Frequently Asked Questions

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1 Frequently Asked Questions What are the requirements for license renewal? Contact Hours Required Simply look at the chart on the following pages, find your state and your required contact hours. How do I complete this course and receive my certificate of completion? On-Line Submission: Go to Counselors.EliteCME.com and follow the prompts.you will be able to print your certificate immediately upon completion of the course. Fax or Submission: Fax to (386) , be sure to include your credit card information. All completions will be processed within 2 business days of receipt and certificates ed to the address provided.* Mail Submission: Use the envelope provided or mail to Elite, PO Box 37, Ormond Beach, FL All completions will be processed and certificates issued within 10 business days from the date it is mailed.* *Please note - providing a valid address is the quickest and most efficient way to receive your certificates when submitting via fax, or mail. Submissions without a valid address will be mailed to the address provided at registration. How much will it cost? Course Title CE Hours Price Ethical Practice for Marriage and Family Therapists and Professional Counseling 6 $24.00 Are you an approved provider? Elite CME has been approved by NBCC as an Approved Continuing Education Provider, ACEP No Programs that do not qualify for NBCC credit are clearly identified. Elite CME is solely responsible for all aspects of the programs. Your state accepts course providers that are approved by this national organization. Are my credit hours reported to my state board? No. Your certificate of completion is proof of course completion. Is my information secure? Yes! Our website is secured by Thawte, we use SSL encryption, and we never share your information with third-parties. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at Counselors.EliteCME.com you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or us at office@elitecme.com or call us toll free at , Monday - Friday 9:00 am - 6:00 pm EST. Important information for licensees: Always check your state s board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Counselors.EliteCME.com Page ii

2 How many continuing education hours do I need? STATE HOURS REQUIRED HOURS ALLOWED BY HOME-STUDY MANDATORY Alabama hours of ethics for ALC; 6 hours of ethics for LPC. Alaska hours of ethics. Arizona None. Arkansas hours of ethics. California hours of laws and ethics each renewal; 7 of hours HIV/ AIDS (one-time requirement). Colorado None. Connecticut hour cultural competency per renewal. Delaware None. District of Columbia hours of ethics; 4 hours of trauma counseling. Florida Every renewal - 2 hours of prevention/medical errors (Board approved); 3 hours of ethics and boundaries. Every 3rd biennium - 3 hours of laws/rules update; 2 hours of domestic violence. Georgia hours of ethics; 15 hours must be core hours and 15 hours have to relate to specialty/ profession. Idaho hours of ethics (must be live). Illinois Clinical Professional Counselors with clinical supervision are required to complete 18 of the 30 hours in clinical supervision training. This is a one time (lifetime) requirement. Indiana hours of ethics in Category I. Iowa hours of ethics. Kansas hours of ethics; 6 hours of diagnosis and treatment of mental disorders. Kentucky None. Louisiana hours of ethics; 6 hours of assessment, diagnosis, and treatment from current DSM-V or of a specific condition; 3 hours of supervison for those approved by board to supervise. Maine hours of Code of Ethics contained in Chapter 8-A of the board s rules, relate to any aspect of the theory or practice of professional counseling, including any additional hours in ethics in excess of the 4 hour minimum. Maryland None. Massachusetts None. Minnesota None. Mississippi hours of professional ethics or legal issues in the delivery of counseling services; 2 hours of supervision for LPC Supervisors. Missouri hours jurisprudence. Montana None. Nebraska hours of mental health practice ethics. Nevada hours of ethics; supervisor needs 1 hour of a supervision. New Hampshire hours of ethics (Category A). New Jersey hours of ethical and legal standards; 3 hours of social and cultural competence. New Mexico hours of ethics; supervisors need 1 hour of supervision. New York 36 (Effective 1/1/2017) 12 2 hours of child abuse reporting (one-time requirement). North Carolina hours or ethics; jurisprudence exam provided by center for credentialing and education. LPC supervisors require an additional 10 hours of continuing counselors education related to professional knowledge and competency in the field of counseling supervision. North Dakota hours of ethics; LPCCs require an additional 10 hours of clinical professional development (preapproved by the board).

3 STATE HOURS REQUIRED HOURS ALLOWED BY HOME-STUDY MANDATORY Ohio hour of ethics; Supervising Professional Counselors are required to complete a 3 hour supervision course. Oklahoma hours of ethics (board approved and live); 3 hours of supervision (live). Oregon hours of ethics. Pennsylvania hours of ethics; 2 hours of state approved child abuse recognition and reporting. Rhode Island None. South Carolina Supervisor must complete 10 hours of supervision oriented continuing education during every two-year licensure period for this license. (5 of the 10 hours can be informal education.) South Dakota hours of ethics. Tennessee hours of ethics and jurisprudence. Texas hours of ethics (completion of Texas jurisprudence exam will count as 1 hour of continuing education in counselor ethics); 6 hours of supervision if licensee has supervisor status. Utah hours of ethics. Vermont hours of professional ethics in the clinical fields of marriage and family therapy, clinical mental health counseling, psychiatry, psychology, or social work. Remaining 36 hours must be in the theory and practice of clinical mental health counseling. Virginia hours of ethics standard of practice or laws governing behavioral science profession in Virginia. Washington Certified Counselors/Advisors 6 hours of professional ethics Licensed Mental Health Couselors West Virginia hours of ethics (must be live); 3 hours of supervision of clinical counseling if a supervisor-title. Wisconsin hours of ethics and professional boundaries. Wyoming hours of ethics. NOTE: CE Rules can change. Always check your state board for the most up-to-date information.

4 Table of Contents CE for Professional Counselors CHAPTER 1: ETHICAL PRACTICE FOR MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELING Page 1 This course will help you identify and define key elements of the NBCC, ACA and AAMFT Code of Ethics related to informed consent, confidentiality, dual relationships and duty to warn. It will also help the reader analyze the relationships between legal directives and ethical guidelines in the practices of therapy and counseling, understand the ethical complaint process, and recognize when the complaint process is appropriate. Ethical Practice for Marriage and Family Therapists and Professional Counseling Final Exam Page 39 Final Examination Answer Sheet Page 43 Course Evaluation Page 44 $4 ONLY per Want more courses to choose from? No problem! credit hour Visit Counselors.EliteCME. com to view our vast course library and get your CE today! Additional courses are added regularly. PLUS... Lowest Price Guaranteed Serving Professionals Since 1999 Elite Continuing Education All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. Page iii Counselors.EliteCME.com

