Ethical Decision Making: Handling Real Life Scenarios

Ethical Decision Making: Handling Real Life Scenarios
By Michele D. Aluoch, MS, LPCC River of Life Professional Counseling, LLC Copyright 2014

Defining Counseling Not just an occupation but a profession with responsibilities Professions: Derived from societal needs Supported by public trust, respect, recognition Addressed needs of health, order, meaning, or security Has earned privileges Has a leading organization: educational standards, practice standards, accreditation, ongoing skill development

Defining Counseling Must act in the public good
Has items it “professes” or acts upon Both legal and moral practice Those in practice and the governing body are in a covenant relationship Goal: for outlining the nature of helping relationships between colleagues, clients, employers/employees surrounding this profession Makes judgments under conditions of technical and ethical uncertainty

From: Ponton,R.F. & Duba, J.D. (2009)
“ Codes of ethics do not come to professions on stone tablets from high mountains. Rather they are always a work in progress. They are developed by committees, examined by professionals and the public they serve, and then lived out by frail humans and adapted to changing contexts.” From: Ponton,R.F. & Duba, J.D. (2009)

Limitations of Ethical Codes:
Profession bound (whereas practice is not) Do not include underlying rationale to help the practitioner make better decisions Can never be comprehensive b/c so many situations Challenges enforcing codes Reactive rather than proactive Personal versus field ethics Must be adapted to various cultural and other contexts Some situations not easily handled by ethical codes

Law Versus Ethics Law- minimal ethical standards of society
Ethics- standards set by profession

Ethics Vs. Legality: (from Thompson, A., 1990)
1) Ethical & Legal 2) Ethical & Illegal 3) Ethical & Alegal 4) Unethical & Legal 5) Unethical & Illegal 6) Unethical & Alegal

Making Ethical Rules: 1) Utilitarianism- judging on the basis of clearly forseeable consequences, not behavior itself but outcomes of behavior (J. Bentham) 2) Moral Institutionalism- consequences are important but not separate from certain mandatory duties (W.D. Ross)

Making Ethical Rules: a) Fidelity b) Reparation c) Gratitude d) Justice e) Beneficence f) Nonmaleficence

Nine Values of Master Therapists (Jennings etc.-Jan.2005)
Category I: Building and Maintaining Interpersonal Attachments 1) Relational connection- supervision and collegial support- formally or informally 2) Autonomy- ability to individually and independently determine the timing and direction for counseling 3)Beneficence- promote well being of clients 4) Nonmaleficence- avoid damage to clients

Nine Values of Master Therapists (Jennings etc.-Jan.2005)
Category Two: Building and Maintaining Expertise 5) Competence- maintaining skills that are useful and current 6) Humility-knowing what you don’t know 7) Professional growth-willingness to reach out to develop cognitive an clinical abilities both through CEUs and personal development 8) Openness to complexity and ambiguity-see intricate counseling situations in context 9) Self awareness- understanding personal needs

Benefits of Ethical Standards
Gives some specific guidance Helps professionals keep their colleagues accountable Gives the public outlines regarding hat should be expected for the welfare of clients

Ethics: The Issues

Scenarios: Sex and Relationships With Clients

Scenarios: Sex/Relationships With Clients
A gentleman arrives before his wife for their scheduled marriage counseling session. The wife calls and states she is on her way just a few minutes behind at a traffic light. The husband begins joking with you about relationship matters- and telling you some jokes about males versus females. How do you respond? A client of the opposite sex winks at you and comments, “you look so nice in that color. You should wear it more often.” How do you respond?

Ethical Dilemmas: Sex with Clients
A client comes into your office dressed in a very revealing way. It is making it difficult to focus on the issues at hand. It seems like each session the behaviors get a little more provocative an the way the client sits and mannerisms become more difficult for you to maintain your focus. How do you handle that? Do you say anything?

You have counseled a single person regarding stresses and depression associated with being single and alone.. You can really empathize and understand because you have felt that way yourself. Later you are at a local community based singles event when you realize that the client is there. After some group activities the client approaches you saying that it must have been destiny since you understand each other so well and maybe the two of you can go out after the singles group.

A client comes in sitting a bit close to you and acting flirtatious throughout the session. The client makes advances and begins joking about sexual things finally making the commet, “Life would be so much better if I could just be with someone like you.” How do you handle this?

You recently lost some weight and are wearing somewhat more form fitting clothes. You notice certain clients looking more intently at parts of your body when you wear these clothes. How do you handle this? It has been over 10 years since you last assessed and treated a past client. You are both single. You run into each other in the community and the past client asks you for a lunch date “since you are not in the relationship any more.” You felt as if you really connected before and you understood the past client well. In your opinion, the person did not have major life issues besides some small life adjustment issues. It has been over 10 years since you counseled the past client. How do you respond?

A teenage client wants to demonstrate the new bump and grind dance moves they do. How do you handle this? A client begins undressing in the office during a counseling session. How do you handle this?

Ethical Issues: Sex With Clients
No sexual relationship allowed: “including kissing, sexual intercourse and or touching by the client or therapist of the others breasts or genitals”, also “no physical advances or verbal or nonverbal conduct that is sexual in nature.” Considerations: vulnerability, power differential, and trust issues “ a therapist who is choosing to engage in a sexual relationship with a current or former patient is effectively choosing to discard his or her career.”

Key Questions to Evaluate Ethics
What are my internal perceptions about this case? What goals need to happen here? What is our treatment plan? What would other counselors do in this situation? Is there anyone with whom I could consult- colleagues, board, liability insurance company? Any precedents of similar cases I could look to? Who am I as a person? As counselor?

Scenarios: Education

Scenarios: Education A potential client shares that he/she “wants a seasoned counselor” regarding the issues they called in for as the presenting problem. You have 10 years of experience including some limited experience on this presenting issue. How do you respond to this inquiry from the potential new client?

Scenarios: Education A friend of yours shares that he/she “was born to help people.” The friend reports numerous examples of ways in which he/she has helped others who comes for advice. The friends then says he/she has completed a 10 course series in helping people heal from emotional wounds so he/she can be a counselor. What do you say?

