster & Black-2007
Quadrant Two: Legalities
• What is lawful
• License requirements
• What can be prosecuted criminally or civilly
Ethical Evaluation
The Four Quadrant Approach of Foster & Black-2007
Quadrant Three: Personal Variables
• Counselor behavior within and outside of counseling
sessions
• How a counselor deals with stress, takes care of oneself,
maintains their own well being, keeps balanced and
reduces compassion fatigue in difficult cases
Ethical Evaluation
The Four Quadrant Approach of Foster & Black-2007
Quadrant Four: Morals
• A counselors personal sense of values, beliefs, and morals
• What is right for the counselor
Key Questions to Evaluate Ethics
•
What factors am I aware of in this case?
•
Are their areas I need additional information on from the client or collateral sources?
•
What is the perspective of the board?
•
Are there any policies which apply to this case?
•
What are the contextual factors involved here- thoughts, beliefs, values, culture?
•
How should I interact with the client?
•
What is my role as a counselor in this case?
Key Questions to Evaluate Ethics
•
•
Is there anything significant about this case?
What are the immediate concerns in this case? The long term
issues or potential uses?
•
What do I need as I work with this person?
•
Is this case within my scope of practice or should I refer?
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