5 Chapter 1: Ethical Practice for Marriage and Family Therapy and Professional Counseling 6 CE Hours By: Wade Lijewski, PhD Learning objectives Identify and define the key elements of the NBCC, ACA, and AAMFT Code of Ethics related to informed consent, confidentiality, dual relationships, and duty to warn. Compare and contrast the ethical guidelines and directives of the NBCC, ACA, and AAMFT on conversion-reparative therapy and counseling. Select and discuss the six purposes of the ACA Code of Ethics. Give two examples of appropriate termination or referral according to the ACA Code of Ethics. Define client privilege and give three examples of violations from the case studies. Explain and give four components of a counseling plan as defined in the ACA Code of Ethics. Outline four competencies for multicultural diversity sensitivity according to the ACA Code of Ethics. Identify and explain four prohibited non-counseling roles and relationships as defined in the ACA Code of Ethics. Discuss five steps in ethical decision making for therapy and counseling. Analyze the relationship between legal directives and ethical guidelines in the practice of therapy and counseling. List and explain three ethical violations in therapy and counseling that may occur when using mobile technology devices. Explain the role of collaboration as it applies to ethical practice and give two examples. Define the term duty to warn and explain how it informs ethical practice. Identify and explain three potential confidentiality violations and safeguards when using technology in therapy and counseling practice. Discuss three ethical standards and directives specific to minor clients. Introduction Today, mental health professionals face many complex ethical considerations related to client diversity and new methods for providing services including distance counseling and therapy, new forms of digital technology and social media. The dynamics of modern practice require counselors and therapists to reconsider issues of confidentiality, informed consent, multiple relationships, patient privacy, and records security. The practitioner must keep pace with revised ethical standards of practice and the needs of an increasingly diverse population. A working knowledge and daily application of revised ethical guidelines is required of all mental health counselors, therapists, and staff to provide highest level of service for the client. Ethics refers to the beliefs individuals hold about what is right. Ethical conduct refers to the behaviors exhibited by the counselor and therapist. Good ethical conduct is grounded in sound moral principles, understanding the ethical codes, and commitment to client welfare. Explain five standards that guide ethical practice in long distance counseling or therapy and five best practices to prevent ethical violations. Describe three new challenges the MFT faces today and apply three related standards in the AAMFT Code of Ethics to meet those challenges. Select and discuss three aspirational core values from the AAMFT Code of Ethics. Define the term binding expectation as written in the AAMFT Code of Ethics and give two examples. Select and explain three examples of advocacy and public participation from the AAMFT Code of Ethics. List and define three standards and directives that address access to client records by family members. Discuss the ethical complaint process and explain when it is appropriate. Identify two situations that may warrant the disclosure of confidential information and give examples for each. Select three standards that define professional competence and discuss three examples that apply to practice. List and explain the requirements for maintaining client records as outlined in the NBCC Code of Ethics. Discuss the use of digital technology and social media in counseling as outlined in the NBCC Code of Ethics. Identify and discuss four directives on records security from the NBCC Code of Ethics and give two examples of each. Define two deceptive techniques that must be avoided in research from the NBCC Code of Ethics. Explain the term harmful multiple relationships as defined in the NBCC Code of Ethics and describe examples from the case studies. Laws and ethical codes regulate the practice of therapists and counselors. Professional organizations do not enforce law but instead develop standards and guidelines to assist the practitioner in delivering services based on ethical behavior and practice. Laws are enforced by government definitions of the minimum standards acceptable to society. In order to educate and guide counselors and therapists, professional associations have developed code of ethics as a resource and a process to review ethics complaints in order to protect the client. The recent revisions to these codes will be discussed as well as the policies and procedures to address ethical complaints if a violation is alleged. The Standards for Privacy of Individual Identifiable Health Information, (Privacy Rule) establishes a set of national standards for the protection of health information. The U.S. Department of Health and Human Services (HHS) issued the Privacy Rule to implement the Counselors.EliteCME.com Page 1

6 requirement of the Health Insurance Portability and Accountability Act of 1996(HIPAA). The Privacy Rule addresses the use and disclosure of individuals health information by professionals in organizations subject to the Privacy Rule (HIPAA, 1996). The major goal of the Privacy Rule is to assure that health information is properly protected, while allowing the flow of information, to promote quality healthcare and protect the public health. The HIPAA Privacy Rule and the codes of ethics for mental health practitioners Historical perspectives Standards of practice and the idea of accountability can be traced back to ancient Egypt around 2000 BC as found in the code of Hammurabi (American College of Physicians, 1984) which contained a description of physician responsibilities and the consequences and punishments if the patient s health did not improve. The Hippocratic oath, written in 400 BC, can be viewed as an early example of a code of ethics to guide the practice of medical professionals and define obligations to their profession, practice, and patients. This ancient oath is the foundation for the values and ethical principles in current codes of ethics. The writings of Aristotle concluded that ethics provide guidelines for virtuous and moral action. In his rule the Gold Mean, Aristotle defined ethical choice as one that falls in to middle of two extremes, one of excess and the other of deficiency. After World War II, the American Psychological Association (APA) saw the need to develop a code of ethics due to a change in the type of professional activity requested of their members. Psychologists were called on to address the mental health needs of many soldiers returning home from the war and responsible for developing psychological assessments that would be used to determine eligibility for the draft. A committee was formed to identify ethical issues that would be effective in guiding the psychologist s practice as well as their behavior. It covered concepts that include as the psychologist s responsibilities when treating clients, training students, consulting colleagues, and ethical research practices (Hobbs, 1948). Through the years, other mental health organizations developed codes of ethics, and subsequent revisions, to address the continuing changes in society and the needs of their clients. The ACA can trace it roots to 1952 when independent member associations held a joint convention. These groups included the The National Vocational Guidance Association (NVGA), the National Association of Guidance and Counselor Trainers (NAGCT), the Student Personnel Association for Teacher Education (SPATE), and the American College Personnel Association. They established the American Personnel and Guidance Association (APGA) to form a professional group uniting all counselors. A Code of Ethics was first developed and adopted in In 1983, the association adopted the name American Association of Counseling and Development that was compliment each other and both were developed to ensure privacy, confidentiality, and the well being of individuals and society. This course will review the Codes of Ethics from the National Board for Certified Counselors (NBCC), the American Counselors Association (ACA) and the American Association of Marriage and Family Therapy (AAMFT). These three codes will be summarized and similarities will be reviewed. These codes have been recently revised and should be reviewed in their entirety on their respective websites, which will be included in the resource section at the end of the course. changed on July 1, 1992, to the American Counseling Association (ACA). This new membership association unified the various counseling professions into one entity reflecting their shared goals, purpose, and commitment to ethical practice. The ACA developed a professional Code of Ethics that has been adopted by licensing boards who use the Code as the basis in counseling decision-making on ethical issues. The ACA Code has been revised every 7 to 10 years and the recent revision adopted in 2014 replaces the 2005 edition. Today the American Counseling Association services professional counselors in the United States and in 50 other countries, including Europe, Latin America, the Philippines, and the Virgin Islands. In addition, the ACA is associated with a comprehensive network of 19 divisions and 56 branches (ACA, 2014). The AAMFT was founded in1942, to address the needs and changing demands of couples and family relationships. The membership association supports research, provides education, tools and resources to provide effective services in the field of marriage and family therapy. Their goal is to ensure trained, ethical professionals meet the needs of clients and society. Today, the AAMFT is the professional membership association for the field of marriage and family therapy with more than 50,000 marriage and family therapists throughout the United States, Canada, and around the world. The National Board for Certified Counselors, Inc. and Affiliates (NBCC) is a not-for-profit, independent certification organization established in 1982 (NBCC, 2014). The organization was founded to create and maintain a voluntary national certification system and identify certified counselors by maintaining a registry of membership. Since then NBCC divisions and affiliates have expanded their commitment to include advancement of the profession with the goal of improving mental health around the world. Today, there are more than 55,000 National Certified Counselors (NCCs) in more than 40 countries. These counselors volunteer to obtain certification through a rigorous program to achieve high national standards, set by the profession based on research, written dissertations, and examinations. Certified NCCs are encouraged to mentor other counselors to improve their practice and obtain certification as an NCC. NCCs may be members of associations such as ACA and AAMFT depending on their area of expertise. One shared belief among therapists and counselors is that professionals will do the right thing and make ethical decisions in the best interest of the client. Trust appears to be the common thread throughout ethical counseling and marriage and family therapy practice. Tremble and Fisher (2006) note that it is not an external force that directs ethical practice, but a combination of internal forces such as trust and respect as a foundation for the practitioner-client relationship. Ridley (2001) provides an ethical decision-making model based on trust and respect in an effective counseling relationship, which is referred to as goodness of fit. The counselor-client relationship impacts ethical decision making Foundations and Shared Beliefs that considers the cultural context of the professional relationship and general ethical principles. Confidentiality is essential in developing an effective relationship between mental health practitioners and clients. Research supports the ethical principle in counseling and therapy that effective practice is based on trust and confidentiality between the practicing professional and client. The client may come to the counselor or therapist feeling vulnerable and seeking assistance in times of crisis. They may be fearful, ashamed, or unwilling to share their feelings at first. If the client believes that information they share will be kept confidential, there is a greater possibility of developing an effective collaborative relationship with the therapist and a positive outcome for the client. Page 2 Counselors.EliteCME.com

