Ethics for Counseling- LMHC LPC

Welcome to the Ethics Review, brought to you by allce.com Most codes of ethics are broad and general rather than precise and specific. They give you an idea about how things would go in the perfect world. Laws, as we'll discuss later, are more precise and specific. They tell you when A happens, you must do B. Ethical awareness and problem solving skills will determine how you translate general guidelines into professional behavior. Codes of ethics fulfill three objectives. They educate professionals about sound ethical conduct, provide a mechanism for professional accountability, and act as a catalyst for improving practice. The purpose of codes of ethics is to safeguard the welfare of clients by providing what is in their best interest to safeguard the public and to guide professionals in their work and to safeguard the professional by providing guidelines for behavior. When we talk about codes of ethics, we need to define certain terms. Community standards are what professionals actually do, whereas ethical standards are what professionals should do. In an ideal world, if everything were to go wonderfully, ethical standards are what we would conform to. Laws define a minimum standard that society will tolerate and are enforced by the government. The American Psychological association indicates that psychologists should seek to resolve conflict in a way that complies with the law and most nearly conforms to the ethics. Values pertain to beliefs rather than attitudes and provide direction to everyday living. You have values. There are certain values inherent in your profession. There are certain values inherent in everything you do, and you need to come to some balance between what your values are and what the values of your profession are. Ethics pertain to the beliefs we hold about what constitutes correct or moral conduct. Ethical conduct is behavior that results from a combination of knowledge and a clear conception of the philosophical principles that underline the ethics code. Community standards often become the ultimate legal criteria for determining whether practitioners are liable for damages, as they often define what is considered reasonable behavior. So if you're taken to court and sued for malpractice, people are not going to look at the ethical standards. We know that those are an ideal set of circumstances. What they're going to look at is the community standards. What do most professionals do, and did you conform to what the community standard is? Mandatory ethics describe a level of ethical functioning wherein counselors merely act in compliance with minimal standards. So mandatory ethics is complying with the law and doing no harm to your client. Aspirational ethics describes the highest standards of conduct to which professional counselors can aspire. Principal ethics is a set of obligations and a method that focuses on moral issues with the goals of solving a particular dilemma and establishing a framework to guide future ethical thinking and behavior. Virtue ethics focuses on the character traits of the counselor and non obligatory ideals to which professionals aspire, rather than on solving specific ethical dilemmas. There are certain characteristics of what we would call virtuous professionals. They're motivated to do what is right for the right reasons. They make business decisions with discernment and sensitivity. They possess compassion. They have regard for the welfare of others and a sensitivity to the suffering of others. And possess self awareness and have the capacity for self observation. There are certain core virtues that should guide ethical decision making. Those are prudence, integrity and benevolence. Certain basic moral principles guiding ethical decision making include autonomy, beneficence, justice, fidelity and veracity. Most of us went over those ad nauseam when we were in our counseling program. These are your basic core ethical principles that you talk about when you take your ethics class. There are certain steps in ethical decision making and there are various models that have different takes on the steps. But basically the first thing to do is recognize the problem, develop a variety of solutions, choose a solution, review the process with the client and re choose solutions as needed. You have to remember this is the client's treatment. So you want to go over what you see as the best solutions and have the client help you make the decision for what the best outcome would be and what's going to ultimately support them in their treatment process. Implement and evaluate the solution and continue reflection. Once you do the solution and evaluate it, that's great, but it's going to have a lasting impact. So you want to continue to evaluate how that decision is impacting treatment and whether you need to go back and tweak things a little bit. Another model says you want to identify the problem or dilemma. Review relevant ethics codes and this is always a good step. Know the applicable laws and regulations. That's your minimum standard for behavior. Obtain consultation, that is from other colleagues. And you might also want to obtain consultation from your client. If the situation is appropriate. Consider the possible and probable courses of action. Enumerate the consequences of various decisions. So make a pro and con list if you want to and decide on what appears to be the best course of action. In order to make ethical decisions, it's imperative that we be self aware. Professionals who work with others have a personal responsibility to be committed to awareness of their own life issues. So if you're not on your game, if you're having a bad day, if you've got crises in your life, if you have transference or countertransference issues, it's your responsibility to be aware. Without a high level of self awareness Counselors are in great danger of obstructing the progress of their clients by shifting the focus of therapy from meeting the client's needs to meeting their needs. We can all think of counselors that we've worked with who have kept clients in treatment longer than they should have because they had a need for that client to be dependent. They've had a need to rescue clients. They end up turning counseling sessions around to get validation for themselves instead of focusing on the client. These are all issues that come up way more often than we would really like to think about and show a gross lack of self awareness on the part of certain clinicians. To the degree to which we are unaware of our needs and personal dynamics, we will probably use our work primarily to satisfy our own unmet needs and steer clients away from exploring conflicts that we ourselves are unwilling to acknowledge. I want you to think about that for a second. We all have stuff. We all have skeletons in our closet, whatever you want to call it. And if there are things that we are unwilling to do, we're probably going to be less inclined to challenge a client to do that. The critical point is not whether you happen to be struggling with personal questions, but how you are struggling with them. Transference is the process in which a client projects onto the therapist feelings or attitudes they have towards significant people in their lives. It can't explain every feeling clients express