Ethical Issues: Education
Do not promote a degree from a school not accredited by the US Dept. of Education “No person may claim, either orally or in writing, to possess an academic degree… or title associated with said degree, unless the person has in fact, been awarded said degree from an institution that is accredited by a regional or professional accrediting agency recognized by the United States Department of Education at the Commission on Recognition of Postsecondary Accredidation.”

Scenarios: Diagnosis

Scenarios: Diagnosis A couple has been coming on for marital counseling. When a session is scheduled the husband is running a little late so the wife says, “since it is our session time- can you tell me what you really think diagnostically of my husband so I know how to deal with him?”

Scenarios: Diagnosis A gentleman comes in through EAP insurance plan regarding how his depression is affecting his job. You have given him a diagnosis of Dysthymia- realizing that he has had some long term low level depression for years that has been exacerbated by some recent stressors. You get a call from the employer who says he “knows that the client is in counseling and that due to a recent yelling outburst and some refusal to comply with his supervisor’s authority the employer is contacting you for diagnostic and prognostic information for this organization “to decide what to do with him (the client).”

Scenarios: Diagnosis An adult male comes in for individual counseling. You are aware and have received specific, measurable documentation of symptoms which substantiate an diagnosis of OCD. He says he “has been reading information and knows that a lesser diagnosis can be given” because he may not be allowed to stay on his job if he has an OCD diagnosis and has to take meds. He says that “he is going through adjustments after all and can just be diagnosed as adjustment disorder with depression or anxiety from his research” so he won’t lose his job. What do you say?

Scenarios: Diagnosis A family contacts you, an LPCC therapist, with a request to “meet with them for assessment and counseling regarding family issues.” During the course of the diagnostic assessment you realize that the adults are hoping to use your diagnosis and recommendations to support or dispute each of their abilities to potentially care for their children during a custody dispute.

Scenarios: Diagnosis Mary, an adult female, has been to numerous counselors before and as complained early on when asked about her treatment history that “none of them know what they are talking about regarding what is wrong with her.” She says she recalls words like “borderline”, “bipolar”, and “something about traumatic stress.” Then after five sessions with you she directly asks you, “so now that you have started to know me what do you say? What ‘ lovely’ words do you want to put on me now?” she asks sarcastically.

Scenarios: Diagnosis A client clearly only fits criteria for adjustment disorder but when insurance comes back as rejected and unpaid you learn that a more serious diagnosis is required- even an NOS diagnosis may be paid. How do you handle this?

Scenarios: Diagnosis A parent brings in his or her 6 year old child for evaluation for possible ADHD after some behavioral issues have arisen in the school. The parent says he really does not want his son to have a bad reputation if anything is found out (diagnostically) through the counseling process but he wants his son to get the help needed.

Scenarios: Diagnosis You feel creeped out by this big, bulky guy. He looks to you like someone from “America’s most wanted.” You think that your instincts are usually right. He must be antisocial personality, delusional, or something serious. You can just feel it. Is your feeling accurate for diagnostic purposes? Why or why not?

Scenarios: Diagnosis A client presents some interesting facts related to practices in his culture about trace states and ritualized behaviors. Taking into consideration this person’s culture, would you still diagnose this behavior you find bizarre as schizophrenic?

Ethical Issues: Diagnosis
Unethical- therapist as moral agent, client no longer autonomous person coming for help Ethical- based on observation of concrete, observable or clients self reported behaviors compared to “norms” and researched and studies standards with respect to client perspectives and worldview with full information and informed consent under a specific “contract” outlining terms of the clinical relationship

Scenarios: Licensure

Scenarios: Licensure You are moving from another state to Ohio. You have been practicing as an independently licensed mental health professional for over 20 years and are well respectd in the field. If you move to Ohio can you expect that you will transition easily into another independent license? Will your years of experience and licensure and training qualify you for a similar independent license in Ohio? What about if you are leaving Ohio with independent licensure and going to another state?

Ethical Issues: Licensure
Citizenship, residency- OH will consider those from other states and even out of US after review of packet Education- Accredited educational institution, specifically counseling, 90 quarter hours min. (including 30 quarter hours in certain areas) Exam- pass standard set by board on national counseling exam Experience- supervised, pre-approved

Scenarios: Supervision

A supervisee comes in very excited and proud about the way he handled a case. He tells you how well he challenged and confronted a client and set boundaries with him. He shares how he taught him techniques to “just be tougher in the trauma.” You are aware that the way the supervisee handled this particular client was not appropriate for the situation and that the client is now at risk for additional issues. The supervisee really thinks he did a great thing but you are certain that worse problems have been created.

A supervisee comes to you saying, “I know one of your areas of competence is not substance abuse treatment but in my counseling session with Mr. Smith I just found out that he has been using drugs. What do I do?”

A supervisee is scheduled to be present for a joint session you have with a married couple. A half hour beforehand you receive a message on your home phone from the supervisee that he or she “needs to stay home and take care of himself and herself” and won’t be there

A supervisee begins to cry excessively and talk about problems in her life regarding her marriage, family, and juggling too many things at once. You see it is affecting her ability to get to counseling sessions on time, to be fully present for clients, and that she may have developed some mental health issues herself. How do you handle this?

A supervisee comes in very excited and proud about the way he handled a case. He tells you how well he challenged and confronted a client and set boundaries with him. He shares how he taught him techniques to “just be tougher in the trauma.” You are aware that the way the supervisee handled this particular client was not appropriate for the situation and that the client is now at risk for additional issues. The supervisee really thinks he did a great thing but you are certain that worse problems have been created.

A client calls you and asks to speak to you as your supervisee’s supervisor. This client (of your supervisee) says that while the supervisee “was a nice person and got them thinking” and “gave them some new ideas” nothing really helped. The client asks you, “can we meet with you or another therapist?”

A supervisee is a bit more lenient with clients giving theme 60 minute sessions instead of the insurance covered 45 minute sessions and not being so specific about boundaries. It is resulting in this supervisee’s clients getting different care than other clients at your agency and having different expectations. How do you handle this before it gets too out of hand?