7 Over the last decade, ethical issues faced by counselors have received increased attention in counseling literature (Corey, Corey, & Callahan, 2003). Counselors are often confronted with situations that require sound ethical decision-making. Determining the appropriate course of action when faced with difficult ethical conflicts can be a challenge and should never be done in isolation. These codes are designed to protect clients and society. Counselors and therapists encounter ethical issues and challenges that require decisions and they must be familiar with ethics codes for their association. They must also know what areas and issues are problematic to avoid potential risks of ethical violations that may harm their clients and families. Client focus Counselors and therapists must be aware that their focus on the client s welfare before their own. The practitioner must understand their own needs, potential for imposing personal values and bias that may impact Right of informed consent Informed consent is an ethical and legal requirement and an integral part of any counseling and therapeutic process. Providing clients with information they need to make informed choices promotes the active participation of clients and families in the counseling plan, which is Confidentiality Confidentiality is a standard of conduct that forbids the professional from disclosing any information concerning clients. Statutes, such as laws enacted by legislatures, administrative law, regulations to implement legislation, or case law that interprets rulings by the court may also include components of confidentiality. Confidentiality is fundamental to the counseling and therapeutic relationship and represents a commitment and stated agreement not to disclose client information without consent. The ethics codes, state and federal laws provide some exceptions to confidentiality standards, which will be discussed. Confidentiality is based on our society s belief that individuals have a right to privacy and to decide what information they will share and with whom. Confidentiality is an ethical principle, which holds the practitioner responsible for respecting the client s privacy and protecting information disclosed during therapy. Both the code of ethics and the HIPAA Privacy Rule provide explicit, detailed, Confidentiality in group counseling Providing services to a family or group presents ethical challenges when the practitioner works with multiple clients at the same time. In these situations, the counselor or therapist must inform all members of the group concerning their rights to confidentiality at the onset of services. This includes a statement that the practitioner will not disclose any information that one family member offered in a private discussion. Some practitioners decide to eliminate this from occurring by meeting only in a group setting with the family and never with one member individually. The practitioner working with a family or group may have to assess progress frequently, as new issues may emerge that need to be addresses and added to the written services agreement. Interventions that were planned for one member of the family may not be appropriate for others or may have a negative effect on some members. The practitioner must always maintain their view of the family as a unit and not appear to focus on one member of the group and keep everyone informed of their obligation to maintain confidentiality. Informed consent is an ongoing process as the treatment plan or service agreement evolves. Ethics in counseling and therapy focuses on ideals rather than obligatory rules and emphasizes the character of the professional and their relationship with the client. The study of ethics is more that solving a specific ethical or legal dilemma. Although ethics codes speak to many issues, the counselor must recognize that these codes are broad and do not cover all ethical issues faced by counselors and therapists. The professional s ethical awareness, behavior, and problem solving skills will determine how they translate and apply these general guidelines to professional practice. Welfel (2002) concludes, ethical codes are not cookbooks for all ethical problems and in fact the codes are silent on many ethical issues. service to clients. Professionals have a responsibility to continually work to expand self-awareness and recognize areas of bias, prejudice, and vulnerability. critical for a positive outcome. Inform consent educates clients about their rights and responsibilities and builds client empowerment for a trusting, collaborative relationship with the therapist or counselor. provisions that cover client consent for disclosure of information and which entities can receive information. Privileged communication, resulting from a therapy or counseling session, is a legal concept that protects the client from having confidential information disclosed without their consent. Confidentiality in the professional-client relationship is consistent with the mission to serve as an advocate for the client and greater society. Confidentiality as addressed in ethics codes and case study examples of violations will be presented in this course. The Tarasoff vs. University of California (1976) case, and resulting legal action, led to revisions to the codes of ethics. This precedent setting case, and others that will be reviewed in this course, have led to changes in many state laws concerning release of confidential information, duty to warn, and protection from harm. In most cases, the initial contact to the therapist or counselors office for assistance is made by one of the group members. The other members may not share their desire or commitment to participate in the treatment plan. Informed consent by all group members is particularly important in these situations especially with minors that cannot legally give consent. The reluctance on the part of some members may complicate the delivery of effective services including maintaining confidentiality. The therapist or counselor will need to take additional steps to avoid being viewed as biased toward one member over another. They will have to work to gain the trust of all members so each will participate in the process, feel comfortable sharing their feelings, and honor the rule of confidentiality. The therapist or counselor should avoid contact with any members outside of the professional setting to avoid any appearance of favoritism and potential ethical boundary violations. When counseling groups or families, confidentiality is difficult to accomplish because the multiple clients have different behaviors, levels of maturity, affiliations, loyalties, attitudes toward the counseling, and varying levels of commitment to keep information Counselors.EliteCME.com Page 3