with or toward the therapist. So if they get angry at you, really evaluate whether this is transference or they have a right to be angry at you. Don't fail to own mistakes. Don't fail to hold up your end of the bargain with self awareness by just saying, oh well, that's transference. Countertransference is any projection by a therapist that can potentially get in the way of helping the client. For example, being overprotective of the client. Treating the client in benign ways to avoid their anger. So placating the client. Needing constant reinforcement and approval from the client. Seeing yourself in the client's shoes. Now there's a difference between empathy and walking a mile in the client's shoes. Being there with the client and all of a sudden seeing how you are the client. Sexual or romantic feelings toward the client, Giving advice compulsively and desiring a sexual relationship with clients. Another thing that we often see in unethical practice is fostering client dependence. Some practitioners feel the need to be available 24 hours a day for any reason, and that communicates to the clients that you're not capable of functioning on your own without my direction. That's not helpful. That teaches the client to be dependent. The therapist who offers quick solutions to a client's problems also prevents the client from developing autonomy. If you don't let them learn how to solve their own problems. If you tell them how to do it, they're never going to learn how to do it on their own. So they're going to be in therapy for the rest of their life and delaying client termination. Again. Not only does this send the message that you can't survive without me, but it also is unethical to the standpoint that you may keep clients in therapy longer than you need to because they're a reliable, billable hour. I see that a lot and it's just absolutely disgusting. When you see clients who have been in treatment for depression for four years, you really need to look at the case notes and see if the client needed to be in treatment for that long. There are occasions when that's true, but they're rare. The effects of client dependence it communicates to the client that they're unable to function without therapist direction, prevents many clients from experiencing a successful relationship termination and exploits the clients financially and or emotionally. There are certain attitudes and ideas that contribute to therapists stress which will make us be off of our game. Some of these ideas are that you should always work at your peak level of enthusiasm and confidence. Not going to happen. Nobody's at the peak all the time or it wouldn't be a peak. You must be able to cope with any client emergency that arises. Well, that's what consultation is for. You're expected to be a model of mental health. Well, you're supposed to demonstrate how to function and how to handle things. But everybody has crises, everybody has times when something happens. So you're expected to model appropriate coping skills and self awareness, but not a model of mental health at all times. You're not always going to be happy and normal, so don't put yourself up on this pedestal. A client's needs always come before my own. If you've worked in addictions or you've worked with people with personality disorders, you're going to wear down really fast. If you're always putting a client's needs before your own. A client in crisis is going to have needs that are extremely demanding. And if you have more than one client, then you're basically running on empty all the time. You need to have backup systems, crisis lines, contracts. You need to help them develop their own support system that does not include you 24 hours a day. Again, they need to not be dependent on you all the time and you're responsible for your client's behavior. Clients are humans. They have the ability and the right to choose their own behavior. You're responsible for not warning people if you think that your client is suicidal or homicidal. But if a client makes a poor choice, that was that client's decision. Sexual involvement with clients is just mind boggling to me how often it occurs. It's often committed by persons with any or all of the following characteristics. They have difficulty with intimacy and their personal lives. They're professionally isolated. They have a need to rescue clients. They have a need for reassurance about their own attractiveness and they often have substance abuse or addiction of some kind. In order to prevent impairment. You want to make sure to continue your professional development. Seek personal therapy as needed. Periodically seek supervision even if you don't think anything's wrong. Meet with a colleague just to get their take on your professional effectiveness. Peer interaction. You don't want to be socially isolated. You don't want to be professionally isolated. Other counselors can kind of understand the stress that goes along with counseling and can empathize in a way that non counselors aren't necessarily as able to do and maintain vitality. Rest. Pay attention to your family. Don't have a one dimensional life that is focused on work all the time. You are a multi dimensional person. Therapeutic neutrality means that you will not necessarily always agree with the values of your clients, but it's essential that you respect the right of your clients to hold a different set of values. It's important to inform clients of any areas in which you think you can't be neutral because your job is not to approve or disapprove of your clients values, but help them explore their values and apply their values to solving their problems. When you experience a value conflict, seek consultation before considering a referral. There are certain important competencies with regard to values, spirituality and ethics. You want to explain the relationship between religious, spiritual and transpersonal phenomena. You want to be able to identify how key events in people's lives contributed to the development of their belief system. And you want to engage in self exploration of people's religious, spiritual and transpersonal beliefs that support or hinder them from respecting and valuing different belief systems. You want to demonstrate empathy for and an understanding of a variety of religious, spiritual and transpersonal phenomena. You want to acquire knowledge needed to better understand the client's religious and spiritual worldview and assess the relevance of the religious, spiritual and transpersonal domains in the client's therapeutic process. Use a client's religious, spiritual or transpersonal phenomenon in pursuit of the client's therapeutic goals. Identify when their understanding or tolerance of religious, spiritual or transpersonal worldviews is insufficient to adequately serve the client. Seek consultation or further training and demonstrate appropriate referral skills if you've reached your limit of tolerance or confidence with regard to that client's religious, spiritual or transpersonal worldviews. When it comes to dealing with suicide, there are a lot of ethical issues that come up with reporting, discussing suicide, that sort of thing. Rational suicide means the person has decided, without coercion from others, to end his or her life because extreme suffering involved with a terminal