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Maintaining an Ethical Practice in Counseling Ian F. Jones, Ph.D., Ph.D., LPC-S, LMFT-S, BCPCC DeAron Washington, M.A., PLPC Description This workshop is designed to refresh the participant's memory about key principles of ethical practice. Special focus will be given to current issues that frequently result in ethical complaints being levied against counselors with licensing boards. The concept of ethical bracketing will be considered. Case scenarios will be used to reinforce and clarify principles of ethical practice. The NBCC, ACA, AAMFT, and NASW Code of Ethics will be utilized in this session. Objectives Participants will: review key principles of ethical practice in counseling. process issues frequently leading to complaints levied against professional counselors. apply ethical codes and best practices to case scenarios. Benefits of Ethical Codes & Litigation Make public any problematic behavior in the profession. Have enabled professional organizations to eliminate unthinking, self-centered therapists from practice The mild anxiety many therapists feel about litigation or ethical complaints, encourages them to be more aware of maintaining best practices & keeping accurate, up to date records Five Ethical Principles for Counseling Autonomy – individual freedom of choice Justice - treating individuals appropriately Beneficence - do good for the client, be proactive, prevent harm Non-maleficence – “Above all do no harm” Fidelity - loyal, faithful, honor commitments o Mental Health Academy (2011). Ethics and ethical dilemmas. The Professional Counsellor, 1 , 5. What Can You Be Sued For? Any intentional or unintentional action or failure to act that impinges on the client’s rights Assault Battery
Wrongful death Sexual harm Abuse of psychotherapeutic process Breach of contract Breach of right to informed consent False imprisonment Defamation Breach of confidentiality Issues Frequently Leading to Complaints Levied Against LPCs & LMFTs HPSO 2019 Counselor Liability Claims Report, 2nd^ ed. Findings Ethical complaints at Louisiana LPC Board 2016-2017, 2019- 2021 Sexual or Romantic Relationships The most frequent professional liability allegation asserted against counselors: o Inappropriate sexual/romantic relationships with clients or the partners or family members of clients According to HPSO, nearly 50% of their paid claims fell in the area of counseling relationship o Inappropriate sexual, romantic relationships o Dual relationships What does your licensing board or ethical code(s) have to say about this? AAMFT Code of Ethics 1.4 Sexual Intimacy with Current Clients and Others. o Sexual intimacy with current clients or with known members of the client’s family system is prohibited. 1.5 Sexual Intimacy with Former Clients and Others. o Sexual intimacy with former clients or with known members of the client’s family system is prohibited. From the Licensing Boards and Ethical Codes: ACA Code of Ethics A.5.a. Sexual and/or Romantic Relationships Prohibited Sexual and/or romantic counselor– client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in person and electronic interactions or relationships. o (Relationships allowed 5 years beyond last professional contact.) NASW Code of Ethics 1.09 Sexual Relationships Social workers should under no circumstances engage in sexual activities, inappropriate sexual communications through the use of technology or in person, or sexual contact with current clients, whether such contact is consensual or forced. HSPO Counselor Spotlight: Boundaries (2019) Managing Professional Boundaries: Clarify your role and boundaries Avoid extending the counseling relationship Use social media wisely Limit self-disclosure Current Ethical Challenges: Ethics and Teletherapy Ethical Arguments For and Against Teletherapy For Against Increased Access Confidentiality Issues Reducing Stigma Therapist Competence and Training Patient Empowerment and Patient control Research Gaps Cross-Border Psychotherapy Communication issues Freedom for Therapist Informed consent issues Online Teaching and Supervision Payment and Insurance Issues Economic Advantages Boundary Issues Stoll, J., Muller J.A., & Trachel, M., (2019), Ethical issues in psychotherapy: A narrative review, Front Psychiatry 10:993.