Ethical Issues: Supervision
*NOTE: New 2008 Ohio codes on this* General Board Rules Re. Supervisors Supervisor/supervisee relationship must be board approved in advance Roles and scope of practice are specifically delineated Start and end dates are delineated Supervisor/supervisee only have supervision in areas of specified competence “Not a family member or relative” Requires documentation of supervisor/supervisee interactions Reports co-signed by the supervisor No more than 6 supervisees per clinical supervisor

Ethical Issues: Supervision
General Board Rules Re. Supervisees Clients of supervisee can pay but only to the agency Supervisee openly acknowledges with clients the rules and limits of supervision Disclosure to clients of supervisee status No reports, forms, or paperwork disseminated without review of supervisor and his/her signature Filling in of training agreements is the supervisee’s responsibility 30 day board notice of changes of supervisors or any other changes in agreement Only counting hours of supervision by a designated supervising counselor

Interviewing Potential Supervisees
Career Goals and Expectations Counseling Goals and Expectations Supervision Goals and Expectations Experiences to This Point/Desired Experiences/Outcomes Areas For Further Training Theoretical Orientations Preferred Special Populations or Issues Preferred Supervision Experiences to this Point- Pros/Cons

Boundaries With Supervisees
Adhere to general, professional, ethical standards Reduce likelihood of exploitation Never- sexual relationships or sexual harassment Honest credit/citation to sources No supervision by a relative Honest evaluation to board, even if it means a person is not necessarily recommended for licensure Regular follow-ups initiated and evaluations: two way

Ethical Considerations in Supervision
Vicarious responsibility Due process afforded supervisee Receiving informed consent (both supervision relationship and trainee/client relationship) Avoiding dual relationships Competency areas of supervisor and supervisee Confidentiality of client issues and supervision issues

Scenarios: Competency

A client comes in “for depression.” Through the use of cognitive-behavioral treatment as depressive symptoms are being dealt with other issues arise. It becomes clear that the client not only has an alcoholic family system but also has some binge drinking and alcohol abuse issues. When you initially agreed to meet with the client you did so knowing that “mood disorders” and “family of origin issues” were competency areas of yours as specified by your disclosure statement. However, substance abuse is not a competency area of yours. How do you handle this?

You have training dealing with abuse and trauma victims using behavioral relaxation, cognitive and behavioral therapies, mindfulness, and EMDR. However, you have not received specialized training in dealing with traumatized people who dissociate. During one of your sessions a client begins to manifest dissociative symptoms. How do you handle this in terms of your competency?

A colleague of yours has filled in for you at your practice when you have been on vacation, overseeing the business and supervision of therapy. She has similar competencies to you. She asks if you could return the favor since she will be going on a vacation the next month. She would like you to oversee the management of the sexual offenders and mandated clients groups as well as treatment for behavior problem children. You have dealt with behavioral disorders routinely and list this as one of your areas on your disclosure statement. However you have never counseled a sexual offender regarding their sexual offenses or run any such groups. Your experience has also been primarily limited to voluntary clients, not mandated or court ordered ones. How do you respond to her request to cover supervision functions for just one week?

Ethical Issues: Competency
Provide reliable evidence of competence- education, specialized training, licensure Practice only within competency areas Based on standards of care- reasonable practice Protection from harm Only accept referrals in competency areas Use proven, appropriate techniques

Scenarios: Confidentiality

A spouse calls in to ask for dates and time of their spouses next (individual) counseling session and to reschedule on behalf of the client. The counseling has never been set up as marriage counseling and you do not have release of consent to speak with this spouse. When the spouse says, “I’d like to reschedule for your client” and “by the way, how are things going? I am very concerned because I want my spouse back” how do you respond?

Some parents comes back after their teenage child’s session stating that they want a summary of exactly what has been said to the counselor by the child. ‘After all, “they state, “we are the ones paying for this counseling.” How do you handle this?

After you call your client back from the waiting room to your office the client mentions that it was interesting to see his next door neighbor there too and to catch up with him in the waiting room. “So I guess you know the scoop on the whole neighborhood now,” the client says. What do you say?

You have met with a couple for marriage counseling. After one of them withdraws from marriage counseling the other wants to continue with you for individual counseling. What do you think?

A disability organization faxes a letter to request copies of records on a particular client. They would like you to send notes, prognosis, and treatment summaries. This is for the purpose of seeing whether or not the client qualifies and will be approved for long term disability. How do you respond?

You are treating a high profile individual in the news. You wish they knew the real story of the client’s life- all the abuse, trauma, pain and wounds. Do you respond to the inquiries of the past of the news media regarding whether you know about this person’s treatment?

If a lawyer sends you a request for records for one of his clients are you mandated to send the records? A client requests to see his or her own chart and to have copies of the entire chart. How do you handle this?

You have received a subpeona requesting you to come to court and bring all the records on a particular patient. Do you bring the records? Can you break confidentiality with a subpeona?

Ethical Issues: Confidentiality
Has to do with private information being protected through reasonable expectation that it will not be further disclosed except for the purpose for which it was provided Areas Protected: Whether or not a person has been a client The frequency and intervals of appointments Types of treatment or services received Reasons for treatment Specific words, behaviors or observations during treatment Client diagnosis Course and prognosis of treatment Summaries and recommendations

Disclosure: Requires informed consent- specifying what consenting to, with discussion to client about advantages and disadvantages and potential limitations of disclosure Should be in your policies and procedures about confidentiality, possible breaks of confidentiality and how this is should be handled Should be in writing and signed by all parties

Information cannot be disclosed in court proceedings unless both: 1) a subpeona has been issued 2) a court order has disclosure. Then court must find that the need for information outweighs the public policy for confidentiality (42 CFR and 45 CFR 164,512 (e) (1) (ii) By law confidentiality continues even after the death of the patient, death of the therapist of sale of the practice to others “When in doubt don’t give it out.”

Scenarios: Practical Privacy Considerations

People in the assessment rooms hear each other’s assessments. This can’t be helped. The walls are too thin and the building is old. What do you say? Is this okay?

Some patients like to talk to you as you leave the office to go to the hall to get your next patient. They don’t take the signal that their time is up. Patients in the waiting room and those coming in the building can all hear all that this patient is saying. Is there anything you can do?

Volunteers whoa re interested in working in the mental health field often pass through the records department where yet to be field charts are laid out, lists of daily activity logs with patient’s names and ID numbers are sitting, and sign in sheets for psychiatric patients are visible. Anything you should do or say?