illness. Aid in dying means providing the person with a means to die, but the person self administers the death. Hastened death involves speeding of the dying process, which can entail withholding or withdrawing life support. In order to decide whether a person's suicide or hastens hastened death is rational, you need to think about whether the person considering suicide has an unremitting and hopeless condition. Are they acting under their own free will? Have they engaged in a sound decision making process that includes consultation with the mental health professional and discussions with objective others including medical and religious professionals, or are they just making this decision on their own? During end of life counseling, you want to find out as much as possible about the course of the client's illness, the prognosis and available treatments. Know the client's family support systems and their views regarding end of life decisions. Realize the client at or near death needs help coping with psychological and physical pain. You need to assume the role of the resource person and help clients understand the importance of various personal and formal documents associated with the end of life, offer compassion and acceptance and understanding related to the difficulties in dealing with life and death issues, and realize the role of offering comfort to loved ones and friends after death. Another area we have to address besides end of life counseling is the fact that we live in a multicultural society, so it's important that we are multiculturally sensitive. Culture broadly means association with the racial or ethnic group as well as with gender, religion, economic status, nationality, physical capacity, or sexual orientation. Ethnicity is the sense of identity that stems from a common ancestry, history, nationality, religion, or race. Minority groups are any category of people who have been discriminated against or subjected to unequal treatment and oppression by society largely because of their group membership. Multiculturalism is any relationship between and within two or more diverse groups. Multicultural counseling is a counseling relationship in which the counselor and the client belong to different cultural groups, hold different assumptions about social reality and subscribe to different worldviews. Diversity refers to individual differences such as age, gender, sexual orientation, religion, and physical ability. Diversity sensitive counseling is a concept that includes sensitivity to individual differences. Culture centered counseling is a three stage developmental sequence for multicultural awareness. Stereotypes are oversimplified and uncritical generalizations about individuals who are identified as belonging to a specific group. Racism is any pattern of behavior that, solely because of race or culture, denies access to opportunities or privileges. Multicultural counseling is based on the following all cultures have meaningful ways of coping with the problems of a particular group. People seek counseling largely because of problems that emerge out of sociocultural conditions. Traditional counseling is a particular form of intervention developed in the west by to cope with psychological distress. All cultures have developed formal or informal ways of dealing with human problems. The culturally encapsulated counselor shows insensitivity to cultural variations, accepts unreasoned assumptions without proof or ignores proof because that might disconfirm his own assumptions. They fail to evaluate other viewpoints and make little attempt to accommodate the behavior of others and are trapped in one way of thinking that resists adaptation and rejects alternatives. You have a moral and professional responsibility with regard to diversity. You need to be aware of and address biases, stereotypes, and assumptions. You need to be aware of the culturally different clients, values and worldview and develop appropriate intervention strategies to take into account the social, cultural, historical, and environmental influences of culturally different clients. You need to engage in continuing education and reflect on the underlying values of your chosen therapy models and how those values coincide with the values of the clients. There are certain common assumptions requiring attention in multicultural counseling. Self disclosure in many cultures reflects not only on the person but also the whole family and it's strongly discouraged to self disclose to a stranger. Assertiveness and directness are not prized in all cultures. An individual autonomy and self actualization of are values only held by a few cultures. Nonverbal behavior such as personal space, eye contact, handshaking dress, perspective on time, and formality of greeting differ widely between cultures. In order to become multiculturally competent, you need to develop attitudes and beliefs which are positive towards multiculturalism and and understanding how your values and biases may get in the way of effective helping. You need to be culturally confident and knowledgeable in understanding of your own worldview, have specific knowledge of the diverse groups with whom you work, and have a basic understanding of socio political influences and you need to appropriately use skills and intervention techniques necessary to serve the diverse client groups with which you work. Multicultural counseling competencies include being aware of your own cultural values and biases, understanding your client's worldview, and developing culturally appropriate intervention strategies and techniques. In order to develop multiculturally sensitive counselors, we must integrate multicultural perspectives throughout the training curriculum. Trainees need to participate in at least one required internship in which they have multicultural experiences or reframe their experiences from a multicultural viewpoint, and they should open themselves to other people and other cultures through reading and travel. Regardless of the culture of your client, regardless of exactly what topics you're dealing with your client, you need to have informed consent. This involves the right of clients to be informed about the therapy and make autonomous decisions pertaining to provides clients with information about the risks, benefits, and alternatives to the proposed treatment. It involves more than the client's signature on the form and is best viewed as an ongoing process and it requires that the client is competent, has knowledge of what will occur, and is in treatment voluntarily. This doesn't always occur in addictions counseling. Sometimes you have involuntary clients, but they do need to know that this is what's going to happen in treatment. And ideally, in this involuntary treatment scenario, there are options they can refuse. Maybe that means they go back to jail. Maybe that means there are other consequences. But having somebody committed to treatment without any options at all borders on unethical. It involves the right of clients to be informed about therapy and make autonomous decisions. That means you need to tell them what's going to happen and allow them to say yes or no and provide them with alternatives. Not all clients are going to be ready to jump in. They're not going to be in the action stage of change. So if