8 from the group sessions private. In all codes of ethics, there are statements that guide the counselor to build commitment to confidentiality: Inform all clients in the group of the rules of confidentiality. Define the parameters of the specific group. Identify who the client is in the counseling setting. Discuss how confidentiality matters will be addressed. Determine how information by one member may be disclosed to other members by the counselor. Discuss how to disclose information that was previously held as secret in the group counseling session. Provide rules for communication, fairness, and respect in the group. Explain that confidentiality cannot be guaranteed in the group setting. The ACA suggests that counselors seek consensus and document in writing the confidentiality agreements among all parties involved in the group counseling setting. These documents should include consent agreements concerning the rights of each individual to confidentiality and any obligation to preserve the confidentiality of the information disclosed (ACA, 2005). The AAMFT notes that as with other information shared in a counseling setting, marriage and family therapists: Do not disclose client confidences except by written authorization, waiver or when mandated by law. Do not take verbal authorization except when permitted in an emergency situation or when ordered by law. Do not disclose information outside the treatment context without a written authorization from each individual competent to execute the waiver. Must disclose to clients the nature of confidentiality and the possible limitations of the clients right to confidentiality. Review with clients the circumstances where confidential information may be requested and when it can be disclosed. Understand the circumstances that may necessitate repeated disclosures. May not reveal any individual s confidences to others in the client group without the prior written permission of that individual (AAMTF, 2001). As previously stated, the information above serves as a guideline only. The entire AAMFT Code of Ethics must be reviewed to understand the complex nature of confidentiality in group therapy. The NBCC 2012 Code of Ethics includes the following directives: When conducting counseling with more than one client at a time discuss with clients the nature, rights and responsibilities as well as the possible limitations of confidentiality. Describe the steps to take if the multiple client sessions create issues between clients. Designate in writing the primary client in the record. Identify in the record individuals who are receiving related professional services. When working with minors or individuals who are unable to give informed consent, discuss relevant considerations regarding the preferences of the individuals receiving services and legal guardian s rights and obligations. This information shall become a part of the client s record. Confidentiality laws with a minor or incapacitated client Federal and state laws mandate reporting of suspected child abuse or neglect and the statutes require the protection of others who may not have the ability to protect themselves such as elderly individuals or those residing in institutions. Counselors and therapists working with these clients are mandated reporters and must study state law that details procedures for reporting abuse including the required time limits and representatives to contact including phone numbers. Counselors and therapists must provide informed consent to their minor or incapacitated clients and discuss the rules of confidentiality at their developmental or cognitive level. The language used must be appropriate so that they will understand that there are times when parents, guardians or other officials must be notified concerning information they share. A statement should be included in the plan of service that indicates what was told to the client and that the practitioner took steps to inform them of disclosure in the following situations: If they report they are being abused. If they say they plan to hurt themselves. If they say they plan to hurt others. The practitioner should have expertise in working with these clients and should have competence in communicating with them. If they believe any of the three indicators of harm are credible they need to follow the appropriate steps for reporting abuse or neglect and to warn others if the threat is deemed a serious one. The rules that govern the actions to take in these cases vary from state to state so the practitioner must follow the mandates of their jurisdiction of practice and license as well as the code of ethics. Case studies and additional considerations will be covered in subsequent sections. The confidentiality requirement of non-disclosure does not apply when imminent danger to the client or others exists. This duty to warn from the Tarasoff case in California has been added to many states laws across the nation. The laws may vary concerning therapist s obligation to warn. Variations across the states include: Whether the practitioner must, warn of imminent danger or may, warn of imminent danger. What constitutes serious and foreseeable danger and imminent danger? Which individuals must be given a warning of imminent danger and when? What circumstances warrant the therapist s obligation to warn of imminent danger? Does the practitioner have to have first hand information of the danger or can a credible source inform them. Who is a credible source? What is the practitioner s assessment of danger conflicts with opinions from medical or law enforcement personnel? Is the practitioner legally accountable if he issues a warning and danger was not imminent? The ACA (2014) general requirement that counselors keep information confidential does not apply when: Disclosure is required to protect clients or identified others from serious and unforseeable harm When legal requirements demand that confidential information must be revealed When the counselor is in doubt as to the validity of the exception and must consult other professionals Additional considerations apply to address end-of-life and child welfare issues (ACA, 2014). The statements above are addressed in detail in the ACA Code of Ethics, which must be studied in its entirety to understand the complexities of confidentiality between the client and the counselor. The NBCC Code of Ethics provides the following directives: NCCs, recognizing the potential for harm, shall not share information that is obtained through the counseling process without specific written consent by the client or legal guardian except to prevent clear, imminent danger to the client or others or when required to do so by a court order. NCCs who provide clinical supervision services shall keep accurate records of supervision goals and progress and consider all Page 4 Counselors.EliteCME.com

