Michele D. Aluoch, PCC River of Life Professional Counseling LLC c. 2013.

Ethical Jeopardy: What Do You Really

Know?

Michele D. Aluoch, PCCRiver of Life Professional Counseling LLC

c. 2013

Gives some specific guidance

Helps professionals keep their colleagues accountable

Gives the public outlines regarding hat should be expected for the welfare of clients

Benefits of Ethical Standards

Categories: Part One (You Pick)General Boundarie

sBoundaries-Gift Giving

Confidentilaity

Privacy

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Informed Consent

Diagnosis Education Discipline Licensure

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Categories: Part Two (You Pick)

Record Keeping

Records Requests

Dependency

Termination

Dual Relationships

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1000 1000 1000 1000 1000

Categories: Part Three (You :Pick)

Duty To Warn

Competency

Advertising & Marketing

Cultural Sensitivity

Supervision

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Categories: Part Four (You Pick)

“ 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)

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

Limitations of Ethical Codes:

1) Ethical & Legal

2) Ethical & Illegal

3) Ethical & Alegal

4) Unethical & Legal

5) Unethical & Illegal

6) Unethical & Alegal

Ethics Vs. Legality:(from Thompson, A., 1990)

Ethics: The Issues

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.”

Ethical Issues: Sex With Clients

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

Boundary Setting

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?

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 service2) for the client to regain status after something lost3) as a payment of homage

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 service2) for the client to regain status after something lost3) as a payment of homage

Ethical Issues: Receiving Gifts From Clients(Gerig,M.-July 2004)

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

Ethical Issues: Confidentiality

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 2.61-2.65 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.”


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)

Practical Privacy Considerations

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

Ethical Issues: Privileged Communication

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.)

Ethical Issues: Informed Consent

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


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

Ethical Issues: Diagnosis

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.”

Ethical Issues: Education

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

Reasons for Discipline by the Board:

Discussing the complaint

Sanctioning the member

Recommending resignation

Recommending the member be dropped

Recommending remedial action (ongoing supervision, personal therapy, additional CEUS)

Possible Reactions to Ethical Complaints:

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

Not the same in every state

Ethical Issues: Licensure

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

Ethical Issues: Record Keeping

What does the client want?

Anything potentially harmful?

What parts should or should not be revealed?

Is discussion beforehand advisable?

Responding to Records Requests

Be clear who the client is (individual, couple, family)

Refer when potential conflicts

Ethical Issues: Family Counseling

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

Disclosure of Records to Family Members:(ORC 5122.31 (a) (7) )

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)

Ethical Issues: Client Dependency:

Solutions to DependencyPromoting 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

Ethical Issues: Client Dependency:

Pros/cons discussed with client

How to apply techniques on an ongoing basis and generalization

Options of referrals

When a therapist leaves the practice

Ethical Issues: Termination

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*

Ethical Issues: Multiple Relationships

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)

Ethical Issues: Duty to Warn

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

Ethical Issues: Competency

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


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


WESTERN Individuality Democratic Nuclear Family Focus

Youth Emphasized Independence Assertiveness Non-conformity

Ethical Issues: Multicultural Contexts

EASTERNRelationshipAuthoritarianismExtended Family FocusMaturity EmphasizedInterdependenceComplianceConformity

WESTERNCompetitionConflictFreedomIndividual needsResponsibility

within individualExpress Feelings


EASTERNCooperationHarmonySecurityCollective goalsResponsibility within societyControl Feelings

WESTERNUniqueness of each

personSelf actualizationFuture focusInnovationMorality-internal,

individual“Change is very

good”


EASTERNUniformity of each personCollective actualizationTraditionalismConservativismMorality-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”


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”)

Ethical Guidelines for Multicultural Counseling(D.W. Sue & D. Sue, 1990)

*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


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

Ethical Considerations in Supervision

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

a) Fidelity

b) Reparation

c) Gratitude

d) Justice

e) Beneficence

f) Nonmaleficence


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?

Ethical Questions To Consider

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?


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?


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?

Ethical Decision Making (Corey, Corey & Callanan, 1993, 11-12)

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.

Preventative Ethical Guidelines(Breggin,P.R.-2008)

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.


PART TWO:

HANDS ON PRACTICE EXERCISES

You have counseled a single person regarding stresses and depression associated with being ingle 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.

Ethical Dilemmas: Sex with Clients

It has been five years since you counseled a client and you happen to see that person out in public by

chance. You get to updating each other and find out you are both single and available. Since it has been

five years after all do you and the other person pursue a relationship?


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?


A client compliments you on how attractive you look today. You notice this happens right as you are

walking back to the office just before the person’s spouse arrives for the marital session. How do you

handle the comment?


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 comet, “Life would be so much better if I could just be with someone like you.” How do you handle this?


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 Dilemmas: 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?

Ethical Dilemmas: Education

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.

Ethical Dilemmas: Diagnosis

A parent brings in his or her 6 year old child for evaluation for possible ADHD after some

behavioral issue 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.


A gentleman comes in through EAP insurance plan regarding how his depression is affecting his job. You have given him a diagnosis of 300.4- 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).”


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?”


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?


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?


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.


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?”

Ethical Dilemmas: Supervision


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?”


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?

Ethical Dilemmas: Boundary Setting/Defining the Clinical Relationship

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 new client comments, “I have heard from my friend that you did amazing things for her and I have seen how much better she is in the months since she has been talking to you. I had to see about how your counseling might also help me get my life on track.


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?”


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.”


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?

Ethical Issues: Competency

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?

Ethical Dilemmas: Therapist Vs. Client Values

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.


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?

Ethical Dilemmas: Practical Privacy Considerations

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 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?


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.

Ethical Dilemmas: Record Keeping

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?

Ethical Dilemmas: Privileged Communication

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?


An attorney’s office calls you stating that they need your input on a client and need copies of records. What do you do? Do you say anything? Does it make a difference if a release of consent is signed?


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.”

Ethical Dilemmas:Client Dependency

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 Dilemmas:Client Dependency

You have been working with a family for a while and the goals of treatment have been met. Initial symptomology is all gone. However the caregiver says that she “would like you to keep meeting with the kids because they have no friends and support systems like you .” You do not see any current counseling goals however . So what do you do regarding termination?

Ethical Dilemmas: 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 psychiarist “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?


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.”

Ethical Dilemmas:Multiple Relationships

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?

Ethical Dilemmas:Family/Marital Counseling

You have been meeting with a family as a group for a while now when you receive a call from one of the family members saying he/she would like to meet with you individually to talk further about the family issue but specifies that “they do not want what they say brought into the family sessions.” How do you respond?

Ethical Dilemmas:Family/Marital Counseling

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 runningher 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?

Ethical Dilemmas: 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?

Ethical Dilemmas: Duty To Warn

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.”

Ethical Dilemmas:Boundaries With Colleagues

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?

Ethical Dilemmas:Boundaries With Colleagues

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.

Ethical Dilemmas: Advertising

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.


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?

Ethical Dilemmas:Multicultural Counseling

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 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.


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Michele D. Aluoch, PCC River of Life Professional Counseling LLC c. 2013.

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