there are alternatives, intensive outpatient instead of residential, or something else that maybe isn't even within your organization, you need to let the client know. There are three elements of the legal definition of informed capacity, comprehension and voluntariness. Capacity. Are they under the influence of alcohol or other drugs? Are they incapable of making the decision on their own? Comprehension? Is what you're telling them in all kinds of legal jargon, or are you only giving them part of the story, or do they fully comprehend what's going to happen? And voluntariness. As I said previously, there has to be some level of voluntariness. An informed consent needs to contain a date, a statement affirming that the client understood what was explained to him or her, a statement of the client's right to withdraw from treatment, benefits and risks associated with therapy, a description of the kind of treatment that would be provided, issues regarding confidentiality and privilege, and the signature of the client. Most informed consent documents also contain a date range that says I am providing informed consent from X date to X date. Due to values impasses, lack of appropriate knowledge on the counselor's part or session restrictions due to managed care. Sometimes referrals are necessary. They should be provided at termination for step down or continuing care in the event that a clinician will be unavailable due to illness or vacation and to clients who can no longer attend therapy as scheduled due to things such as moving work or school conflicts or being in jail. You need to remember when you're writing your notes, when you're writing your assessments that clients have the right to inspect and obtain copies of records. They have the right to request information in their chart be changed if they believe it's inaccurate and with regard to third party payers, clients do not have control over who can receive information about the diagnosis. But if your client gets the file, you need to make sure that the way you write the information is objective and concrete and won't do more harm by letting them read what is in the file because there is a chance that they will get it and they will read it. Record keeping assists the clinician in providing the best service possible, provides the basis for safeguarding practitioners in the event of the lawsuit by documenting their decisions and actions, fulfills the requirements for reimbursement, aids in the referral process and can be subpoenaed. Many of us really dislike recordkeeping, but it's vital it covers your behind in the event that you get taken into court. You do need to put information down. You need to be objective, you need to be specific. I find it most helpful to work with the client in writing progress notes. That way they feel they have input into the progress that they've made and we write down together what their goals are for the next meeting that we have. Recordkeeping doesn't have to be a dissertation. You can have a form that you fill out after each client visit or during each client visit that has the mini mental status exam that has the questions that you want to make sure are covered in the progress notes. You don't have to have 15 pages, but you do have to have something. Psychotherapy clinical records should include client identifying information, the client's primary care physician objective findings from the most recent physical documentation of a mental status exam, an intake form assigned informed consent for treatment, a diagnosis and prognosis, any treatment plans, and past and present data from psychological tests. Additionally, you want to include documentation of referrals to other providers, your progress notes once they terminate, a termination summary and releases of information as appropriate. Sometimes professionals will engage in both face to face and online counseling, or maybe even exclusively online counseling. Online counseling is governed by the rules in the state in which the counselor practices, as well as in the state in which the client resides. The counselor currently needs to only be licensed in a state in which he or she practices though. So if you're in Florida and you're treating somebody in Maine, you're governed by the rules in both states, but you only have to be licensed in Florida. Online counseling does have some advantages. It's brief, convenient and anonymous. It appeals to some people who might not participate in traditional therapy. It provides improved access for persons with disabilities and to clients in rural areas. It enhances record keeping because a lot of your chats and online sessions you can record, save and put in a secure file and it increases flexibility in scheduling. The disadvantages though, include a lack of behavioral clues which may lead to an inaccurate diagnosis or ineffective treatment. Confidentiality and privacy cannot be guaranteed. Although if you're doing online counseling, you need to make sure that your emails, your texts, anything that goes across the Internet is encrypted in at least 128 bit encryption. Your duty to warn or protect others is restricted. Clients who are suicidal or are in crisis may not receive adequate immediate attention. Anonymity enables minors to masquerade as adults seeking treatment and complex long term psychological problems cannot successfully be treated. Additionally, there are certain things that are recommended to not be treated online, such as ptsd, borderline personality disorder, eating disorders, anything where the client could rapidly devolve into crisis or where you need to have eyes on to ensure medical stability. There are certain suggestions for ethical practice of online counseling. Evaluate and diagnose the client at the beginning of treatment to determine whether the client is a good candidate for online counseling. Ideally, the evaluation would be face to face. Even better, if you're doing online counseling, it's best to have both of you on again encrypted by video cam. That way you can see the client. Require the client to be evaluated by a physician to rule out physical causes for the client's problems. This is true whether it's online or face to face. It's always good to have a current physical fully inform the client of the limits and expectations of the online relationship, develop a written plan for emergencies, inform the client in advance of the limitations involved in confidentiality of the Internet and what actions might be taken in the event that confidentiality is compromised, and discuss with the client in advance how situations involving technological failure will be handled. For example, if your Internet goes out or their Internet goes out. Do you call on the phone? Do you skip the appointment? Will they be charged? What happens. Online or face to face? When you're counseling children and adolescents, it's important to know certain things. For example, parents are entitled to general information from the counselor about the children's progress in counseling. Informed consent of parents or guardians may not be legally required when a minor is seeking counseling for drugs or narcotics, for STDs, for pregnancy and birth control, or for an examination following an alleged sexual assault of a minor over the age of 12. That's a lot of caveats, and you