American Counseling Association 2014 Code of Ethics “Counselors also explore their own cultural identities and how these affect their values and beliefs about the counseling process” (Section A, p.4) Whereas multicultural counseling competency is required across all counseling specialties, counselors gain knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor in working with a diverse client population (Section C.2.a)” Cultural Humility Hook et al. (2013) adapt the definition for counseling and states: “cultural humility involves the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client” (p. 354). Supervision and Psychotherapy as “cultural encounters” Case Study “You are working with a family that emigrated to the US from South Asia. The family was referred to therapy by child services because the parents refused medical treatment for the daughter’s seizures. Emergency room doctors have become familiar with the family because of the multiple emergency rooms visits. The hospital contacted child services because the little girl’s condition is worsening and will continue to do so unless she receives care. Through an interpreter, you can glean that the reason the family is refusing medical treatment is religious.” Identify some ethical issues in this case How would you respond? Ethical Bracketing Worldview Defined “A worldview is a commitment, a fundamental orientation of the heart, that can be expressed as a story or in a set of presuppositions (assumptions which may be true, partially true or entirely false) which we hold (consciously or subconsciously, consistently or inconsistently) about the basic constitution of reality, and that provides the foundation on which we live and move and have our being.” o James Sire, The Universe Next Door: A Basic Worldview Catalog, 5 th^ ed. (Downers Grove, IL.: InterVarsity Press, 2009), 20. Worldviews Conflict: Naturalism & Theism Many scholars view the worldview of naturalism as not only important to traditional science but also neutral to theism. This neutrality has long provided the justification for psychological science to inform and even correct theistic understandings. Still, this view of neutrality, as the authors show, stems from the presumption that these two worldviews are philosophically compatible. The authors’ review of the traditional candidates for compatibility suggests not only that these candidates fail to reconcile naturalism and theism but also that these worldviews are fundamentally in compatible. Therefore, attempts to use the insights gleaned from a naturalistic worldview to inform or correct the understandings of a theistic worldview could constitute a significant prejudice against theism and theists. o Slife, B. D., & Reber, J. S. (2009). Is there a pervasive implicit bias against theism in psychology? Journal of Theoretical and Philosophical Psychology, 29 (2), 63–79. Theism vs. Naturalism Why not just overlook the conflict? o Many theistically grounded counselors overlook the naturalistic grounding of psychology, assuming a neutral view of theology toward counseling theories and methods. o But theism requires God for a complete understanding of the world because he is currently active in world events (Plantinga 1997). Conflict in assumptions o Naturalistic assumptions: determinism, atomism, materialism, hedonism, positivism o Theistic assumptions: free will, holism, spirituality, altruism, theistic realism o Slife, Brent D., & Whoolery, Matthew (2006). Are psychology’s main methods biased against the worldview of many religious people? Journal of Psychology and Theology, 34 (3), 217-231. Value and ethical conflicts are not unique to religious clinicians “a Catholic counselor and a client considering an abortion, (b) a Mormon counselor and a client whose lifestyle includes smoking cigarettes and drinking alcohol, (c) a devoutly religious counselor and an atheist client, (d) a Jewish counselor and a bigoted client who uses offensive and anti-Semitic language to describe Jews, (e) a self-identified liberal or progressive counselor and an evangelical Christian client, and (f) a feminist counselor and a client who is an exotic dancer at a gentlemen’s club.” (p. 183) o Kocet, M. M., & Herlihy, B. J. (2014). Addressing value‐based conflicts within the counseling relationship: A decision‐making model. Journal of Counseling & Development, 92 (2), 180-186. Navigating Ethical Dilemmas: An Islamic Perspective Khalid Elzamzamy, K., & Hooman Keshavarzi, H (2019). “... the individualistic and secular nature of Western psychology has apparently affected the development of Western professional ethics’ disregard of the metaphysical, social, and public aspects of certain religious values and assume that these can simply be bracketed in order to maintain adherence to these secular codes of conduct. (p. 62)
