Ethics in Counseling

Issues and Ethics

 Steps in Making Ethical
Decisions
Approach to thinking through ethical dilemmas:
1. Identify the problem or dilemma
2. Identify the potential issues involved
3. Review the relevant ethics codes
4. Know the applicable laws and regulations
5. Obtain consultation
6. Consider possible and probable courses of action
7. Enumerate the consequences of various decisions
8. Decide on what appears to be the best course of
action
 The Counselor as a Person
and as a Professional
• Counselors must be aware of the influence of
their own personality and needs
• Personal needs of counselors based on
unresolved personal conflicts:
– a need to tell people what to do
– a desire to take away all pain from clients
– a need to have all the answers and to be perfect
– a need to be recognized and appreciated
– a tendency to assume too much responsibility for
the changes of clients
– a fear of doing harm, however inadvertently
 Transference

• Transference is the process whereby clients

project onto their therapists past feelings or
attitudes they had toward significant people in
their lives
• Transference: the “unreal” relationship in
therapy
– Counselors need to be aware of their personal
reactions to a client’s transference
– All reactions of clients to a therapist are not to be
considered as transference
– Ethical issue is dealing appropriately with
transference
 Countertransference

• Countertransference is the counselor’s reaction

to the client’s transference response
• Examples:
– being overprotective with a client
– treating clients in benign ways
– rejecting a client
– needing constant reinforcement and approval
– seeing yourself in your clients
– developing sexual or romantic feelings for a client
– giving advice compulsively
– desiring a social relationship with clients
 Stress in the Counseling
Profession
• Counseling can be a hazardous profession
• Some sources of stress for counselors are:
– Feeling they are not helping their clients
– The tendency to accept full responsibility for
clients’ progress
– Feeling a pressure to quickly solve the problems
of clients
– Having extremely high personal goals and
perfectionistic strivings
 Counselor Impairment

• Impaired counselors have lost the ability to

resolve stressful events and are not able to
function professionally
• Shared characteristics of impaired counselors:
– fragile self-esteem
– difficulty establishing intimacy in one’s personal life
– professional isolation
– a need to rescue clients
– a need for reassurance about one’s attractiveness
– substance abuse
 Maintaining Vitality as a
Counselor
• Counselors are often not prepared to maintain their
vitality
• Sustaining the personal self is an ethical obligation
• Personal vitality is a prerequisite to functioning in a
professional role
• Main challenge is to create a balanced life in these
areas:
– Spirituality § Self-direction
– Work and leisure § Friendship
– Love
 Values and the Helping
Relationship
• Value conflicts:
– To refer or not to refer
– Referrals appropriate when moral, religious, or
political values are centrally involved in a client’s
presenting problems and when:
• therapist’s boundaries of competence have been reached
• therapist has extreme discomfort with a client’s values
• therapist is unable to maintain objectivity
• therapist has grave concerns about imposing his or her
values on the client
 Values
• Development of value systems are
influenced by:
– Family
– Peer group
– Culture
– Media
– Religion
– Education
– Politics
 Value Areas

• Health—Emotional and
• Education/New
Physical
Knowledge
• Love/Affection
• Money/Possessions
• Achievement/Recogniti
• Religion/Morals
on
• Helping Others
• Marriage/Family
• Friendships
• Security
• Work/Career
• Leisure
 Role of Spiritual and Religious
Values in Counseling
• Spirituality refers to:
– general sensitivity to moral, ethical, humanitarian,
and existential issues without reference to any
particular religious doctrine
• Religion refers to:
– the way people express their devotion to a deity or
an ultimate reality
• Key issues:
– Can the counselor understand the religious beliefs of
the client?
– Can the counselor work within the framework of the
client?
Policy on End-of-Life Decisions

• Various continuing care or treatment options

exist,
such as:
– aggressive treatment of the medical condition(s)
• life-sustaining treatment
– medical intervention intended to alleviate suffering
(but not to cure)
– withdrawing life-sustaining treatment
– voluntary active euthanasia
– physician-assisted suicide
Values Pertaining to Sexuality