9 information gained in supervision as confidential except to prevent clear, imminent danger to the client or others or when legally required to do so by a court or government agency order. The AAMFT Code of Ethics includes the following standards: Marriage and family therapists disclose to clients and other interested parties at the outset of services the nature of confidentiality and possible limitations of the client s right to confidentiality. Therapists review with clients the circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. Circumstances may necessitate repeated disclosures. Multi-cultural issues A major focus of the ACA Code of Ethics revision of 2005 was multicultural diversity competency and has been expanded in the revised 2014 code. It is a major component of the NBCC and AAMFT ethics codes as well. As the population increases in multicultural diversity, therapists and counselors must consider personal values and bias. Cultural influences define reality in many ways and must be recognized and appreciated in order to build trust and collaboration for effective counseling and therapeutic relationships. Cultural influences are complex and have given rise to a variety of counseling and therapy styles. Marriage and family therapists may work with client groups that represent multiple sexual orientations, genders, cultures, ethnic, racial, generational and religious groups so multi-cultural diversity awareness and acceptance is central to effective therapy. Ethical challenges in multicultural diversity may begin with the validity of assessments because appropriate evaluation tools may not be available. It is difficult, if not impossible, to locate a culture fair or culture free method of assessment. The counselor must be trained to interpret data from assessments within the context of the client s culture (Paniagua, 2001). The client s cultural identity impacts assessment, communication, client goals and methods of service so counselors must expand their repertoire of strategies and skills to be effective in a variety of cultural contexts. Problems may also arise when making a diagnosis in a multicultural context when using the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). There are many cultural beliefs and experiences that are normal for the client s culture, but viewed from a western perspective, may seem pathological (Pedersen, 2007). Clearly, it is impossible to be an expert in working with all cultures and many researchers in this field say it is more important to look and the Non-traditional family groups The professional today will encounter a variety of non-traditional families and groups. Same-sex parents; multi-racial families; heterosexual, transgender, and same-sex family members; biological and step parents; and children within these groups. Today there is no typical family group and each person in the family may face issues related to their unique family composition. These issues may include discrimination, bullying, loss of employment, child custody issues, antigay prejudice or violence, feeling ostracized or isolated in the community, and feeling devalued by society. The family or group counselor or therapist should acquire specialized skills and experience to understand the complexities of non-traditional family groups to practice in a non-judgmental and supportive manner. The following issues may present: Sexual or gender orientation within the family group may lead to prejudice, discrimination or bias in the community. Minority sexual orientation or gender issues may be the focus in custody issues the family is facing. Marriage and family therapists do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law. When providing couple, family, or group treatment, the therapist does not disclose information outside the treatment context without a written authorization from each individual competent to execute a waiver. Marriage and family therapists store, safeguard, and dispose of client records in ways that maintain confidentiality and in accord with applicable laws and professional standards. universal principles and standards that are at the core of therapy and counseling. These are basic human rights and the promotion of mental health to reach an individual s full potential. A counselor should be able to work beyond their cultural beliefs and social systems and strive to understand the client s from their viewpoint and be aware of external influences that impact the client when developing service plans. There are many training and educational programs to build diversity competence and help the practitioner appreciate social and cultural influences that shape the client s view of the world. Practitioners who do not consider these influences may incorrectly evaluate or label the client and risk diagnosing behavior as pathological or impaired though it is an accepted and normal practice in the client s culture. Multicultural awareness in counseling and therapy is critical for the counselor to communicate effectively in a way that is culturally sensitive. They must consider the effects of the client s culture in all phases of the service plan to deliver effective services. In addition to training and educational programs, the practitioner should increase their multicultural competence through hands on experiences with local cultures in their community of practice. This could include attending special events, volunteering, consulting professionals in the community, participating in workshops, advocacy programs, and discussion groups along with consulting supervisors or other colleagues who have experience with the community. These activities, combined with guidelines from the code of ethics, may help practitioners develop competencies to serve clients from diverse cultures. The practitioner must identify and understand their own cultural perspective as it impacts their practice with diverse populations. Co-parenting and blended families may present added stress to all family members. Children may face issues at school or in the community due to their family composition. Same-sex or transgender couples may be dealing with discrimination related to adoption or conceiving a child through a surrogate. There may be conflicts between the biological parent and a stepparent who now has custody of the child. Extended family may not accept the non-traditional family members. Parents may need support in helping their children feel confident and comfortable with a lifestyle that contradicts what they see and experience outside of the home. The parents made need strategies to help their children face discrimination, isolation and negative stereotypes they may encounter. Teens and children may face challenges due to their sexual or gender identity. Counselors.EliteCME.com Page 5

10 It may take additional time to build a trusting collaborative relationship with members of the group to overcome their reluctant to share their feelings due to negative, judgmental experiences they may have had in the past. Technology-assisted services This decade has presented a new area of ethical concern that affects every mental health organization today. Computers and other forms of technology are the standard method for recording storing, retrieving, and transmitting patient information, clinical records, session notes, insurance information, evaluation results, and all other data involved in a client s case. Massive amounts of information can now be stored on increasingly smaller and more portable electronic devices, providing audio and visual records of every part of the therapeutic and counseling service with clients. The convenience, ease of use, and portability of these systems can unfortunately lead to confidential information being stolen, lost, or transmitted accidently. The constant upgrades and expansion among these systems leads to more possibility of privacy violations and other ethical concerns for maintaining confidentiality in cyberspace. Interception of messages, by unauthorized parties, is a widespread problem and a violation of client privacy. Some companies and agencies feel justified in monitoring worksite accounts and Internet use because they view employee accounts as company property and part of the technology infrastructure. The other justification they claim is to determine if personal business is being conducted on work time or if inappropriate Internet sites have been accessed. One example is the school system that flags certain words and content to monitor student and faculty use. If a school counselor or therapist reports to the Principal that a child threatened to kill themselves, in an the word kill would be red flagged by the county technology monitor in an office in another city and trigger an investigation by individuals outside of the counseling relationship. Technology has taken therapy and counseling out of the office and across geographic borders allowing a practitioner to work with clients from any location at all times of the day and night. This may be convenient for both parties but it opens up many opportunities for a breach of confidentiality and privacy rights, which will be covered in detail in subsequent sections. In addition to crossing geographic boundaries, technology leads to boundary issues that cross the line from professional to personal with clients. Counselors and therapists may have websites and social media pages that are professional in addition to personal online pages. The two types must be kept separate at all times to maintain the appropriate boundaries with clients. An example might be a Facebook page that can be used for professional purposes while a profile can include personal information that may include interactions with friends. Of greater concern is the publishing or posting of information and photos by others that the therapist cannot control. The counselor or therapist should always be aware of information or pictures online for all to access and the lack of security and control of anything posted online. The ethical decision-making model Ethical decision-making is a process that involves the informed judgment of the counselor and therapist. The codes advise that there will be issues with clients that contain ethical questions for which there are no simple answers. The practitioner should consider how their actions would be judged in a peer review process and what ethical standards would apply. The codes stress that the practitioner should seek consultation, from professionals in their employing organization, state board, or professional association regarding ethical decisions and never to act alone. A member of the family may be questioning their sexual orientation, gender or in transition and need support through the process. The family made need services to help them adjust to the changes in the family. Practitioners need to use caution with all communications online including s, text messages, blog, tweets, photos, and other social media posts, and review them frequently. The online presence must be professional and cannot cause harm to a clients or anyone viewing the information. Professional counselors and therapists would not cross boundaries and interact as friends in real life but clients and others may become confused online with terms like friending on Facebook, which the professional should never do. If personal information or status with someone is posted on Facebook, it is open to be reposted and seen by anyone associated with the person that reposted the information. Any counselor or therapist with a professional website, networking site or social media page should review their code of ethics as well as any state law that regulates technology or practice within and outside the state boundaries of the professional license. In recent years, many systems have been compromised, hacked, or cracked resulting in lost or stolen personal, medical, and financial information. The practitioner can never be completely confident that they can protect the privacy rights of clients when using technology for communication or distance service. Practitioners must follow numerous safeguards and be extremely vigilant when using technology in their practice. Revisions to the code of ethics in all professional associations for counselors and therapists address the benefits and risks of technology use and the provision of distance services. The use of technology affects the components of confidentiality, privilege, legal jurisdiction, client safety, duty to warn, and the quality of the practitioner-client relationship. HIPAA laws provide extensive regulation of information gathered, transmitted, and stored using all forms of technology including audio, visual, computer, fax, and phone. The expanded use of technology and social media in service delivery brings many ethical conflicts to the forefront that was not addressed in previous ethical codes. The revised codes in this course contain guidelines in this area but as the technology continues to change the therapist and counselor must remain vigilant, review the sections on ethical technology use, and collaborate with other professionals to make sound ethical decisions. The course will address the guidelines in codes of ethics and the requirements in the HIPAA Privacy Rule that govern the use of new technology and social media to prevent unintentional or accidental violations of privacy. In addition, the counselor and therapist must maintain close contact with their professional associations for further code revisions and guidance and stay informed of any changes in state and federal law related to informed consent, confidentiality and duty to warn and privacy when using technology. In the decision-making process the practitioner must review the values, principles, and standards and apply their knowledge of the code of ethics for their association and the standards and principles of their employing organization employer. When codes do not contain information on a particular issue, the practitioner is still responsible for making correct ethical decisions to protect the welfare of the client. The responsibility of making the correct ethical decision is complex with serious ramifications for the client and practitioner. A sound ethical decision-making process must Page 6 Counselors.EliteCME.com

