1. Ethical, Legal & Professional Issues

2. Morality
Values
Duties

3. Morality
Personal Morals
Societal Morals
Group Morals

4. Morals vs. Ethics Ethics = systematic reflection on morality
Ethics = applied morals
Ethical Decisions - most difficult when ethical dilemmas exist

5. Ethics - Definition
“Do the right thing” (Spike Lee)

6. Categorization of Moral Theories
Relativism vs. Absolutism
Micro ethics vs. Macro ethics
Deontological vs. Teleological

7. Relativism vs. Absolutism
What is right and wrong varies from person to person and culture to culture
There are no absolute moral standards
Absolutism
There are absolute moral standards that are both universal and objective

8. Micro ethics vs. Macro ethics
The happiness of the individual is the highest good
The good of the group = the good of the individuals who comprise the group
Macro ethics
The happiness of the group itself (city, state, nation or race) is the highest good

9. Deontological vs. Teleological Theories
Deontological Theories
The correct way to proceed is to learn basic duties and rights of individuals or groups and act accordingly
e.g. Kant’s Categorical Imperative
Teleological Theories
Sometimes adherence to duty leads to consequences contrary to well-being.
E.g. Utilitarianism ( Bentham, Mill)

10. Ethical Principles Beneficence Autonomy Nonmaleficence Justice
Fidelity

11. Beneficence Comes with risks General Societal Obligations?
Strength of Duty Factors
Significant need
Ability to assist
probability of success
Benefit outweighs risk
Role-related obligation

12. Risks of Beneficence: Paternalism
Undermines dignity
promotes dependence
conflicts with rights to autonomy
When is paternalism justified?
Competency is seriously limited
C has ability to promote Cl’s best interests
Cl’s interests are considered primary
Risk for loss must be real & significant

13. Autonomy 3 conditions necessary for autonomy
Voluntariness
Competence
Full Disclosure
What & how much should one disclose?
The “reasonable person” standard
Individualized standard
Does client/patient truly understand?

14. Informed Consent enables cliept to make autonomous choices
minimizes harm/risk by enabling cl to protect self
encourages c & cl to discuss issues openly & plan together

15. Promoting Autonomy Assess Teach
Encourage choice wherever & whenever possible

16. Nonmaleficence Beneficence vs. Nonmaleficence
Beneficence: Doing Good
Nonmaleficence: Avoiding Harm to another by
not directly causing harm
avoiding placing others at risk for harm
“Above all, do no harm” - role obligations
Obligation to prevent harm is stronger than obligation to do good
In rehab, must take some risks for later benefit

17. Negligence: Failure to act or to exercise due care
Failure to exercise due care toward another
Due Care = Proper training + Proper skills + Diligence
Includes both deliberately & carelessly imposed risks
Types of Negligence
Culpable ignorance
Personal Incompetence
Environmental factors

18. Justice Most problem in conditions of scarcity and competition
Actions based on justice (examples)
avoiding discrimination
avoiding exploitation
distributing resources fairly

19. Material principles of Justice
Equal shares
need
motivation/effort
contribution
free market exchange
fair opportunity
FUNDAMENTAL NEED: person will be harmed if need is not met - takes priority

20. Quantitative criteria of Distributive Justice
Cost-effectiveness
Limitations:
Quantity isn’t everything (can’t quantify human dignity & worth
Efficiency ignores common values e.g. hospice, etc.

21. Fidelity Focuses on relationships
Caregivers make implicit promises of trustworthiness
Assymetric relationship increases duty to fidelity

22. Confidentiality
Assumed by your willingness to enter into therapist-patient relationship
Circumstances under which confidentiality can be broken
clear & imminent danger to self or others
others as determined by law (e.g. child abuse, elder abuse)
court actions/subpoena
Importance of disclosure

23. Dual Relationships Sexual, family, friend, business, supervisor, etc.
Pt. Needs to be free of your problems
may impair objectivity & professional judgement

24. Fidelity in Professional Relationships
Fidelity to employer
Fidelity to profession
Fidelity to colleagues/team

25. Ethical Dilemma
Choice must be made between two or more courses of action
Significant consequences for any course of action
Each action can be supported by ethical principle(s)
Ethical principle supporting unchosen course of action is compromised

26. Ethical Decision Making Model for Rehabilitation Counselors
Review the situation & determine the possible courses of action
List the factually based reasons supporting each course of action
Identify the ethical principles that support each action
List the factually based reasons for not supporting each course of action
Identify the ethical principles that would be compromised if each action were taken