One of your counselors at your agency is currently with a client while he is with that client an important call comes in from another client that was scheduled for later that day. How do you pass the urgent message to the counselor so as to protect privacy for both clients?

You work for an agency that has someone clean after hours. You and a colleague are still needing to pull charts and do paperwork while the cleaning help is there. How do you handle that? A client comes in regarding dealing with grief from having an affair with am married man who she says “is the love of her life but she knows she can’t have.” Simultaneously, you are counseling a woman and her child who you later understand are the wife of the “affair man” and his daughter who don’t know about the affair. How do you handle this?

You are counseling a teacher regarding marital difficulties she is having . During her session she mentions the name of the school she teaches at which happens to be the school where your next child client attends. How do you handle this ? You call a home number to speak to a client regarding scheduling. The client’s family member answers and asks who you are and to take a message. What do you say?

Practical Privacy Considerations:
Respecting those in waiting room from hearing sessions or session or client related information Telephone calls in reception area should not be overheard by clients Messages regarding client information should not be given in ways that violate privacy Training support staff regarding confidentiality (e.g. sign a pledge)

Scenarios: Informed Consent

A parent lets you know that his or her attorney will be asking your expert opinion regarding custody decisions, especially which house the child belongs at. What do you say regarding your role as a therapist? A shy, withdrawn codependent woman seeks therapy “to set boundaries and be more assertive.” How do you present assertiveness therapy to her?

What do you do or say if a new client comes in for your psychotherapy but keeps calling you “doctor” (when you do not have an MD and are not a Ph.D.)? A diagnosis is required for insurances to cover treatment. However, diagnosis may stay with people for some time so some clients do not want that. If no diagnosis is given and insurance is not used this means that the person is essentially self pay. What do you say to the client?

When a client comes in for an initial assessment after signing paperwork you realize that the client is illiterate and can’t read. How do you get informed consent?

Ethical Issues: Informed Consent
Extent and nature of services Pros and cons (counseling in general, electronic counseling, phone counseling, techniques used, setting) Limitations In clear, understandable, non-technical language Specified provider name Therapist’s responsibility to make sure the client understands (e.g. if cannot read, blind, etc.)

Defines role of counselor (versus mediator, court guardian, expert witness) Expectations of both therapist and client behaviors Risks/benefits of therapy Qualifications of the therapist Financial considerations and responsibilities

Time per session Confidentiality and its limitations Releases of info.- when required, specifications (provider, what information, to whom, 1 or 2 way, time frame, nature of release and intended use) Signature of individual or someone authorized to sign on their behalf

Scenarios: Responding To Records Requests

An employer requests information to determine whether or not they will be keeping an employee on the job. Because of the client’s behavioral reactions on the job recently they want your recommendations about whether or not the employee should be fired. Can you give this recommendation without a release? With release?

You receive a phone call from a guardian ad litem asking for copies of records on a child client the guardian for the child in court oversees. Do you have to send records or call this person back based on the phone message?

You receive a faxed copy of a release of consent but there is no end date and no specific words regarding the types of things from the record requested. Is this release appropriate? Why or why not?

A client has signed several releases of consent requesting that you talk with certain collateral sources. You do not believe the information being out is in the client’s best interest and may even be damaging to the client. Do you have to release information on any client if he or she has signed a release of consent? Can you refuse requests for information when a release has been sent?

Responding to Records Requests
What does the client want? Anything potentially harmful? What parts should or should not be revealed? Is discussion beforehand advisable?

Scenarios: Record Keeping

You have several different pieces of information in a case from courts, law enforcement, and various social service agencies. The client presents certain ways which are consistent with some of the input from other collateral sources and inconsistent with other information from collateral sources. How do you document clinical impressions, diagnosis, and treatment information in this instance?

A child of divorced parent domes in for counseling, usually brought by his biological mother. The child mentions some harsh and critical tendencies of his father throughout sessions. You want to document thoroughly the client’s self report on things but are concerned that if dad requests records the child may be punished for his comments and opinions about the severe harshness of dad. How do you document the client’s input?

Ethical Dilemmas: Record Keeping
What would you correct or change if anything about this note a clinician put in a client’s file? Susie returned to counseling after a two week break. Upon entering the room it was apparent that her depression had become worse. We talked about the struggles she had in the past two weeks because she has not been to counseling. Then we processed her struggles regarding family members she lives with. It was clear to me that her dad is in fact an abusive man as she said before. Used grief counseling techniques to assist her in grieving and expressing anger she would have liked to express to add in session. I told her it would be good for her to bring the dad with her next session We will meet in one week instead of two weeks. Next session we will aim at confronting dad’s abuse and the consequences it has on Susie.

You notice in reviewing a colleague’s notes on a client that she has written in the client notes comments like, “Client’s appearance was overweight and disgusting looking- needs to lose weight. Disheveled and unclean, filthy to be around. I felt afraid of catching a disease being near this person.” How do you handle this?

You receive via responses to releases of information copies of information from other agencies. Can you re- release to third parties faxed info. from other agencies if they request copies of the chart?

Ethical Issues: Record Keeping
Diagnostic assessment Psycho-social history Specific, concrete behavioral symptoms Tx plan- service goals and outcomes (justifiable, research based standard of practice) Measurable clinical outcomes Direct quotes from clients (in quotation marks) Monitor progress, re-evaluate goals periodically

Ethical Issues: Record Keeping
NOT Opinions Assumptions based on behaviors Questions and investigations Second hand judgments of clients or others in the client’s life Diagnosis of people who are non-clients

Scenarios: Privileged Communication

Ethical Issues: Privileged Communication
Privilege: a legal term, legal protection against breaking confidentiality in legal proceedings The client holds the privilege Must have clearly been in context in which specified “not be disclosed” ahead of time Would cause injury if shared

Ethical Issues: Privileged Communication
Exceptions: judicial discretion, nature of the violation (e.g. harm to others- abuse, homicide, likelihood to commit future crimes) 3 Automatic Waivers of Privilege 1. If requires immediate hospitalization 2. If court ordered 3. If specifying info. on the emotional condition of the patient is part of the client’s defense in a court case

Scenarios: Client Dependency

It is nice to have a cooperative client who arrives early to sessions, listens and seems to apply what is taught. It feels refreshing because especially now it seems like your other clients are having one crisis after another. Your client would like to stay because she says she just doesn’t have the support systems like you out there and that she has found a “best friend and confidant” in you. How do you handle this since her treatment goals have been met?