11 be applied that will lead the practitioner, with assistance from other professionals, to resolve the ethical conflict in accordance with the code of ethics. Reasonable differences of opinion may exist among professionals as they seek to apply values, principles, and ethical standards to resolve the conflict. There are many models for ethical decision-making model but none that is deemed most effective. Professional counselors and therapist are expected to be familiar with credible models of decision-making that involve the professional team and will withstand peer review and public scrutiny. When no clear answer is apparent after reviewing the code, or conflicts arise among the team concerning interpretation, it is time to implement an ethical decision making model. As the team works through each phase of the decision-making process, and applies their professional expertise to the ethical issue, they will be empowered to resolve the conflict in the best interest of the client. The decision-making model that is used most frequently and complements most of the professional codes of ethics is an eight-step model (Corey, Corey, and Callahan (2004). The eight steps are: Identify the problem or dilemma. Identify the potential issues. Look at relevant codes of ethics for general guidance. Consider applicable laws and regulations, and determine how they may have bearing on an ethical dilemma. Seek consultation from more than one source to gain multiple perspectives on the dilemma. Brainstorm various courses of action. Enumerate consequences of various decisions. Implement the course of action. The professional team should be allowed the appropriate time and resources so that all stakeholders feel confident in the decision they reach to resolve the ethical issue. At any point, the members should discuss the issue with their supervisors, administrators or professional associations to include them in the process. Current ethical codes A revision of the ACA Code of Ethics was completed in 2014 and contains changes that will impact professional counselors across all settings and specialties. The revised 2014 ACA Code of Ethics is the first new edition since 2005.The AAMFT Code was revised on January 1, 2015 and the NBCC Code in June The major change in the new codes addresses the use of technology for distance counseling and social media for communicating with clients. The code covers guidelines to address ethical considerations for confidentiality, client verification, and effectiveness of therapy that must be considered while using these new forms of service delivery with clients. Other new additions in the codes provide guidance to avoid any influence or bias toward clients based on imposing the counselor s personal values. The new codes replace all others and provide additional guidelines for ensuring confidentiality, maintaining boundaries in dual relationships, increased focus on multicultural diversity, safeguards for recordkeeping and securing information, assessment and diagnosis of mental illness and the selection of interventions. The growing population of clients older than age 60 years led to the inclusion of guidelines in the codes to handle counseling issues and ethics related to end-of-life care, managed care, and Medicaid/Medicare. Payment for services for these clients is particularly complex. Services have been expanded through the federally mandated Affordable Care Act (ACA), though some states have opted out of paying for additional services not covered under the ACA. Some states with a large population of citizens older than 65 years have opted out of funding additional Medicaid and Medicare After the team has decided and agreed on a course of action and the plan to move forward, they should review the plan to see if it presents any new considerations involving ethics and client welfare. Stadler (1986) suggests applying three simple tests to the course of action to be sure it is appropriate. The three tests are: Justice This test assesses fairness by asking if the decision and treatment would be extended to other clients in a similar situation? Publicity-Would the practitioner allows the ethical decision or course of action to be reported by the press? Universality- Could they recommend the same decision and course of action to another counselor in the same situation? If the team believes they can meet all three tests, they should feel confident that their decision is ethically sound and the practitioner can move forward with the client. When one or more of the tests cannot be answered in the affirmative, the team should analyze the reasons why their decision has failed in that test. Then they can revisit the decisionmaking process to review the part of the test that has not been met and pinpoint the part of the plan that is not just, would not hold up under public scrutiny or lacked universality, for example. In every client, the practitioner should apply formative evaluation methods periodically to monitor and judge the effectiveness of their services as they progress through sessions with the client. This is especially important when implementing a new decision or plan to resolve an ethical issue. The evaluation may be informal and answer the following questions: Did the course of action based on the decision result in the anticipated effect? Did positive consequences result from the decision or course of action? Was the decision or course of action aligned with the plan of service? Did the decision or course of action promote the clients goals? Is the course of action in the best interest of client welfare? Is the client positive and participating in the course of action? Is there anything that should change in method or practice to be more effective for the client? programs, which affects payment for mental health services, including counseling and therapy. A review of the ethics codes for the National Board for Certified Counselors (NBCC), the American Counseling Association (ACA), and the American Association of Marriage and Family Therapists (AAMFT), reveals similarities in the values, principals, and standards that guide their professions. All have the mission to enhance human development and well being, recognize diversity, promote self worth, dignity, potential, and independence for all people within their social and cultural contexts. These associations have ethics codes that apply to scientific, educational, and professional roles. They share common terms and definitions and are based on the premise that the client s welfare always has the highest priority. These codes clarify the ethical responsibilities of professional practice and provide guidelines when professional obligations conflict or ethical uncertainties arise. The code for each association includes information in the following areas: Building trust for effective, collaborative client relationships Communication, informed consent, privacy, and confidentiality Multicultural diversity in practice Professional responsibility for ethical behavior and practice Evaluation, assessment, and interpretation of data Ethical use of technology and social media Training, teaching, and supervision Research and publication Counselors.EliteCME.com Page 7