• Counselors need to know their attitude toward:

– the belief that sex should be reserved for marriage
only
– sex as an expression of love and commitment
– casual sex
– group sex
– extramarital sex
– premarital sex
– homosexuality
– teenage sex
Need for Multicultural Emphasis

• Key Terms:
– Ethnicity
– Minority group
– Multiculturalism (cross-cultural, transcultural,
intercultural, similar meanings)
– Multicultural counseling
– Diversity-sensitive counseling
– Racism
– Stereotypes
– Culturally encapsulated counselor
 Multicultural Competence
• Recognizing our limitations
• Manifested in our willingness to:
– seek consultation
– seek continuing education
– make referrals
 Counselor Attitudes in Working
with Culturally Diverse Clients
• Overt racist
– overtly hostile, homophobic, racist, ageist,
sexist, judgmental (should stay out of the field)
• Covert prejudice
– tries to hide negative, stereotyped opinions but
client picks up cues
• Culturally ignorant
– lack of knowledge based on homogeneous
background (need to learn about other cultures
before working with them)
 Counselor Attitudes in Working
with Culturally Diverse Clients
• Color blind
– denies differences: "I don’t recognize
differences; I treat everyone the same."
• Culturally liberated
– recognize, appreciate, and celebrate cultural
differences; strives for freedom from
judgments of diverse clients
 Examining Common
Assumptions
• Assumptions about self-disclosure
• About assertiveness
• About self-actualization and trusting
relationships
• About nonverbal behavior
• About directness
 Cultural Issues in Counseling

• Counselors will encounter diversity in areas such

as:
– gender
– race
– culture
– socioeconomic background
– physical ability
– age
– sexual orientation
 Cultural Issues in Counseling

• In dealing with diversity, counselors need to:

– acquire academic and experiential
multicultural training
– develop working therapeutic relationships
– be flexible in applying theories
– be open to being challenged and tested
– be aware of their own value systems, potential
stereotyping, and any traces of prejudice
 Guidelines for Addressing
Sexual Orientation
• In order to change therapeutic strategies,
one must be open to changing assumptions
about sexual orientation
• Counselors need to become conscious of
their own faulty assumptions
• Counselors are challenged to confront their
personal fears, myths, and stereotypes
regarding sexual orientation
Counseling Gays and Lesbians

• Exemplary practice includes:

– not attempting to change sexual orientation without
evidence that client desires change
– recognizing that gay and lesbian individuals can
live happy and fulfilled lives
– recognizing the importance of educating others
about gay and lesbian issues
– recognizing ways in which social prejudices and
discrimination create problems for clients
 Gay and Lesbian Myths
– Gay people can be identified by their mannerisms or
physical characteristics
– Most gay people could be cured by having a good sexual
experience with a member of the opposite sex
– The majority of child molesters are gay
– Gay people have made a conscious decision to be gay
– Gay adults will try to convert youth to their lifestyle
– Homosexuality is a psychological disorder that can be
cured by appropriate psychotherapy
– In gay relationships, one partner usually plays the
“husband/butch” role and the other plays the “wife/femme”
role
– Homosexuality is caused by a defective gene
– Homosexuality is unnatural, since it does not exist in other
 Asian Americans
• I. Family structure patterns:
– traditional gender roles
– honor parents, listen to words of wisdom that
come with age
– extended family rules—especially within the
first few generations
 Asian Americans
• II. Values and attitudes:
– education is the ladder to success
– persevere, don’t give up
– self-denial is the secret to success
– respect traditions and culture of forefathers
– don’t be ostentatious, forward, brash
– austerity and renunciation valued
– duty to family and country
– spiritual evolution sought
 Checklist for Informed Consent