You have been counseling a family for almost two years. This nontraditional family of four young children stay with the grandmother since the children’s parents are all not consistently in the picture. During the counseling you have worked with each child individually as well as the family through numerous adjustments. Now, in your clinical judgment, it seems as though things have stabilized for months and you have taught all the skills and techniques you know to do. But when you share with the grandmother about phasing out counseling she says that “the kids look forward to meetings” and she “likes to know she has the support she needs to fall back on because raising the grandkids is not easy stuff.”

A borderline seems to always be “in crisis” according to her self report. She says that once per week counseling “is not enough” yet when she comes in for her weekly counseling sessions she repeatedly has not done homework and just wants to complain about problem people in her life. She says that she has “lost everyone she has known and loved,” that “you are the only one who has given me the time of day and taken time to understand me.”

Ethical Issues: Client Dependency:
Issues such as when to introduce topics, how long to talk about topics, and when to keep a client on a topic he or she may feel uncomfortable about Ask client regarding his or her comfort level Client as equal partner in therapeutic process Avoid high ambiguity situations- promoted dependency (ex: high usage of sessions, more time with the therapist) Use balance in giving homework assignments Avoid judgments like, “you are doing much better now.” (Instead, stick to concrete behavioral outcomes)

Solutions to Dependency Promoting Autonomy
Avoid doing what clients can do for themselves Let the clients be active in their treatment (e.g. cognitive- behavioral treatment of noting thought and behavior patterns) Adjusting frequency of sessions Termination plan and closure sessions

Scenarios: Termination

You have met with a client a few times and devised a detailed treatment plan which the client consented to. The suddenly the client withdrew from counseling after he calls and said that he has gotten the meds he needs from a psychiatrist “he wanted” and does not need your help anymore. What do you do about this case?

You periodically evaluate counseling goals with your clients. During a recent review of counseling goals a client agrees that the goals have been met. However, she does not want to consider lessening the frequency of treatment or termination. You notice the comments in her sessions appear to be shifting more towards personal things in her life as opposed to the clinical presenting concerns. How do you handle this?

You are just beginning with a diagnostic assessment with a client. You have never met this person before but you are aware from his initial phone conversation that he has had over a dozen therapist’s in the past year. Do you do any preventative work or have any discussion the first session knowing that this person has a pattern of only remaining in counseling for no more than a few sessions with each of his past therapists in this past year?

You have seen many people suddenly leave counseling when they believe they have gotten better or have no need for counseling anymore. How do you create a plan for generalizing skills taught in counseling so that clients do not suddenly leave when they obtain some gains before the ideal course of therapy?

Ethical Issues: Termination
Pros/cons discussed with client How to apply techniques on an ongoing basis and generalization Options of referrals When a therapist leaves the practice

Scenarios: Multiple or Dual Relationships

Scenarios: Multiple/Dual Relationships
You get a call from a friend who is having a challenging situation. She begins by apologizing: “I am sorry to bug you but I do not know where to turn.” Even though she had a counselor the counselor is now out of network so a few months ago your friend stopped seeing the counselor. “ I know I am not your client but maybe since you are a counselor you can just help me get through this rough time until I can find someone in my insurance network.”

An adult woman has been with you in treatment for a few months and has already established rapport and is on the right track prognostically. She states she can no longer afford treatment and asks if she can help clean the office in the meantime to make up for it because she does not “want to lose you.”

You have been counseling a health professional who has some borderline features and is one of your more challenging clients. You decide to start attending a grief support group for yourself after the death of your mother at one of the local community organizations. When you arrive at the grief group excited about having found a group that really sounds like it pertains to you, you discover that the group is actually led by your very own borderline health professional client. What do you do?

Years ago you counseled dually diagnosed persons. One person you counseled in the past was Mary, a substance user and sporadic abuser who had some past criminal history. After years of a successful treatment regimen Mary was terminated. One of your tasks for a mental health agency is to work with the court programs. Ironically, the program director is Mary your former client who now assists other young people with drug and alcohol and criminal problems to overcome what she had successfully gotten through herself.

Ethical Issues: Multiple Relationships
Definition- relationships which have the potential to dilute or diminish the therapeutic relationship, reciprocal relationships, bartering relationships Not in general a good idea All alternatives discussed Must be outlined and documented as to how/why beneficial Should not have room for exploitation *NOTE: New 2008 Ohio codes on this*

Scenarios: Family Counseling

You began counseling a woman for her marriage relationship issues. With her consent eventually she and her husband had a few sessions together about her concerns to practice the skills she had been taught in her individual sessions about the marriage. After one year the two of them got a divorce and you receive a call from the ex husband. He said he felt like what you said in past was beneficial to both of them and though they are divorced wondered if he could be your client now. Do you accept him as a client?

You are already counseling a man about how he can no longer bear the stress in his relationship. He wants to learn assertiveness and boundary setting to end what he considers a toxic relationship. Unbeknownst to him his partner separately calls in asking for individual counseling to work on dealing with the fact that her boyfriend has cold feet and lack of commitment issues. You do not realize they are in a relationship with each other and both separately are your clients until after you have begun with each. How do you handle this when you realize it?

A young girl has been coming in for anxiety and panic issues. After a few months of meeting with her you realize that this is not really her problem but that the issue is actually her overhearing the parents domestic issues. Do you do anything with this realization? How do you address this in treatment?

Ethical Issues: Family Counseling
Be clear who the client is (individual, couple, family) Refer when potential conflicts

Disclosure of Records to Family Members: (ORC 5122.31 (a) (7) )
Limited circumstances The family member is involved directly in planning, providing, and monitoring services to the client Client notifications and informed consent without objection Only information with intention of supporting client’s mental health

Disclosure of Records to Family Members: (ORC 5122.31 (a) (7) )
Under 18 years old- patients have right to disclosure of records except SA whereby only child can give consent Emancipated child under 18 - full control of all records and parent- none

Scenarios: Duty To Warn

Scenario: Duty To Warn You meet with a teenager who says to you two months prior to school getting out that she “hates a girl at her school so much that she knows how to beat the crap out of her.” The teenage client tells you of a plan the last day of school or the following day for her and her gang “to find the girl outside of school and beat her until she is as close to dead but not kill her.” The client has a habit of really running her mouth but this time she has verbalized a specific plan to physically injure severely a girl she does not like at school. You know the name of the school and the girl’s name. What do you do if anything?