Under pressure from such value conflicts, clinicians find themselves forced to make ethical choices, such as (a) accepting or refusing to work with a certain client, (b) referring a client to a different therapist, (c) self-disclosing their own values, and (d) imposing or bracketing their personal values. (p. 43) Malik Badri (1979) argues that Muslim psychologists must be critical of modern psychology drawn from the West and beware of the contradictions it poses to their religion and culture. He views Western psychology as a culture-bound discipline stemming from secular anti-religious roots and therefore largely reductionistic in nature, by which he means that it limits its scope to biological, social, and psychological factors and ignores the soul and spirituality as essential ingredients of human experiences (Kasapovic, 2018). (p. 48) Three core features of the Islamic worldview that diverge significantly from secular codes of conduct: Islamic ethics are largely (a) theistic in origin, (b) metaphysical and transcendental in scope, and (c) community-oriented or collectivistic. (p. 49) Proposed resolutions such as Ethical Bracketing and a “both/and not either/or” approach have significant limitations. o (The “both/and not either/or” approach uses the client-centered approach of practicing with congruence and comfort by expressing unconditional positive empathy toward clients. Instead of projecting their own views or seeing “either” the clinicians “or” the client’s realities as acceptable, clinicians are encouraged to accept “both” realities.) Both of these approaches are, in essence, very similar. But despite having gained wide acceptance among clinicians and mental health ethicists, they do not really encompass the dilemmas experienced by many religious clinicians. These approaches seem to postulate that values are just deeply held beliefs or preferences that have no practical ramifications. However,.. .Islamic principles.. .call for some form of action and mandate a level of social collectivistic responsibility. They also defy the very conception of “do no harm,” as the religiously devout should, in essence, seek their clients’ welfare in the afterlife perhaps even more than their welfare in this world. (p. 58). The authors suggest that a reconciliatory approach could entail a less optimal solution from an Islamic standpoint but still a compatible one based upon “holding one’s beliefs and values in one’s heart, given the professional ethical sanctions against expressing their concern about their client’s immoral behavior. This ultimately amounts to the “both/and not either/or” approach and EB.” (p. 58) Two options to consider: o A collaborative transparent approach proposed by Kocet and Herlihy (2014) is discussed, using a “joint clinician-client exploration of the potential value-based conflicts and their potential impact on the therapeutic relationship.” (p.
o Consenting to an Islamically Integrated Therapy Model Khalid Elzamzamy, K., & Hooman Keshavarzi, H (2019). Navigating Ethical Dilemmas in Mental Health Practice Between Professional Ethics and Islamic Values, The Journal of Islamic Faith and Practice, 2 (2), 40-71. Counselor Values-Based Conflict & Ethical Bracketing o Kocet, M. M., & Herlihy, B. J. (2014). Addressing value-based conflicts within the counseling relationship: A decision-making model. Journal of Counseling & Development, 92 (2), 180-186. “Counselors bring their professional, personal, and cultural values into their relationships with clients and are not expected to be value-free in their counseling practice. They must strive to integrate their values and beliefs into their ethical practice (Evans, Kincade, & Seem, 2011), yet, at the same time, they must avoid imposing those values and beliefs onto their clients. Finding this balance can be a challenging task (p. 182).” Ethical Bracketing (EB) Adapted from qualitative research literature Ethical bracketing (EB): “the intentional separating of a counselor’s personal values from his or her professional values or the intentional setting aside of the counselor’s personal values in order to provide ethical and appropriate counseling to all clients, especially those whose worldviews, values, belief systems, and decisions differ significantly from those of the counselor.” “When counselors deliberately set aside or bracket their personal values to honor their professional obligations, they help to avoid imposing those values onto clients and contributes to empowering clients to achieve their therapeutic goals” (p. 182). Ethical Bracketing (EB) Steps Steps when faced with a value conflict:
- Immersion in self-reflection and awareness about the nature of the value conflict you are facing with the client goals. (Looking inward)
- Education on professional & ethical boundaries, diversity, the appropriate professional codes of ethics, literature on best practices. (Looking outward)
- Consultation with expert colleagues, supervisors, and specialists on applying the ethical bracketing process to a specific value- based conflict.