• Voluntary participation
• Client involvement
• Counselor involvement
• No guarantees
• Risks associated with counseling
• Confidentiality and privilege
• Exceptions to confidentiality and privilege
• Counseling approach or theory
• Counseling and financial records
• Ethical guidelines
 Checklist for Informed Consent
• Licensing regulations
• Credentials
• Fees and charges
• Insurance reimbursement
• Responsibility for payment
• Disputes and complaints
• Cancellation policy
• Affiliation membership
• Supervisory relationship
• Colleague consultation
Content of Informed Consent
• The therapeutic process
• Background of therapist
• Costs involved in therapy
• The length of therapy and termination
• Consultation with colleagues
• Interruptions in therapy
• Clients’ right of access to their files
• Rights pertaining to diagnostic labeling
• The nature and purpose of confidentiality
• Benefits and risks of treatment
• Alternatives to traditional therapy
• Tape-recording or videotaping sessions
 Ethical Issues in Online
Counseling
• It is the counselor’s responsibility to examine the ethical,
legal, and clinical issues related to online counseling
• Providing counseling services online is controversial
• There are potential legal issues that must be addressed, a
few of which include:
– Competence of practitioner in providing online counseling
– Informing client of limits and expectations of the relationship
– Developing a plan for how emergencies can be addressed
 Some Advantages of
Online Counseling
• Reaching clients who may not participate in
face-to-face therapy
• Improving client access in rural areas
• Increasing flexibility in scheduling
• Facilitating assigning and completing of client
homework
• Augmenting a problem-solving approach
• Improving an orientation to the counseling
process
• Enhancing the provision of referral services
 Some Disadvantages of
Online Counseling
• Danger of making an inaccurate diagnosis
• Compromising of confidentiality and privacy
• Problems involved in being able to protect suicidal
clients
• Difficulties in attending to clients who are in crisis
situations
• Absence of traditional client-therapist relationship
• Inability to address a range of more complex
psychological problems
• Inability to deal with interpersonal concerns in the
therapy process
 Reasons for Malpractice Suits

• Failure to obtain or document informed consent

• Client abandonment
• Marked departures from established therapeutic
practices
• Practicing beyond the scope of competency
• Misdiagnosis
• Crisis intervention
• Repressed or false memory
• Unhealthy transference relationships
• Sexual abuse of client
• Failure to control a dangerous client
• Managed care and malpractice
 Signs of Child Abuse

• Wary of physical contact with adults

• Apparent fear of parents or going home
• Inappropriate reaction to injury
• Lack of reaction to frightening events
• Apprehensive when other children cry
• Acting-out behavior to get attention
• Fearful, withdrawal behavior
• Short attention span or learning difficulties
• Regression into earlier stages of development
• Sudden change in behavior
• Fearful reaction to questions about injury
 Limits of Confidentiality

– When clerical assistants handle confidential

information
– When counselor consults
– When counselor is being supervised
– When client has given consent
– When client poses danger to self or others
– When client discloses intention to commit a crime
– When counselor suspects abuse or neglect of a child
or vulnerable adult
– When a court orders counselor to make records
available
Duty to Protect Potential Victims

• Identify clients who are likely to do

physical harm to third parties
• Protect third parties from clients judged
potentially to be dangerous
• Treat those clients who are dangerous
 Liability for Civil Damages When
Practitioners Neglect Duty by:
• Failing to diagnose or predict dangerousness
• Failing to warn potential victims of violent
behavior
• Failing to commit dangerous individuals
• Prematurely discharging dangerous clients
from
a hospital
 Legal Precedents