27. Ethical Decision Making Model continued
Formulate a justification
Rubin et al. (1990)

28. The Eclectic Decision-Making Model of Ethical Behavior
Tarvydas (1998

29. Stage I: Interpreting the Situation through Awareness and Fact-Finding
>Enhance sensitivity and awareness
>Dilemma vs. issue?
>Determine major stakeholders & their ethical claims in the situation
>Engage in the fact-finding process

30. Stage II: Formulating an Ethical Decision
Review the dilemma
Determine what ethical codes, laws, principles, and institutional policies and procedures apply
Generate possible and probable courses of action
Consider potential positive and negative consequences
Select the best ethical course of action

31. Stage III: Selecting an Action by Weighing Competing, Nonmoral Values
>Engage in reflective recognition and analysis of personal competing values
>Consider contextual influences on values selection at the collegial, team, institutional, and societal levels

32. Stage IV: Planning and Executing the Selected Course of Action
Figure out a reasonable sequence of concrete actions to be taken
Anticipate & work out personal & contextual barriers to effective execution of the plan, and effective counter-measures for them
Carry out and evaluate the course of action as planned

33. Principles vs. Standards
Principles: General Guidelines to govern one’s actions
Standards: Generally derived from principles and prescribe appropriate behavior in a given circumstance
Rules
Laws
Codes

34. Ethical Codes
Assist counselors in deciding what to do when situations of conflict arise
Help clarify the counselor’s responsibility to the client and protect the client from the counselor’s failure to fulfill these responsibilities
Give the profession a means of self governance

35. Ethical Codes of Interest to Rehabilitation Counselors
Code of Professional Ethics for Rehabilitation Counselors (CRCC)
American Counseling Association (ACA)
International Association of Rehabilitation Professionals (IARP)
American Psychological Association (APA)
National Association of Social Workers (NASW)
American Association for Marriage & Family Therapy (AAMFT)
Association for Specialists in Group Work (ASGW)

36. Code of Professional Ethics for Rehabilitation Counselors
CRCC Ethics Committee initiated
2001 update due to
Changes in practice
Changes in technology
Experience of Ethics Committee

37. Code Structure Table of Contents Preamble
Enforceable Standards of Ethical Practice
11 Sections (A-K)
Rules within each Section

38. Sections of Code A The Counseling Relationship B Confidentiality
C Advocacy and Accessibility
D Professional Responsibility
E Relationships with Other Professionals
F Evaluation, Assessment and Interpretation

39. Sections of Code continued
G Teaching, Training, and Supervision
H Research and Publication
I Electronic Communication and Emerging Applications
J Business Practices
K Resolving Ethical Issues

40. Consultation Model Code of Ethics Supervisor Colleagues Experts
Licensure &/or Certification Boards

41. Questions to Ask Have I Consulted with the Code? Others?
Have I Documented Everything?
What if this was the Newspaper Headline?
What if this was the one I most love?

42. Processing Ethical Complaints
The CRCC Ethics Committee Process and Procedures for Processing Ethical Complaints

43. Commission on Rehabilitation Counselor Certification (CRCC)
CRC Credential
Assures certified RCs meet minimum ed, experience and competency standards
Consumer protection
Accountability

44. CRCC Ethics Committee
Promotes Ethical Practice among Certified Rehabilitation Counselors
CRCC Code of Ethics
Education
Advisory Opinions
Self Governance/Judicial Function

45. Reporting Ethical Violations
Who Reports?
The Ethics Complaint Form

46. Steps in the Process The Ethical Complaint Process Flowchart
Details actions of Ethics Committee and Administrative Office
Blueprint for processing complaints

47. Suggested Procedures for Initial Case Review (Tarvydas)
Summarize charge
If true, as alleged, would there be an ethical violation?
Identify specific Ethical Canon(s) and Rule(s)
Accept complaint if violation may have occurred
What additional info/evidence is needed?

48. Ethics Committee Actions
Letter of Instruction
Reprimand
Probation
Suspension
Revocation

49. Decisions at the End of Life

50. Introduction Increasingly, Americans die in medical facilities
85% of Americans die in some kind of healthcare facility (hospitals, nursing homes, hospices, etc.)
Of this group, 70% (60% of the population as a whole) choose to withhold some kind of life-sustaining treatment

51. The Right to Die Do we have a right to die?
Negative right (others may not interfere
Positive right (others must help
Do we own our own bodies and our lives? Do we have the right to do whatever we want with them?
Isn’t it cruel to let people suffer pointlessly?