12 Relationships, consultation and ethical responsibilities with colleagues and other Professionals Ethical responsibilities to society Resolving ethical issues, complaints, or inquiries. This course will review and discuss key elements of the codes of ethics for marriage and family therapy and professional counseling, ethical decision-making, and the association s policies and procedures for addressing ethical complaints. It is not a comprehensive guide for compliance or a source of legal information or advice. The codes of ethics state that they do not cover every possible ethical dilemma that the therapist or counselor may face in their practice. The practitioner must seek professional assistance and collaboration as directed by their association and refer to code guidelines on a regular basis. In addition, all professional associations provide assistance for questions related to ethical practice and contact information will be included. Counseling and Marriage and Family Therapist associations, NBCC, ACA, and AAMFT, have terms and definitions in common that are seen throughout their ethics codes. Some of the most commonly used terms and their definitions are: Abandonment the ending or termination of a counseling or therapeutic relationship that harms the client or puts them at risk. Advocacy actions to promote the welfare of individuals and groups to remove barriers and increase access to reach their full potential. It includes supporting policy changes to promote these goals for all individuals. Assent actions that indicated or demonstrate agreement when a person is not capable or competent to give informed consent. Bartering goods or services that are accepted from clients in exchange for counseling or therapy services. Client individual or groups at the point where they make contact and ask for services Client record the paper or electronic system containing all information gathered and stored throughout service delivery. This may include written, electronic audio, and video records. Clinical supervision guidance, mentoring, education, coaching, and monitoring by a practicing professional to enable the development of professional skills and facilitate learning in application of skills to practice settings. Competency therapists and counselors provide services only within the boundaries of their expertise based on education, training, license, certification, and experience. Confidentiality the ethical duty of counselors to protect client identity, communications or any information related to the relationship with clients. Consultation a professional collaboration that includes advice, information, assistance, support or testimony. The codes promote professional consultation. Counseling a professional relationship that provides assistance to diverse individuals, families, and groups of all ages to enhance mental health, wellness, education, and career goals. Counselor educator a professional counselor engaged in developing, implementing, supervising, monitoring, and evaluating the educational preparation of professional counselors. Counselor services agreement written document that inform the client of the terms and conditions of the counseling or therapeutic service. This includes potential benefits and risks. Counselor supervisor a licensed, practicing counselor in a formal professional relationship with a student counselor or counselor-in-training to oversee the individual s counseling work or clinical skill development. Culture the customary beliefs, social norms, institutions, behavior patterns, values, and lifestyles of a particular community or group. Terms and Definitions Deceptive methods any methods used in which clients are unaware misinformed and denied informed consent. Digital technology digitized information recorded in binary code of combinations of the digits 0 and 1, called bits, which represent words and images. Digital technology enables immense amounts of information to be compressed on small storage devices that can be easily preserved and transported including the Internet, digital mobile devices, and systems used in communication and social media. Discrimination to make distinctions or to differentiate based on preference or prejudicial views of an individual or group. Distance counseling the therapeutic or counseling services delivered without physical proximity to the client using technology as the point of access. Diversity the differences and distinct qualities within cultures and social groups. Documents written, digital, or audio/ visual records of client information within the counseling or therapeutic relationship with clients. Encryption process of encoding information to protect identity and block access by unauthorized parties. Examinee the client being assessed for the purpose of determining psychological, educational or developments levels to inform the counseling or therapeutic process. Exploitation unethical actions for one s own advantage. Fee splitting the division of payment for referrals or services. Forensic evaluation assessment to inform professional knowledge to prepare for testimony legal proceedings. These reports due not fall under HIPPA guidelines and may cover evaluations for determining child custody decisions, competency to stand trial, and criminal culpability. Harmful multiple relationships relationships outside of the professional relationship that do not protect the welfare of the client and erode ethical practice of counseling and therapy. Impairment a diminished strength, value, fitness, and quality that renders the professional incapable of delivering ethical services to clients. Informed consent a process of advising clients on all aspects of the counseling or therapeutic process prior to services. This includes all benefits, risks, rights and responsibilities, and explanations required by the client to understand all phases of the treatment and make a decision to consent or decline the service. Adjustments may be required as the service progress so consent must be revisited. Intellectual property original work, invention, or creation, to which one has rights of ownership. Interdisciplinary teams teams of professionals who collaborate to serve clients from variety from applicable areas of expertise. The team should be in agreement with the counselor and therapist regarding confidentiality. Page 8 Counselors.EliteCME.com

13 Minors individuals younger than the age of 18 years; however, the age will vary according to state statute. In some jurisdictions, minors may have the right to consent to counseling or therapy independent of the parent or guardian. Multicultural/diversity competence an approach to counseling or therapy from the context of the personal culture of the client. Multicultural/diversity counseling professional services that accommodate differences in religion, spirituality, sexual orientation, gender, age and maturity, socioeconomic class, family history and emphasize the worth, dignity, potential, and uniqueness of individuals. Non-counseling relationships all relationships that exist outside of the context of the professional counseling practice. Personal virtual relationship a relationship that exists through technology or social media that is outside the professional boundaries for therapy or counseling. These relationships should be avoided and lead to unethical practice. Privacy the right of an individual to control their personal information and avoid unauthorized disclosure. Privilege a legal term denoting the protection of confidential client information in a legal proceeding, including subpoena, deposition, and testimony. Pro bono publico contributing professional services for without regard for financial gain. Professional virtual relationship using technology and or social media in the delivery of professional, ethical services to clients. Psychosocial interrelation of social factors and individual thought and behavior. Records custodian the person responsible keeping records in the ordinary course of the practice. In some organizations, the custodian is responsible for the accuracy and security of records following all ethical guidelines and legal requirements. Self-growth a process of self-examination and professional development to enhance professional competence. Serious and foreseeable a concept used in negligence tort law to limit the liability of a party to those acts carrying a risk of foreseeable harm, meaning a reasonable person would be able to predict or anticipate the harmful consequence of their actions. Sexual harassment unwanted and offensive physical, verbal, or non-verbal sexual conducts in a workplace, professional or social situation. Social justice equity for all people, including the distribution of wealth, opportunities, and privileges within a society to end oppression and provide access in communities, schools, workplaces, governments, and other social and institutional systems. Social media websites and applications that enable users to create and share content communicate or participate in social networking. Subpoena duces tecum a writ ordering a person to appear before the court and bring relevant documents other tangible evidence for use at a hearing or trial. The National Board for Certified Counselors (NBCC) certifies licensed counselors who volunteer to enter the program from a variety of specialty areas and professional associations. NBCC offers general counselor certification as well as a choice of specialty areas in accordance with the counselor s specific practice. The NBCC Code of Ethics is applicable to all NBCC applicants and National Certified Counselors (NCCs) regardless of their area of practice or choice of professional association membership (NBCC, 2014). According to the organization, the NBCC Code represents standards for ethical behaviors and seeks to provide assurance of ethical behavior among counselors that provide professional practice as an Summary of the NBCC Code of Ethics NCC. The standards in the code provide directives for ethical behavior and practice and all NCC are expected to follow the Code in their service to clients. The Code serves as a resource for the professional counselor and provides recourse for clients that suspect an ethical violation has occurred by NCCs. Applicants and credentialed NCC holders under this Code will be sanctioned by the NBCC if the association determines that any directive or standard in the NBCC Code of Ethics have not been followed, which constitutes an ethical violation. The NBCC is available to assist in ethical decisions and can be contacted by phone at or by at ethics.nbcc.org. A summary of directives from the NBCC Code of Ethics The following information is a summary of the Code and it may be of termination of counseling or supervision with clients or with viewed in it s entirety on the NBCC website nbcc.org. former clients. NCCs take appropriate action to prevent harm. Do not engage in sexual harassment. Take proactive measures to avoid interruptions of counseling services. This includes the following directives: Create written procedures regarding the handling of client records Recognize the potential for harm. that must be kept confidential except to prevent clear, imminent Share information from the counseling process only with consent danger to the client or others or when legally required to disclose in writing from the client or legal guardian, or when ordered by by a court or government agency order. the court. Protect client s confidentiality and unnecessary invasion of privacy Respect client s privacy and solicit only information that when seeking consultation by providing only the information contributes to counseling. relevant to the topic of consultation and protect client identity. Do not accept goods or services from clients in return for Protect the welfare of research participants by taking precautions counseling services. (See Code for extenuating circumstances.) to prevent negative psychological or physical effects. Do not accept gifts from clients, except in cases when it is Recognize the potential harm of technology and the use of culturally appropriate or therapeutically relevant. social media with clients, former clients, their families, and Avoid entering into harmful multiple relationships with clients, personal friends. students, or supervisees, including any form of sexual, romantic, Develop written practice procedures and obtain consent when or intimate encounter. This is in effect for 2 years after the date using digital technology and social media. Counselors.EliteCME.com Page 9