want to make sure to check in your state to see what the law actually requires. It is suggested that the family be included in a minor's counseling and that counselors involve parents in the initial meeting with the child in order to arrive at a clear mutual agreement regarding the nature and extent of the information that will be provided to the parents. It's a good policy to provide minors with treatment alternatives and to enlist their participation in defining goals for therapy. Well, that's a good policy for adults too. Because minors are special client populations, distinct education, training and supervised practice are required for counselors. This is an ethical guideline in most instances. Most states do not say that you have to have special training, but ethically you are really not capable of treating minors without the special training. It goes back to the community standards. Most people will not treat minors if they don't have prior training and such. State laws pertaining to confidentiality with minor clients are also not uniform. Again, review your state laws very carefully with regard to anything for ethics, treatment, etc. It's imperative that the counselor uses the least restrictive alternative to treatment whenever working with clients. But occasionally you need to involuntarily commit a client for their own safety or for the safety of others. You need to be familiar with the state laws and regulations pertaining to the voluntary and involuntary commitment of clients. And as soon as you notice the client's condition is deteriorating, consult with colleagues and document that consultation Carefully consider what you hope to obtain by recommending commitment. You've got to remember that involuntary commitment is basically stripping a person of their right to choose, so not committing them if they go out and do harm, or committing them. Both of them have pros and cons and issues that may come up, which is why it's so important to consult with a colleague and document. That way you've got multiple perspectives of what the community standard would be. Before deciding on a course leading to commitment, consider other options, including the Advisability of referring a client to another professional for evaluation. Ask yourself how commitment will affect the client's attitude towards you as a therapist and toward therapy in general. Know the procedural steps for involuntary commitment under your state laws and ensure that you can produce reasons for commitment. The procedure used by the practitioner was not within the realm of accepted professional practice is one of the main reasons that malpractice suits are filed. The practitioner employs a technique that he or she was not trained to use, for example, hypnosis. Don't use hypnosis if you're not a certified or licensed hypnotherapist or you haven't had training that's required by your state. The professional does not use a procedure that would have been more helpful or the therapist failed to warn or protect others from a violent client. Informed consent to treatment was not obtained or documented. The professional does not explain the possible consequences of treatment or the professional abandons the client. Now, client abandonment is a tricky one because if a client drops out of treatment and you fail to follow up and you fail to send a termination letter saying, jim Bob, we haven't heard from you in X and so time and you missed your appointment on X and so day, your case will be closed, blah blah, blah blah blah, you need to have that letter in the file. Otherwise it can be considered client abandonment. The client didn't show up, you didn't follow up, and something happens to the client, you could potentially be held liable. So always make sure there is some sort of closure even if the client drops out of treatment. There are four elements that must be present in order for you to actually be guilty of malpractice duty. There needs to be a professional relationship in existence between you and the client. You can't commit malpractice if you never had a relationship with the client. For example, if the client never actually entered treatment with you, they just called to see about maybe setting up an appointment. Breach of duty. You must have acted in a negligent or improper manner or have deviated from the standard of care. Injury. The client must suffer harm or injury and that injury must be demonstrated and causation. A legally demonstrated causal relationship between your negligence or breach of duty and the damage or injury claimed by the client. Intentionality doesn't need to be present. So even if you didn't mean to hurt the client, you didn't mean to abandon the client, whatever, that doesn't absolve you of malpractice. If you did, you did. In order to prevent malpractice, you want to take risk management steps, identify potential risk areas, evaluate whether those risk areas are serious enough to merit further attention, identify preventative and risk control strategies and periodically review treatments to ascertain your risk strategy effectiveness. Now we'll move on to confidentiality. Confidentiality means clients have the right to expect the communications will be kept within the bounds of the professional relationship. Nevertheless, there are certain reasons for breaching confidentiality that you need to let your clients be aware of at the front end of treatment if you need to provide needed professional services to the patient or to the individual if you need to obtain appropriate professional consultations in order to protect the patient or client or others from harm to obtain payment for services when required by a court order, when the client consents to disclosure, when the client files a complaint against the counselor, when the client claims psychological damage in a lawsuit, or when civil commitment proceedings are initiated. All of these are potential reasons for breaching confidentiality that you need to make your client aware of. Now. Privileged communication is different from confidentiality. Privileged communication is a legal concept of protected communications which keeps counselors from having to disclose information in legal proceedings which would cause a breach of confidentiality. When you are required to breach confidentiality, it's important to make use of informed consent statements regarding the parameters of confidentiality. That is Let the clients know ahead of time if there's a court order or if you file a complaint against me or any of those other things in the list, I may have to break confidentiality. You need to inform the client of the situation and involve them in the process. If they didn't initiate it. You need to take reasonable steps to protect the client's confidentiality to the extent possible. That is don't go start volunteering stuff that the judge didn't ask for or that is not necessarily germane to the situation. With permission, contact the client's attorney. Obviously this would be in the case of a legal proceeding, document all action taken and what information was disclosed and always consult with colleagues regarding clinical judgments and with attorneys regarding legal obligations when there's an issue regarding breach of confidentiality. Privacy, on the other hand, is a matter of law referring to the constitutional