- Supervision and formal consultation (when steps 1-3 fail to resolve issue) when applying the EB process to a specific value- based conflict.
- Personal counseling or advanced remediation when necessary to identify barriers and personal biases that may prevent you from creating an effective therapeutic relationship with the client.
Counselor Values-Based Conflict Model Step 1 : Determine Nature of Value-Based Conflict Personal values conflicts could stem from a cultural, religious, moral, or personal belief, life experience, or a potential countertransference issue. Professional values conflicts could stem from a lack of requisite skills or training to be effective in providing counseling services. Step 2: Explore Core Issues and Potential Barriers to Providing Appropriate Standard of Care Step 3. Seek Assistance Remediation for Providing Appropriate Stand of care EB may be appropriate to integrate into this step to help the counselor bracket his/her personal values and thus support the counseling plan and help the client achieve her or his therapeutic goals. At this step, the counselor is also encouraged to identify any potential judgmental perspectives or biases that are hindering the counseling relationship. Step 4: Determine and Evaluate Possible Courses of Action If the value-based conflict has not been resolved by this point, the counselor may examine whether the value in question is so strong that it warrants the counselor referring the client to another practitioner. On the professional side of the model, the counselor should identify what additional training or clinical supervision would best assist the counselor in working through the personal value-based conflict with the current client or similar clients in the future. Remediation plan—e.g., studying the professional literature, attending continuing education workshops. Step 5: Ensure That Proposed Actions Promote Client Welfare Examine whether the action the counselor intends to take promotes the welfare and well-being of the client. The counselor should implement the proposed action only after ensuring that it will promote client welfare. New Ethical Challenges for Christian Counseling Issue: “How to honor a clinician’s religious liberty and still demonstrate unconditional respect for diverse sociocultural identities and developmental pathways.” (p. 4) Greggo challenges guilds in a pluralistic society “to come to terms with the deep richness of cultural and religious uniqueness. Such a movement to fully embrace pluralism would require the creation of opportunities for transparency that acknowledge the profound reality of the distinctive worldviews which the constituency of the counseling profession now represent.” (p. 4) o Greggo, S. T. (2016, November). The New Ethical Challenges for Evangelicals who Counsel: The “Bracketing” Controversy. Paper presented at the 68th^ Annual Meeting of the Evangelical Theological Society, San Antonio, Texas. The ACA (2014 Code) revisions: No value-based referrals No right of conscience Client autonomy as an absolute Counselor worldview as a personal value Issues: Two competing (conflicting) values: social justice & clinician’s moral code “Conflicts are likely to occur when counselors with faith convictions express allegiance to one’s profession via ethical client service while maintaining an alignment to a theological worldview that recognizes transcendent purposes for moral guidelines.” (Greggo, p. 8) o Do counselors, like medical professionals, have freedom of conscience? Response: “EB has merit for client care within the contemporary climate of diversity across age, culture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital/partnership status, language preference, socioeconomic status, immigration status, or any other basis proscribed by law (AC, 2014, Standard C.5.). EB is essential for clinicians to master as they apply the ethical code of the counseling profession as it now stands.” (p. 14) Greggo draws from the mission, preamble, and core principles of the ACA code of ethics to give four propositions in applying ethical bracketing to manage value conflicts, while avoiding a conflict of worldviews Ethical Bracketing: Four Propositions Applying ethical bracketing (EB) to manage value conflicts, four propositions:
- Counseling has a contextual surround. Counseling services occur within a context in which implicit and explicit worldview assumptions need to be clarified in the host setting. Expectations for counselor, treatment goals, and priorities vary in different settings, e.g., public schools, medical facilities, hospices, prisons, Christian settings, public agencies. Christian counselors employed in public agencies are likely to face daily value discrepancies and should be prepared to “apply EB across the widest range of potential value conflicts.” (p. 16)
- Embrace Clinician Diversity. “…honoring diversity entails creating a way to embrace the unique worldviews of its clinicians, including differences in religiosity and spirituality that speak into treasured moral codes.” (p. 17) Beneficence means focusing on the priorities of the client. Clinicians must develop sufficient relational fluidity to bend and meet clients where they are. A thick commitment to a cultural or religious niche may make such a counselor the ideal professional to serve in an agency
where the particular religious worldview perspective is viewed as an asset and not as a liability. This is a full recognition of the global, multicultural, and pluralistic conditions in our age.” (pp. 17-18)
- Clinician Worldview Transparency. (p. 18) “In the interests of veracity, facilitate methods for clinicians to make transparent statements in biographies and within informed consent documentation, particularly in settings that welcome such commitments as attractive to the agency clientele (i.e. worldview, culture, and faith tradition). (p. 18) Provide professional procedures that “allow clinicians to expose one’s faith tradition when it matters” assisting clients to be “informed and selective when choosing a counselor.” Such available information will further client autonomy and increase the possibility of a preferred match.