52. The Sanctity of Life Life is a “gift from God”
Importance of ministering to the sick and dying
See life as “priceless” (Kant)

53. Compassion for Suffering
The larger question in many of these situations is: how do we respond to suffering?
Hospice and palliative care
Aggressive pain-killing medications
Sitting with the dying
Euthanasia

54. What are we striving for?
Euthanasia means “a good death”, “dying well”
What is a good death?
Peaceful
Painless
Lucid
With loved ones gathered around

55. Some Initial Distinctions
Active vs. Passive Euthanasia
Voluntary, Non-voluntary, and Involuntary Euthanasia
Assisted vs. Unassisted Euthanasia

56. Assisted vs. Unassisted Euthanasia
Many patients who want to die are unable to do so without assistance
Some who are able to assist themselves commit suicide with guns, etc. - - ways that are much harder and difficult for those who are left behind

57. Voluntary, Non-voluntary and Involuntary Euthanasia
Voluntary: Patient chooses to be put to death
Non-voluntary: Patient is unable to make a choice at all
Involuntary: Patient chooses not to be put to death, but is anyway

58. Active vs. Passive Euthanasia
Active euthanasia
Occurs in those instances in which someone takes active means, such as a lethal injection, to bring about someone’s death
Passive euthanasia
Occurs in those instances in which someone simply refuses to intervene in order to prevent someone’s death

59. Active Euthanasia Typical case for active euthanasia
There is no doubt that the patient will die soon
Passive measures will not bring about the death of the patient
The option of passive euthanasia causes significantly more pain for the patient (and often the family as well) than active

60. Criticisms of the Active/Passive Distinction in Euthanasia
Conceptual Clarity – vague dividing line between active and passive, depending on notions of “normal care”
Moral Significance – does passive euthanasia sometimes cause more suffering?

61. Health Care Advance Directives
Planning Ahead for End of Life Decisions

62. Health Care Advance Directive
A document in which you give instructions about your health care if, in the future, you cannot speak for yourself
Living Will: State wishes about life-sustaining medical treatments
Health Care Power of Attorney: Appoint another to make medical treatment decisions for yo if you cannot make them for yourself

63. Health Care Advance Directives
Should provide specific guidance regarding your wishes about:
Artificial respiration
Nutritional support & hydration
Medication use for
Pain relief
Prolonging life
Organ Donation

64. Legally Binding? Legal document in most states
Medicaid requires discussion for admission to healthcare facilities
Durable Power of Attorney
Most courts tend to honor wishes expressed in living will

65. The Slippery Slope Worrisome examples from history:
Nazi eugenics program
Chinese orphanages
Special danger to undervalued groups in our society
The elderly
Minorities
Persons with disabilities
Groups that are typically discriminated against

66. Legal/Ethical Interface
Understanding the Legal Issues impacting Rehabilitation Counselors

67. Types of Procedural Law
Civil Law
Criminal Law
Mental Health Law

68. Civil Law Lawsuits brought by private parties against each other
Losing means financial loss
Burden of Proof:
Fair preponderance of the evidence
Burden is on Plaintiff

69. Criminal Law Disputes between state & persons
Losing means loss of liberty
Burden of Proof:
Beyond a reasonable doubt
Burden is on the State

70. Mental Health Law
Regulates how state helps mentall ill persons (commitment hearings)
Considered type of Civil Law
Conflict: right to freedom vs. state’s resp. to protect those unable to protect selves
Burden of Proof
Because psych is too inexact to meet reasonable doubt, must meet level of reasonable medical certainty test
Clear & convincing evidence
Burden is on those bringing the proceedings

71. Case Law Tarasoff v. Regents of the University of California
Requires therapists to protect foreseeable victims of dangerous clients (Duty to Warn or Duty to Protect).
Wyatt v. Stickney, Donaldson v. O’Connor & O’Connor v. Donaldson:
Duty to treat involuntarily confined mental patients or release them
Caesar v. Mountanos
The client is the sole holder of the psychotherapist-client privilege

72. Therapists are regulated by Laws at three levels:
Federal
State
Statute
Regulations
Local
County/City

73. Florida Law Themes Confidentiality
Allowable Exceptions to Confidentiality
Mandated Reporting of Abuse or Neglect of:
Aged persons
Disabled adults
Children
Psychotherapist-Patient Privilege
Involuntary Admission (Baker Act)
Guardians and Substitute decision-making
Children & Families (confidentiality, custody,etc)

74. Mandatory Reporting Discretionary Reporting Duty to Protect
Ethics and The Law
Mandatory Reporting
Discretionary Reporting
Duty to Protect

75. Ethics and The Law Linda R. Shaw, Ph.D., CRC, LMHC
Associate Professor & Graduate Coordinator
University of Florida Dept. of Rehabilitation Counseling
This presentation provides general guidance only. All questions related to Florida Law should be directed to an attorney specializing in mental health law.