right of an individual to decide the time, place, manner, and extent of sharing oneself with others. One area in which privacy is often breached is through the use of answering machines, voicemail, pagers, faxes, and email. I said earlier, any communication you have with your client should be over the Internet. Should be encrypted in at least 128 bit encryption. If it indicates that you are a therapist you don't want to assume that the client is the only one that's going to read that. You don't know who has passwords to his or her email, who can check their voicemail, who may have access to their pagers, or heaven forbid, who may be checking the fax machine. So be very considerate when you are contacting clients about how you introduce yourself, how you identify yourself, and what information you do or do not leave. When using telecommunication devices, you want to ensure that any computer based communications are encrypted in at least one 128bit encryption. Verify to the best of your ability that you're actually talking to the intended person. When you get just any random person on the phone, you need to try to verify who it is. And if you get an answering machine and it's just one of those generic you know you have called 352-123-1234, please leave a message. If you can't verify that person's answering machine, you probably don't want to leave a message. Be professional, brief and cautious in talking about confidential information on a telephone. Remember, there's no way to prevent your conversations from being recorded or monitored by an unintended person. Now, that goes a little above and beyond what the normal person would have to be concerned about, but you know, it's always good to err on the side of being overly cautious. Avoid making any comments that you would not want your client to hear or you would not want to repeat. In a legal proceeding. Don't allow unauthorized persons to hear answering machine messages. Protect computer and answering machine access codes and when at all possible, don't leave a recorded message on an answering machine unless you know the client is the only person who has access to that machine and or you have a release of information giving you permission to leave messages. Some people work in small towns and there are certain issues that come up when you live and work in a small town where everybody knows everybody. One thing is that you want to discuss with your clients how meetings in public will be handled. Attempt to have a private exit for clients separate from the waiting room and discuss with your clients any potential breaches of privacy, such as depositing their checks at the local bank. Counselors have a duty to warn, protect and predict when a client has communicated to the therapist a serious threat of physical violence against a reasonably identifiable victim or victims. So warn, protect and predict. There are certain warning signs of dangerousness that need to be evaluated. Obviously direct verbal warnings or threats, a previous history of suicide or homicide attempts, clients who have depression or bipolar disorder, especially bipolar in a depressive phase clients who express feelings of hopelessness or helplessness clients who are experiencing interpersonal stressors, including loss and separation clients with severe anxiety and panic attacks those who have communicated a plan and those with a history of severe alcohol or drug abuse. Additionally, if clients start giving away prized possessions or finalizing business affairs, you probably need to do a further evaluation. If there's a previous history of psychiatric treatment or hospitalization, if the client has few social supports, or if the client is elderly or between the ages of 15 and 24, there's a higher risk that they may try to commit suicide. When conducting a suicide assessment, you want to obtain relevant history and previous treatment records directly evaluate their suicidal thoughts consult with one or more professionals discuss the limits of confidentiality with the client implement appropriate suicide interventions Provide resources to the client such as crisis numbers, numbers to the emergency room numbers, to law enforcement numbers to self help groups. It depends on the client and what precipitated the crisis. What resources may be needed Contact authorities and family members. If the client is at high risk for suicide or homicide, counselors must exercise the ordinary skill and care of a reasonable professional in identifying clients who are likely to be physically harmful to third parties, in protecting third parties from clients judged to be potentially dangerous, and in treating those clients who are dangerous. Privilege and confidentiality don't apply in cases of child abuse and neglect or elder abuse and neglect. Most states provide immunity by law from civil suits that may arise from reporting suspected child abuse and neglect if the report is made in good faith. It is important to note, however, that mandatory reporting laws differ from state to state. Another situation which you may encounter are ethical and legal considerations in AIDS related cases. The ACA guidelines state that we may be ethically justified in breaching confidentiality to a third party who is at risk from an effective partner, but you are not obligated to take this course of action further. Under many state laws, a therapist who closes a person's HIV status to an unauthorized third party is subject to criminal charges and malpractice action. In many states, the criminal charges are felony charges. Very few states have legal protection against liability for practitioners who waive confidentiality to warn third parties at risk of contracting hiv. So what does this all mean ethically? In an ideal world you'd be able to breach confidentiality, but in most states it is way against the law. Neglect of duty means failing to diagnose or predict dangerousness, failing to warn potential victims of violent behavior, failing to commit dangerous clients and prematurely discharging clients from a hospital in order to protect yourself from neglect of duty on this prematurely discharging, you also want to be aware that if a client leaves ama, you want to make sure and again, this is up to your agency. I've seen it done the other way that you discharge them and note that it was against medical advice and they left, as opposed to discharging them and saying they reach their maximal benefit at this level of care and then they go out and commit suicide or homicide or suffer some injury. We all want to protect ourselves from liability, so examine your informed consent document and ensure that it's clear that confidentiality may be breached in the event of a threat of dangerousness associated for others. Know how to contact the legal counsel of your professional organization. Familiarize yourself with professionals who are experienced in dealing with violence, and take at least one workshop in the assessment and management of dangerous clients. Ensure that the limits of your professional liability insurance are adequate. Record the source content and date and significant information on risk and rationale and dates of all actions taken to prevent violence. Develop policy statements and guidelines for handling risk and subject these guidelines to clinical