Scenario: Duty To Warn A woman tells of how she is sick and tired of abuse by her husband although in session the example she gives points to two way emotional abuse by both her and her husband. She says she “wishes he wasn’t there” and “would not be offended if he just died.” She makes a general comment of, “I just wish I could kill him. It would be so much easier.” She laughs as she speaks and offers no specific plan for how she would do anything but just says she wants the problems to get over. She also says she “is just plain tired of the attention his girlfriend’s get that she should get as his wife.” How do you respond?

Scenario: Duty To Warn A gentleman comes to you for counseling regarding some work issues and anger with his supervisor at the job. He has been placed on leave during the rime of counseling. During this past session you and the client are planning to talk about the transition of his return to work this upcoming week. During this discussion the client comments, “my supervisor will pay. He’ll get what’s coming to him. He better not be around me when I return that day. You know I’m a shooting man and a pretty good one at that and he’s the type of target I’d be sure not to miss. He better not even think of pissing me off the day I return or he won’t live to see many more days.”

Scenario: Duty To Warn An angry employee tells you in a counseling session about a co-worker, “he will wish that he never met me. I will be their worst enemy. He better be watching his back because if he doesn’t straighten up I will be on him like a leech. I will be following him like a shadow if he gets on my nerves.” Anything you need to do when you hear this? What should your response be?

Ethical Issues: Duty to Warn
Therapist to use professional knowledge, client judgment Burden to prevent harm Consideration of alternatives: tx programs, decrease access to weapons, referral to MD’s for meds, voluntary or involuntary hospitalization, warnings to intended victims, notifying authorities

Ethical Issues: Duty to Warn
Clinicians- protected against liability when a clear, credible, explicit threat of imminent and serious harm or identifiable potential threat (if client attempts to hospitalize, tx plan supported by reasonable standard of care of other professionals, likelihood of that threat- serious, and warning to intended victims and law enforcement w/ specific reference to the nature of the threat)

Scenarios: Advertising Your Practice

Correct or change anything you think needs adjusted in the following scenarios: 1) Our practice specializes in stress management techniques geared toward managing depression, anxiety, and overwhelming feelings Because we have been in business over 25 years we certainly know what works and what does not. Our practice only uses tried and true methods. And our stress management methods have been used by people in some of the most stressful jobs. If you have a stressful life, try our stress management program of six sessions to the new, improved healthier you.

2) Dr. Mia Ethical is consultant to many in the counseling field. Her individual, couples, and group sessions with adults with traumas have assisted over 500 clients n learning skills to manage flashbacks, relax their bodies in stressful situations, and counteract negative thought and behavior patterns.

3) Dr. Ison Me is a leading expert in addiction recovery. He is a worldwide author of articles on addiction and a known, reputable colleague to many in this field of addiction recovery. For many people the addictions that used to be a struggle for them are now subdued or eliminated entirely due to Dr. Ison Me’s techniques.

4) Mike Quickfix, LPCC can assist you in developing assertiveness skills. While others offer assertiveness programs for the equivalent of over $1,000 most of Mr. Quickfix’s clinical clients are bolder, more direct, and more highly assertive in less than half the cost and less time.

Ethical Issues: Advertising Your Practice
Must be accurate statements of qualifications, affiliations, functions (NOTE: if limited time or space does not mean everything has to be included but that that which is included is true) Must give general information so consumer can make an informed decisions o whether or not to use the service NO- statements that are predictive NO-statements that play on client fears to get a person to come in

Ethical Issues: Advertising Your Practice
“professional, scientifically acceptable, and factually accurate informative manner.” Should not use extra-ordinary methods, sensationalism or exaggeration Research participants: tell pros/cons Do NOT promise, “this will guarantee ____ result.” You can say something about techniques used, outcomes, or populations served but make sure you can substantiate or document it. Dangers- testimonials and radio shows

Advertising Versus Marketing
Focus on your specialties on your disclosure statement Follow up with EAPs, lawyers, ministers, guidance counselors, physicians Provide clinical information to clients on issues of concern which apply to their counseling Speak to community groups, churches, businesses, organizations, etc. Avoid personality descriptions Avoid clinical jargon Know trends in your field

Scenarios: Multicultural Counseling

A Mexican couple have been having marital difficulties. During their first few sessions they share that one of the approaches they have used to try and work through their problems has been to involve the extended family and friends in their marital debates. This is a cultural norm for them but it also appears (from their self report) to make the arguments worse.

An adult male of African decent talks about the frustrations of being in America and being trapped between family of origin who are native born Africans and their values versus some mixture of differing values he may have. How do you approach counseling goals with him?

A young Asian female comes into counseling very quiet and reserved slow to open up. After three sessions she speaks up a little more but not like your other clients. Do you confront her regarding the “necessity” of speaking more or not? If so, how?

A young lady comes to you with panic anxiety. While treating her for the anxiety with behavioral relaxation and some cognitive behavioral the therapy you also realize that she may benefit from some anti- anxiety medication. However you are aware that having counseled her for over four months now that she has some strong religious beliefs about seeing and hearing from God which are consistent with her Pentecostal background. You are concerned that the psychiatrist who is not of a Pentecostal Christian religious background will possibly medicate her for psychosis when she describes having spiritual dreams or hearing from God in prayer. How do you approach the psychiatrist and do collateral consultation on this case if at all?

An inner city youth comes to counseling wanting to share his music with you, draw pictures, and make art as opposed to sitting and talking about problems. Is this resistance? How do you know? An elderly woman likes to bring in examples of her handmade crafts and tell folk stories from the town. How do you determine if she is just wasting your and her time? Is there any way you can use this in therapy?

A southern woman talks a lot about being a victim to oppression, a single parent home, physical and sexual abuses, and natural disasters. She describes how she has barely survived so many things in here life. Does this victim talk mean that for sure she is avoiding the real issues of therapy? Could there be any usefulness of this victim narrative and historical survival story in treatment?