76. Presumption of Confidentiality
Confidentiality is necessary to preserve:
Client privacy, dignity & respect
A relationship characterized by trust
Client Autonomy (freedom to decide with whom information will be shared)
Florida LMHCs are included in Testimonial Privilege Law – Cl. has right to keep confidential communications from being disclosed in a legal proceeding (Fla Statute ).

77. Rationale for Exceptions to Confidentiality
Must balance client’s right to privacy & autonomy with competing societal interests
Exceptions may be either
Mandatory – Counselor shall report
Permissive – Counselor may report
Whether an exception is permissive or mandatory depends on the importance of the societal interest at stake

78. Mandated Exceptions to Confidentiality Reporting
Generally referred to as “Mandated Reporting”
Requires that certain information applying to particularly vulnerable groups be disclosed to ensure their safety & well-being

79. Mandated Reporting
Required of all persons who, in a professional capacity, come into contact with individuals comprising three groups:
Groups include:
Children
Elderly
Disabled Adults

80. Mandated Reporting Children (Fla. Statutes 39.01 and 827.03)
Must report any incident of known or suspected abuse, abandonment or neglect
Definitions:
Abuse: “any willful act or threatened act that results in a physical, mental or sexual injury or harm that causes or is likely to cause the child’s physical, mental, or emotional health to be significantly impaired” (Fla. Statute 39.01) Also includes the active “encouragement of any person to commit an act that results or could reasonably be expected to result in physical of mental injury to a child” (Fla Statute )

81. Mandated Reporting Children (Fla. Statutes 39.01 and 827.03)
Must report any incident of known or suspected abuse, abandonment or neglect
Definitions:
Neglect: a caregiver’s failure to (1) provide a child with necessary care, supervision, and services and (2) to make a reasonable effort to protect a child from abuse, neglect or exploitation (Fla Statutes and ).
Abandonment: when a parent sufficiently fails to support and nurture a child so as to evince a willful rejection of parental obligations (Fla. Statute 39.01[1]).

82. Mandated Reporting Children
Fla. Statutes and list specific examples of situations that would constitute abuse and/or neglect – e.g.
Cuts, bites, burns, scalding
Excessively harsh discipline likely to result in physical injury
Failure to provide child with adequate food or clothing

83. Mandated Reporting Elders and Disabled Adults (Fla. Statute 415)
Definitions:
Abuse: the “nonaccidental infliction of physical or psychological injury or sexual abuse” (Fla Stat. Ch [1])
Neglect: “the failure or omission To provide care, supervision, and services necessary to maintain the physical and mental health of the disabled adult or elderly person.”(Fla. Stat. Ch [2]).
Exploitation includes “financial exploitation and misuse of funds” (Fla. Stat. Ch [2]).

84. Mandated Reporting Standard for reporting Timing of report
Must report if the mandated reporter “knows or has reasonable cause to suspect” that harm is occurring or has occurred.
Timing of report
As soon as mandated reporter has reasonable cause to suspect

85. Florida Abuse Hotline Department of Children and Famlies
Contact Information:
ServicePhone: (850)
Suncom:
Toll Free: (800)

86. Liability Failure to report (e.g. Fla. Statute 491)
Possible criminal sanctions – “knowingly & willfully”
Civil sanctions
Professional discipline
Release from liability (Fla. Statute , )
No civil or criminal sanctions attach when report is made in good faith

87. Permissive Reporting
Allows counselor to exercise discretion and to violate confidentiality under certain conditions:

88. Permissive Exceptions to Confidentiality
Client consent
Treatment emergencies
Facilitation of Treatment
Provision of mental health services
Peer & administrative review
The legal system
Research
Public safety

89. Exceptions to Confidentiality to Protect the Public Safety
Florida and the Tarasoff Decision
Tarasoff v. California Board of Regents
Created a duty to protect identifiable 3rd party
Florida is not a Tarasoff state

90. Florida Laws related to public safety
Confidentiality may be waived when “there is a clear and immediate probability of physical harm to the patient or to the society”(Fla. Statute )”
Psychiatrists have the option to to disclose when the patient has made an “actual threat” to “physically harm” an “identifiable victim” (Fla Statute )