- The Golden Rule and the Civic Virtue. “Counselor educators in faith-based programs can strive to cultivate a deeper sense of civic virtue, hospitality, and commitment to the Golden Rule as a means to manage religious pluralism and the expanding diversity issues (i.e. worldview, culture, ethnicity, gender, sexual orientation, marital status, or disability).” (p. 19) Engaging in mutual exchange through cooperation, dialogue, and exchange between religious groups was found to “enhance understanding and enrich appreciation for other traditions. Mutual exchange did not remove deeply held convictions about the nature of reality or core tenets of the faith.” (p. 19) Find common ground within pluralism. References American Counseling Association (2014). ACA code of ethics. American Association for Marriage and Family Therapy (2015). AAMFT code of ethics. Cottone, R. R. (2006). Counseling ethics and decision making. Pearson. Coleman, A. K. An ethical decision-making model for practitioners. Downloaded from http://www.pitt.edu/~cedar/forum/coleman.html on February 15, 2017. CNA and HPSO (2019). Counselor liability claims report. Chicago, IL: CNA; Hatboro, PA: HPSO. Greggo, S. T. (2016, November). The new ethical challenges for evangelicals who counsel: The “bracketing” controversy. Paper presented at the 68th^ Annual Meeting of the Evangelical Theological Society, San Antonio, Texas. Hook, J. N., Davis, D., Owens, J., & DeBlaere, C. (2017). Cultural humility: Engaging diverse identities in therapy. APA. Kocet, M. M., & Herlihy, B. J. (2014). Addressing value-based conflicts within the counseling relationship: A decision-making model. Journal of Counseling & Development, 92 (2), 180-186. Koonin LM, Hoots B, Tsang CA, et al. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep 2020;69:1595–1599. DOI: http://dx.doi.org/10.15585/mmwr.mm6943a Leslie, R. (2010). The ABCs of avoiding liability. Avoiding Liability Bulletin. CPH & Associates. Downloaded from http://www.cphins.com/the-alphabet-some-hints-on-avoiding-liability/on February 15, 2017. Mental Health Academy (2011). Ethics and ethical dilemmas. The Professional Counsellor, 1 , 5- 8. National Board for Certified Counselors. NBCC code of ethics. NASW 2021 Code of Ethics Sire, J. (2009). The universe next door: A basic worldview catalog , 5th^ ed. Downers Grove, IL.: InterVarsity Press. Slife, B. D., & Reber, J. S. (2009). Is there a pervasive implicit bias against theism in psychology? Journal of Theoretical and Philosophical Psychology, 29 (2), 63–79. Stoll, J., Muller J.A., & Trachel, M., (2019), Ethical issues in psychotherapy: A narrative review, Front Psychiatry 10:993. URL & QR Code for NOBTS 2021 Counseling Conference: https://www.nobts.edu/counselingconference/conference-powerpoints-handouts.html