• Tarasoff Case
– duty to warn of harm to self or others
– duty to protect
• Bradley Case
– duty not to negligently release a dangerous client
• Jablonski Case
– duty to commit a dangerous individual
• Hedlund Case
– extends duty to warn to anyone who might be near the intended
victim and who might also be in danger
• Jaffee Case
– communications between licensed psychotherapists and their
clients are privileged and therefore protected from forced
disclosure in cases arising under federal law
 Guidelines for Implementing
Duty to Warn Requirements
• Get informed consent
• Plan ahead through consultation
• Develop contingency plans
• Obtain professional liability insurance
• Involve the client
• Obtain a detailed history
• Document in writing
• Implement procedures to warn
 Guidelines for Assessing
Suicidal Behavior
• Take direct verbal warnings seriously
• Pay attention to previous suicide attempts
• Identify clients suffering from depression
• Be alert for feelings of hopelessness and helplessness
• Monitor severe anxiety and panic attacks
• Determine whether individual has a plan
• Identify clients who have a history of severe alcohol or
drug abuse
• Be alert to client behaviors (e.g. giving prized
possessions away, finalizing business affairs, or
revising wills)
• Determine history of psychiatric treatment
 Ethical Guidelines for
Disclosure
of a Client’s HIV Status
• Sufficient factual grounds for high risk of harm
to
third party
• Third party is at risk of death or substantial
bodily harm
• Harm to the third party is not likely to be
prevented unless counselor makes disclosure
• Third party cannot reasonably be expected to
foresee or comprehend high risk of harm to
self
 Recommendations in
Counseling HIV Clients
• All limits to confidentiality should be
discussed with the client at the outset of
treatment
• Therapists must be aware of state laws
regarding their professional interactions with
HIV-positive clients
• Therapists need to keep current with regard to
relevant medical information
• Therapists need to know which sexual
practices are safe
Dual and Multiple Relationships

• Identify measures aimed at minimizing the

risks:
– set healthy boundaries from the outset
– secure informed consent of clients
– discuss both potential risks and benefits
– consult with other professionals to resolve any
dilemmas
– seek supervision when needed
– document in clinical case notes
– examine your own motivations
– refer when necessary
 Accepting Gifts

• Questions to consider in making a decision of

whether or not to accept gifts from the client
– What is the monetary value of the gift?
– What are the clinical implications of accepting or
rejecting the gift?
– When in the therapy process is the offering of a gift
occurring?
– What are the therapist’s motivations for accepting or
rejecting a client’s gift?
– What are the cultural implications of offering a gift?
 Recommendations Concerning
Bartering Relationship
• Evaluate whether it puts you at risk of
impaired professional judgment
• Determine the value of goods or services in a
collaborative fashion
• Determine the appropriate length of time for
arrangement
• Document the arrangement
• Consult with experienced colleagues or
supervisors
 Bartering

• Additional guidelines to clarify bartering

arrangements
– Minimize unique financial arrangements
– If bartering is used, it is better to exchange
goods rather than services
– Both therapist and client should have a
written agreement for the compensation by
bartering
 Signs of Unhealthy
Professional Boundaries
• I. Intimacy distortions
– falling in love with client
– parentification of client
• II. Inadequate boundaries
– not noticing boundary invasion
– over-responsible for client
– over-involvement with client
– over-identification with client
– role confusion/reversal
– inappropriate touch
– being manipulated by client’s unreasonable demands
– responding to inappropriate personal questions
– acting on sexual attraction
 Types of Sexual Abuse
in Psychotherapy
• Sexual touch as therapy
• “Learning to love” as therapy
• Exploring sexual identity
• Becoming romantically involved
• Brief loss of control
• “Bonding” and other types of closeness
 Suggestions on Dealing with
Sexual Attraction to Clients

• Acknowledge the feelings

• Explore the reasons for attraction
• Never act on feelings
• Seek out experienced colleague or supervisor for
consultation
• Seek personal counseling if necessary
• Monitor boundaries by setting clear limits
• If unable to resolve feelings, terminate the
relationship and refer
 Continuum of Sexual Contact
Between Counselor and Client
• Psychological abuse
– The client is put in the position of becoming caretaker of
counselor’s needs.
• Covert abuse
– The counselor intrudes into client’s intimacy boundaries by
sexual hugging, professional voyeurism, sexual gazes, over-
attention to client’s dress and appearance,
or seductive behavior
• Overt forms of sexual misconduct
– Counselor initiates or allows sexual remarks, passionate
kissing, fondling, sexual intercourse, oral or anal sex,
or sexual penetration with objects