91. Florida Laws related to public safety
Mental health counselors may disclose to a HIV positive patient’s sexual or needle-sharing partner when
Patient has disclosed the identity; and
Patient has refused to notify the partner nor will he/she refrain from high-risk activity (Fla Statute )

92. Protections against Malpractice
Abide by the Law of No Surprises
Informed Consent
Professional Disclosure

93. Professional Disclosure
The nature & purpose of the services provided
Risks and Benefits
Alternatives to service provision
Information about the procedures and duration of counseling
Limitations on confidentiality
Client’s right to make complaints and/or discontinue services
Logistics of counseling (Making & canceling appointments, etc.)
What to do in an emergency
Policies and procedures regarding fees

94. Protections against Malpractice
Know your legal and ethical responsibilities
Codes of Ethics
Statutes & Regulations

95. Consult Allows for “reality testing”
Establishes standard for “reasonable” care
Establishes evidence for reasonable & prudent action

96. Document If its not written down, it didn’t happen
Never alter documentation!

97. Insure against malpractice
Anyone can be sued at any time
Institution liability insurance may not be adequate
Available through professional associations

98. Mental Health Counseling: Definition
Broad definition
Includes “methods of a psychological nature used to evaluate, assess, diagnose & treat
“Includes counseling, behavior modification, consultation, advocacy, crisis intervention, client education, research . . .”
“individuals, couples, families, groups, organizations, & communities”

99. Academic Preparation Generally based upon CACREP requirements
Major revision, effective Jan 1, 2001
Requires:
60 hr. masters program
1,000 hours of practicum &/or internship
Specified coursework

100. Required Coursework – 3 hrs of:
Counseling Theories & Practice
Human Growth & Development
Diagnosis & Treatment of psychopathology
Human sexuality
Group theories & practice
Individual evaluation and assessment
Career and Lifestyle Assessment

101. Required Coursework – 3 hrs of:
Research and program evaluation
Social & cultural foundations
Counseling in community settings
Substance abuse
Legal ethical and professional standards
IT IS ESSENTIAL THAT YOU KEEP COURSE SYLLABI!!

102. Supervised Experience
A minimum of:
2 years =1500 face to face over at least 100 weeks
100 hrs. of supervision per 1500 hrs. of face to face
1 hr. of supervision q 2 wks.
1 hr. of supervision per 15 hrs. of face to face
Focus on raw data

103. Supervised Experience
No more than 50% group supervision (2-6 supervisees)
Post-masters experience can commence when 7 of 11 required courses, including diagnosis & treatment has been completed.
IT IS ESSENTIAL THAT YOU PROPERLY DOCUMENT SUPERVISION!!

104. Supervisor Qualifications
LMHC,LMFT, LCSW or equivalent in another state
M.D. Psychiatrist, Board Certified
Licensed Psychologist + 3 yrs. Of experience providing psychotherapy (incl. 750 hr. face to face)
AAMFT-approved or NCC-ACS supervisor

105. Supervisor Qualifications cont.
Supervisors must have completed 5 years clinical experience & training in supervision in one of the following:
Graduate level supervision course
Continuing Education course (16 hr)
Meet AAMFT or SW supervision course requirements

106. Registered Intern Requirement
Before beginning supervised experience, must apply for intern registration
Includes review of coursework and I.d. of qualified supervisor
Title: Registered Mental Health Counselor Intern

107. Provisional License
For individuals who have satisfied clinical experience
Allows individuals to work under supervision while completing additional coursework or exam requirements.

108. Exam Taken at conclusion of 2 years of supervised experience
National Clinical Mental Health Counseling (NCMHC) Exam

109. Laws & Rules HIV/AIDS Laws & Rules HIV/AIDS
Must complete 8 hr. course covering
Specified Fla. Laws & rules
Integration with competencies required for clinical practice & interactive discussion of case examples
HIV/AIDS
Must complete course by time of licensure (or within 6 mos. In extenuating circumstances)

110. Additional Approved Training
Domestic Battery
Medical Errors

111. Purposes of Professional Associations
Represent members in lobbying, professional advocacy efforts
Provide networking opportunities
Provide opportunities for professional development
Promote professional practice
Support accreditation, certification
Promote ethical practice & self-regulation
Advocate for PWD

112. Exercise Name of Association Structure Benefits to membership
Divisions
State/Regional/Local
Governance Structure
Committee
Benefits to membership