and legal review all of us at one time or another, are going to encounter a situation in which there is a dual or multiple relationship. In order to minimize the risks, maintain healthy boundaries from the beginning, secure informed consent from the client or supervisee and discuss with them the potential risks and benefits of the dual relationship or any kind of blending of roles. Remain willing to talk with the client or supervisee about any potential problems or conflicts that arise, and consult with other professionals to resolve any dilemmas. Seek supervision when the dual relationship becomes particularly problematic or the risk for harm is high. When necessary, refer clients to another professional when it's at all possible. Don't have outside relationships with clients until they've been out of your care for at least 24 months. Some places say your client is a client in perpetuity, so make sure you know your local laws There are certain key themes surrounding dual or multiple roles in counseling. They affect virtually all mental health practitioners. All professional codes of ethics caution of the potential exploitation in dual relationships. But not all multiple relationships can be avoided, nor are they necessarily harmful. Multiple role relationships challenge us to monitor ourselves and examine our motivation. Whenever you think you're becoming involved in a dual or multiple relationship, seek consultation from a trusted colleague or supervisor. The caution for entering into dual or multiple relationships should be for the benefit of the client or others rather than to protect ourselves in determining whether to proceed with a dual or multiple relationship. Consider whether the potential benefit outweighs the potential for harm. It's the responsibility of the counselor to look at and learn about boundary issues and explore multiple relationship questions in their training. Counselor education programs have the responsibility to develop their own guidelines, policies, policies and procedures for dealing with multiple roles and role conflict within the program. If you engage in bartering, you want to evaluate whether the bartering arrangement puts you at risk of impaired professional judgment, determine the value of the goods or services in a collaborative fashion with the client at the outset of the bartering agreement. Determine the length of appropriate time for the barter arrangement and schedule in the date on which the arrangement will end or be renegotiated if a misunderstanding begins to develop. The matter should be dealt with by a mediator, not by you and your client and with permission from your client. It would be a good idea to tape record the discussion of the arrangement. When it comes to giving or receiving gifts, we all have to make a judgment call. Some things to consider would be the monetary value of the gifts, the clinical implications of accepting or rejecting the gifts. When in the therapy process the offering of a gift is occurring, what are your own motivations for accepting or rejecting the client's gifts and what are the cultural implications of accepting or rejecting a gift? Just as we talked about dual and multiple relationships before, there are many reasons to not become socially involved with clients. You may not be as confrontive as you need to be with your clients when you know them socially. Your own needs to be liked and accepted may cause you to be less challenging, and your own needs may be enmeshed with those of your clients to the point that objectivity is lost. Again, sexual conduct before two years after termination is unethical and in some states, any contact with a client forever once they become your client is against regulations. Harmful Effects of relationship with clients 90% of patients who report sexual involvement with a therapist report adverse effects. This ranges from mistrust or deterioration of opposite sex relationships to hospitalization and suicide. The therapist client syndrome associated with sexual contact between therapist and client bears a striking resemblance to the rape trauma syndrome. Relationships between therapists and clients are never the fault of the client. In some states, including Florida, sexual misconduct in a therapeutic relationship is a felony. There are certain suggestions for dealing with attractions. First, acknowledge the feelings of attraction to yourself. Explore the reasons you're attracted to a client. Seek out consultation or personal therapy to help you decide the course of action. Monitor your boundaries by setting clear limits on physical contact, self disclosure, and client's request for personal information. Finally, if you're unable to resolve your feelings appropriately, terminate and refer. In certain situations, there is physical contact with clients and there are some considerations. First, how well do I know the client? What makes me think that touch is indicated? Could this be misinterpreted by the client or the client's family as a sexual overture? And is touching appropriate in this particular circumstance? There are all kinds of other things to factor in, such as the client's boundaries and whether it's the client who wants to be touched, needs to be consoled, whatever. Hugging, for example, not necessarily always appropriate. In order to protect our profession, we have licensure. Licensure protects the public by setting minimum standards of competence, protects the public from its own ignorance about mental health services, allows the professionals to take on the values of a group, improves accessibility to affordable mental health care and increases the number of practitioners reimbursed by third parties, allows the profession to define for itself what it will and will not do, and promotes a sense of professional identity on the path to licensure. We all have to go through supervision, and it's recommended to seek supervision periodically, even after you're licensed. But what are the goals of supervision? Well, they're to enhance the skills and knowledge of the supervisee, to ensure the welfare of the supervisee's clients, and to serve as a gatekeeping function for the profession. Now, this last one is one again that I see that is often ignored. I see too many supervisors just going through the motions, doing the supervision, and even incompetent therapists get through the supervisory practice without being sort of called on the carpet and held accountable for their ineptitudes. Supervisees have rights. However. Supervisees have the right for a supervisory session free from interruptions and distractions, to be fully informed of the supervisor's approach to supervision, to confidentiality, and to continual access to any records maintained during supervision. They also have the right to offer feedback to supervisors concerning the helpfulness of supervision, to receive timely feedback, assessment and evaluation from the supervisor, and to seek consultation from other professionals as necessary. Supervisors have certain roles and responsibilities. One is to provide training and supervised experiences that will enable supervisees to to deliver ethical and effective services, to ensure the safety of supervisees clients, to maintain records pertaining to their work with trainees or supervisees, to state specific objectives of