Ethical Issues: Multicultural Contexts
WESTERN Individuality Democratic Nuclear Family Focus Youth Emphasized Independence Assertiveness Non-conformity EASTERN Relationship Authoritarianism Extended Family Focus Maturity Emphasized Interdependence Compliance Conformity

WESTERN Competition Conflict Freedom Individual needs Responsibility within individual Express Feelings EASTERN Cooperation Harmony Security Collective goals Responsibility within society Control Feelings

WESTERN Uniqueness of each person Self actualization Future focus Innovation Morality-internal, individual “Change is very good” EASTERN Uniformity of each person Collective actualization Traditionalism Conservativism Morality-relational “Support is very good”

Dealing With Cultural Differences
Counselor and Client Perspectives: Do you share same cultural perspective or not? Is this important or central to the counseling? What do you wish to do about differences of approach? Defining Value systems/Cultural Context- “teach me”

Ethical Guidelines for Multicultural Counseling (D. W. Sue & D
Ethical Guidelines for Multicultural Counseling (D.W. Sue & D. Sue, 1990) Therapist awareness of own beliefs, values, feelings and biases Ability to accept, value, and integrate client culture Not threatened with referrals or consultations when appropriate Judge client reactions of treatment approaches within cultural context rather than personally Therapist learns /allows self to be educated on that culture (Same guidelines apply to all “special populations”)

Scenarios: Boundary Setting

You are assisting in teaching a class at the university to counselor education interns. During a break you hear three students discussing some challenging cases in detail outside the restroom. They discuss the names of the clients, their reputations on campus, and other personal and clinical details. Others can overhear them. How do you react?

During a staff lunch another therapist brings up in a joking manner how he had to deal with “John,” a client that everyone at the mental health center knows of who is a routine substance abuser and known around the community. The therapist jokes about how “John” is so stupid that he used his pocket knife when drunk sitting in a tree to cut the rope he was going to hang himself with. Clinical staff, secretarial staff, and various workers at this lunch joke about how John acted and that “dumb people like this keep our business going.”

A parent of a college-aged (over 18 year old) adult says, “since I will be paying for my college-aged son to see you I am hoping we can at least spend a few minutes at the end of each session or on the phone so I know how it is going? I am the parent after all and I really care for him because he still lives with us and his behaviors affect us all.”

A potential client calls in stating, “I just read that cognitive-behavioral therapy is good for the issue I am having and my insurance lists you as doing that so can I set up an appointment?” During a phone consultation before initial appointment a potential client says, “I am not tying to be hard on you but you know there are so many people to pick from out there- I saw on my insurance list so many but how do I know you are the best one for me?”

During a first session a client says, “so I realize that by your license and length of time owning the practice that you have been around over 15 years. So how do you approach situations? And I saw some of your specialties- they sound interesting- so I think maybe the Christian counseling can be good for me- so what do you think?”

Client says: “I have been to counseling a few times before but I have a feeling that this time I am really ready for change. What do you think? At scheduling time a client comments, “I am so glad your office has so many days and hours open- I can only come on Wednesday evenings at like 6 or 7 pm because my life is so busy.”

A client states to you, “I know you plan to go on vacation but I don’t feel comfortable talking to anyone else but you. I have never felt so comfortable with anyone and I have been through lots of people before.”

Boundary Setting Know your clients’ beliefs/expectations (clients most/least comfortable with, values and belief systems, theoretical approaches preferred) Know the standards of your agency (policies and procedures, mission/goals, methods of dealing with things) Know/keep up with the latest board rules and regulations Be familiar with the social, multicultural, and interpersonal qualities of who you serve, where you are situated How will you communicate these? Verbally Written policies & procedures Other

Scenarios: Personal Stress Management

After 5 years in the mental health field you begin to find yourself looking at the clock through client’s sessions, getting more easily frustrated with things in the field, and wondering if you can really “help everyone.” The enthusiasm you had at the beginning to seemingly help the whole world has waned to where you are not sure if you should even be in the field. How do you handle this?

You notice yourself having increasingly negative conversations about your organization, colleagues, lack of pay, and dissatisfaction with the field. What do you do next?

When you begin assessing particularly traumatic clients it reminds you of when you survived abuse as a child yourself. You picture yourself actively in your client’s situations, like your empathy is on overdrive. Their story becomes your story. What might be a useful suggestion so you can best be present for your client?

In cognitive behavioral therapy we teach clients to be aware of the shoulds, absolutes, have tos, and concrete self critical thoughts. You notice that you are having many of these types of thoughts with regard to working in the field. Some of them are: “If I am not completely successful with every client I should not have been in the field”, “I have to be accessible and emotionally present 100% of the time for all types of clients and all situations or I am a personal failure,” “Every stress reaction is just evidence that I should have never gone into the field.” How do you process these negative, irrational beliefs of burnout prone therapists?

Ethical Issues: Personal Stress Management & Burnout Prevention
Warnings: irritability, exhaustion, abuse of alcohol/drugs, reduced personal effectiveness, compulsive working, drastic behavior changes, isolation from other professionals, lack of balance- empathy and professional distance, taking work concerns with you

Irrational Beliefs of Burnout Prone Therapists (Deutsch, 1984)
“I should always work at my peak level of enthusiasm and competence.” “I should be able to cope with any client emergency.” “ I should be able to help every client.” “Client lack of progress is my fault.” “I should always be available when clients need me.” “I should be able to work with all types of clients.” “I should be on call always.” “Client needs come before my own needs.” “I am responsible for my client’s behaviors.” “I have power to help, control, or fix a client.”

Scenarios: Receiving Gifts From Clients

Scenarios: Gift Giving
As you approach termination of counseling a clients asks if he can give you a free gym membership to his gym because he was unable to pay all copays. How do you handle this?

A client gives you a Christmas card with a $100 gift card to a fancy steak restaurant for you and your husband enclosed. What do you do? An older woman sews together a blanket for you with your last name and a flower as a sign of appreciation. How do you handle this when she tries to present it to you?

A child brings in some drawings he made. He asks, “you will put them on your wall, won’t you? The child’s full name is on the front of the picture. How do you respond? What do you say? A low income person requests your service. This person cannot afford even a basic sliding scale fee but asks if he/she can give you some fresh farm crops from their field in exchange for your services or if their spouse a give you some free haircuts and styles in their shop. Do you barter? If so, what does the agreement look like?

Ethical Issues: Receiving Gifts From Clients (Gerig,M.-July 2004)
Voluntarily given form one person to another With both natural and symbolic value Recipient sees it as a gift A form of communication Three categories: 1) a “tip” for good service 2) for the client to regain status after something lost 3) as a payment of homage

Ethical Issues: Receiving Gifts From Clients (Gerig,M.-July 2004)
Questions to Consider Regarding Gift Giving What will accepting (or not accepting) this gift do to the dignity and worth of the other person? Is there potential for exploitation? Would this be considered boundary crossing? Do I have any approach-avoidance conflict within me? What are the meanings behind accepting this gift?

Scenarios: Therapist Versus Client Values

A 40 year old married woman with two young children comes in stating that she “is ready to transition from housewife to doing what she wants to do for a change.” She wants your help with leaving her husband, attending school and working two jobs and changing her lifestyle entirely.“ How do you handle this?

A client comes in complaining regarding the son’s engagement to a girl of a different race. This client wishes to have the counseling goal of receiving assistance in learning skills for “expressing to the son the concerns that may arise” and “the reasons this is a bad idea.” What the client does not know is that you are married to someone of a different culture yourself.

A young adult comes in saying he/she has been “hurt and burned by relationships” and now realizes that “no commitment and multiple relationships at once is the way to go.” You personally believe in monogamy and commitment only to the relationship at hand and see dangerous on many levels in dating multiple people.

A mother calls in for therapy because she has had “an awakening” stating that she no longer wants to be married or be around her kids and wants to be free to do what she wants. She has decided she wants to live on here own, go where she wants to go, and not be tied down with a family. You personally have strong beliefs about the value of the family unit and are deeply concerned about her sudden abandonment of her husband and kids. Her stated therapeutic goal is to receive support and assistance with the transition to her new life and personal goals. How do you handle the inner struggle about personally disagreeing with this person’s values?

Reasons for Discipline by the Board:
Violation of Board rules Falsification of information regarding licensure & registration Accepting a commission or rebate for referring persons to the board Conviction of a felony in Ohio Impaired ability to practice (drugs/alcohol, physical or mental conditions) Misdemeanors in any state in the course of practice under licensure Practice outside your scope of practice Practice without supervision

Possible Reactions to Ethical Complaints:
Discussing the complaint Sanctioning the member Recommending resignation Recommending the member be dropped Recommending remedial action (ongoing supervision, personal therapy, additional CEUS)

Ethical Decision Making (Corey, Corey & Callanan, 1993, 11-12)
1. What is the problem or dilemma? Is it an ethical legal or moral issue? 2. Who does it affect? 3. What ethical guidelines fit this situation? 4. What do colleagues think? (reasonable standard of practice) 5. What possible consequences of action can be taken? 6. What are the consequences of various decisions? 7. What appears to be the best course of action?

Preventative Ethical Guidelines (Breggin,P.R.-2008)
1. Every session welcome he client with kindness, empathic understanding and genuine care and concern 2. Be genuinely caring and show “true empathy.” 3. Maintain an atmosphere of trust in the clinical relationship. 4. Make ethical and professional standards an expected part of your interactions with each client and convey this to him or her. 5. Comment on behaviors of concern in a timely manner.

6. Call attention by asking the client to tell his or her story regarding areas you find unusual or do not understand. 7. Cultivate the sense that of the entire personhood of the client not just focusing primarily on their mental health problems. Context and settings are important. 8. Frame as assisting the client in shaping, shaping and making productive decisions about his or her clinical issues. 9. Convey balanced optimism. 10. Convey balanced optimism. 11. Self evaluate.

12. Personalize therapeutic techniques to the specific needs of each given client. 13. Focus on the client’s ability to develop life skills. 14. Maintain the voluntary nature of counseling as much as is able. 15. Demonstrate in words and behaviors that appropriate expression of client feelings can be met with empathy, understanding and potential for behavior change. 16. Make clients aware of your values and the extent to which they may impact counseling. Redirect them elsewhere when necessary. 17. Be careful not to further facilitate helplessness in extremely vulnerable persons. 18. Offer practical direction and techniques, homework, and applied skills to facilitate behavior change when appropriate.

19. Reframe your role as clinician as partner, helper, and facilitator rather than simply expert .Also, remind the client that you are one option. 20. Do not delay in addressing issues that are important for the client, no matter how ridiculous they may seem to you. 21. Remain calm ad attentive and professional emergencies. Do not allow yourself to be emotionally reactive. 22. Share the last resorts and options when needed.

Ethical Decision Making Models
Problem Solving Models: 1. Identify the problem. 2.Define goals by consulting with various sources. 3.Generate possible courses of action. 4. Consider possible consequences of each action. 5. Evaluate the situation as a whole.

Standards of Care Models Judge ethical decisions against socially accepted norms Looking at what a counselor in your shoes would do reasonably- legal, precedent defined

Principle Ethics Use the standards (e.g. beneficence, nonmaleficience, etc.) to judge each situation against

Ethical Evaluation The Four Quadrant Approach of Foster & Black-2007
All quadrants exist simultaneously What is good and what is right Quadrant One: Ethics & Justice What we typically think of as “ethics” Standards of he ethics committee The principles of counselor/client interactions Counselor education, supervision, training, accredidation

Quadrant Two: Legalities What is lawful License requirements What can be prosecuted criminally or civilly

Quadrant Three: Personal Variables Counselor behavior within and outside of counseling sessions How a counselor deals with stress, takes care of oneself, maintains their own well being, keeps balanced and reduces compassion fatigue in difficult cases

Quadrant Four: Morals A counselors personal sense of values, beliefs, and morals What is right for the counselor

What factors am I aware of in this case? Are their areas I need additional information on from the client or collateral sources? What is the perspective of the board? Are there any policies which apply to this case? What are the contextual factors involved here- thoughts, beliefs, values, culture? How should I interact with the client? What is my role as a counselor in this case?

Is there anything significant about this case? What are the immediate concerns in this case? The long term issues or potential uses? What do I need as I work with this person? Is this case within my scope of practice or should I refer?

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