supervision, to formulate a sound supervisory contract, to negotiate mutual decisions, and to clarify the supervisory role. As opposed to supervision, there are certain things that occur in consultation. Common characteristics of consultation include the consultant providing indirect service to the client by providing direct service to staff Participation in consultation is voluntary by all parties. Staff have the freedom to decide what they will do with the suggestions and recommendations of the consultant. Consultants may take on a variety of roles depending on the nature of the consultation and the desired outcomes and consultation occurs in an organizational context as opposed to an individual context. In order to be a responsible consultant, you want to carefully identify the real clients prior to beginning the consultation, identify the cultural context in which the consultation occurs, and recognize that even though the optimal consultative relationship is an equal one, the potential for dual relationships exists. It's imperative to investigate the goals of an agency before agreeing upon a contract for consultation. You don't want to go in after you've already signed a contract and be blindsided. Inform the consultees about the goals and purpose of the consultation, the limits of confidentiality, the potential benefits and risks and potential outcomes of the intervention. Again, this is basically like providing the consultees informed consent. Consultation contracts clearly specify the work to be completed, identify any work products which are expected, identify lines of authority and the person to whom the consultant is responsible, establish compensation arrangements, including the method of payment, and specify any special arrangements agreed upon by the parties. Another issue that we have to consider in ethics is the benefit of diagnosis. Some people do not like to diagnose because they feel that creates a self fulfilling prophecy. They feel that's too limiting. Whatever, but diagnosis enables third party reimbursement. It provides a convenient shorthand for professionals to communicate, provides a list of symptoms which can individually be identified as objectives in resolving the main problem and can assist in demystifying the process of counseling and diagnosis by demonstrating to the client the diagnoses are simply a shorthand to refer to a cluster of symptoms. Drawbacks to diagnosis include minimizing the uniqueness of the client, focusing on symptoms and ignoring natural capacities for healing, emphasizing pathology deficits, limitations and symptoms and discouraging people from finding and utilizing their strengths to competencies and abilities, creating self fulfilling prophecies and narrowing therapists vision by encouraging them to look for behavior that fits a certain category. Diagnosis is also based on the assumption that distress in the family or social context is the result of an individual's pathology. It's generally not multiculturally sensitive and is often used by persons who do not possess the competence to make a diagnosis. In order to make a diagnosis, sometimes people like to use tests, but it's imperative to be familiar with the test that you're using. The groups on which they were validated their generalizability, their validity and reliability and specifically what they're measuring. Let's go through those. Validation means the group on which it was tested and identified to be reliable and valid. It measured what it purported to measure and it did it multiple times. There's test retest reliability. Generalizability means whether your client can take this test and the results can be generalized to be appropriate. Counselors should know the codes of ethics with respect to confidence in working with tests, and you should have a clear rationale for the reasons you administer certain tests. So don't just administer a battery of tests to everybody that walks through the door on a fishing expedition to try to identify a problem they might have. There should be a clear rationale for every test you administer. For clients requesting testing, discuss the benefits and drawbacks and limitations of any tests. Tests should never form the sole basis for any assessment, and it's important to consider how test results will be handled. Clients should be informed about what each test is intended to discover, how it relates to the situation, and how the test results will be used. Test results should always be placed in proper perspective within the context of other relevant factors. Aside from testing and assessment and all these other things we've gone through, when you start dealing with managed care, there are other ethical dilemmas that arise. Four major areas where ethical dilemmas most commonly surface in managed care are informed consent, confidentiality, abandonment and utilization review, not providing adequate informed consent, breaching confidentiality when you're not supposed to, client abandonment, not following up when a client drops out of treatment and utilization review, not making sure that you're conforming to best practices and guidelines and, as I mentioned before, sometimes keeping a client in treatment too long because they are a guaranteed billable hour. That's not effective utilization of the managed care company's resources. There are things to consider when hiring an alcohol and drug abuse counselor. Those things include level of experience, if the client has a prior history of addiction, their duration of sobriety, which should be at least two years the reasons the person is in the field and whether the person has or has had a family member with an addiction problem and how they've dealt with that issue. Patients should always be offered a choice of treatment options, provided a thorough informed consent, provided individualized treatment, and have confidentiality in their communications as regulated by their State and Title 42 of the Federal regulations. Financial exploitation occurs easily in the alcohol and drug abuse field because many recovering addicts are unable to think clearly for months or or even years after ceasing use. Exploitation in the form of publicity can occur for social as well as financial gain. For example, making someone a star client Social contacts with patients may result in exploitation due to a dual relationship and sponsorship of a patient in a 12 step program by the therapist is strongly discouraged. One frequent but unethical practice is to alter a patient's diagnosis in order to ensure compensation from managed care. Another unethical practice involves failing to identify the addiction's diagnosis in order to prevent stigma or repercussions for clients. A challenge for many addictions programs is the lack of reimbursability for family based services to treat a disease which is often systemic and family based in nature. Current trends often place counselors in precarious positions due to a lack of sufficient different levels of treatment. Therefore, they're faced with over treating, such as in residential or under treating, such as in traditional outpatient. Many organizations aggressively recruit patients, often patients who are private pay with due diligence and a little common sense. Most counselors have no problems adhering to ethical and legal guidelines.