14 Avoid the use of social media, including updates, tweets, and blogs that include confidential information regarding client cases without consent from the client. NCCs provide only those services for which they have education and qualified experience. Counselors perform only those professional services for which they are qualified by education and supervised experience. Seek professional assistance or withdraw from practice if mental or physical conditions render the counselor unable to provide services. Seeking supervision, consultation, and collaboration with qualified professionals when unsure about client treatment or professional practice responsibilities. Use or interpret only the specific tests and assessments for which they have the required education and supervised experience. NCCs shall demonstrate multicultural competence and shall not use techniques that discriminate against or show hostility towards individuals or groups based on gender, ethnicity, race, national origin, sexual orientation, disability, religion, or any other legally prohibited basis. Techniques shall be based on established theory NCCs promote the welfare of clients, students, supervisees, or the recipients of professional services provided. Discuss with prospective clients the appropriateness of counseling services offered and do not offer services if there is reasonable cause to believe clients will not benefit. Promote the welfare of supervisees by discussing ethical practices relating to supervision and the legal standards that regulate the practice of counseling. Request assistance and consultation to promote client welfare. Limit the use of tests and assessments for use in a given situation or with a particular client. Protect the confidentiality and security of tests or assessments, reports, data, and any transmission of information in any form. NCCs communicate truthfully Represent qualifications and counseling credentials accurately. Report all assessment, test and evaluation results accurately and avoid making decisions based on a single assessment. Include all electronic communications exchanged with clients and supervisees, as well as information obtained through digital technology or social media methods, as part of the client record. NCCs recognize that their behavior reflects on the integrity of the profession as a whole and avoid actions, which can reasonably be expected to damage trust. Retain client records for a minimum of 5 years unless state or federal laws require additional time and dispose of records in a manner that protects client confidentiality. Act in a professional manner by protecting against unauthorized access to confidential information. Disclose only the required confidential client information when ordered by a court or governmental agency. Retire or depart from practice only after notifying current and former clients. Refrain from conducting forensic services with current or former clients, client s family members, friends, own family, or colleagues. Never misuse professional influence at the expense of client welfare. Limit use of information obtained through Facebook, LinkedIn, Twitter, or any other form of digital technology or social media. NCCs recognize the importance of and encourage active participation of clients, students or supervisees. When conducting counseling with more than one client at a time the NCC will discuss the nature, rights and responsibilities, possible additional limitations of confidentiality, and the steps that they will take to ensure confidentiality. Inform clients of the purposes, goals, procedures, limitations, potential risks, and benefits of services and techniques prior to or during the initial session. Respond to client requests for access to or copies of records within a reasonable and practical timeframe. If the NCC is aware of another professional s unethical behavior they will first attempt to resolve issues through reasonable means except when state regulations require immediate reporting. Work collaboratively with clients to create written plans of treatment with attainable goals and appropriate techniques. When working with minors or individuals who are unable to give informed consent, discuss relevant considerations regarding the preferences of the individuals receiving services and legal guardian s rights and obligations. Discuss service termination with clients when there is a belief that the clients are no longer benefiting from or are unlikely to benefit from future services. Do not terminate counseling services without good cause or justification and without an appropriate referral. Provide critical information to potential research subjects that will assist them in reaching a determination about participation. Do not employ deceptive techniques in research unless there are no alternatives and there is significant scientific, educational, or clinical value. Review potential techniques and not use any that can be reasonably expected to cause harm, as well as provide an explanation to participants during the debriefing. Always consider ethical implications, including confidentiality and multiple relationships, prior to conducting research with students, supervisees, or clients. NBCC Standards for the Ethical Practice of WebCounseling The Board of Directors for NBCC addressed the potential impact of computers on the counseling profession beginning in The NBCC adopted the Standards for the Ethical Practice of WebCounseling, which was the first time a national association in the mental health profession had addressed standards in this critical area. Technology is constantly changing so the NBCC Board of Directors continues to review and revise the standards and policies. The Board approved the current revision in 2012 to guide the practice of online counseling. The entire document should be reviewed at the NBCC website before proceeding with distance services. This course provides the following summary of the fundamental concepts and standards and may be viewed on the NBCC, 2014 website: The NBCC Policy Regarding the Provision of Distance Professional Services replaces previous editions. Distance professional services involve the use of electronics to provide services, such as counseling, supervision, consultation, or education. NBCC recognizes that some counselors provide a combination of face-to-face and distance services even in the context of one particular client or supervisee. Standards described in this policy supplement the National Board for Certified Counselors (NBCC) Code of Ethics. Page 10 Counselors.EliteCME.com

15 Standards for distance professional services All NCCs shall: Adhere to policies and procedures including the Code of Ethics. Provide only services are qualified for by education and experience via distance means. Adhere to legal regulations before providing distance services, including the state where the counselor is licensed and the state where the client is located. Ensure that any electronic means used in distance service provision are in compliance with current regulatory standards. Use encryption security for all digital technology communications of a therapeutic type. Prevent loss of digital communications or records and maintain secure backup systems. Screen potential distance service recipients for appropriateness to receive services via distance methods. Provide potential recipients with a detailed written description of the distance counseling process and service provision Adopt behaviors to prevent the distribution of confidential information to unauthorized individuals. Provide recipients of distance professional services with information concerning their credentials and links to the respective credentialing organization Web sites. Summary of the NBCC ethical complain process In 2012, the NBCC developed a process to review alleged ethics violations by their NCCs and administer discipline if warranted. NCCs are bound by the decisions by NBCC, which are governed by the laws of North Carolina. They are very detailed and for the purpose of this course will be outlined. NCCs should have complete knowledge of these procedures and frequently visit the nbcc.org website to review the entire ethics section. Section A: General NBCC Process: These procedures identify the means to resolve ethical concerns regarding an applicant or certificate s conduct and are not formal legal proceedings. Section B: Informal Resolution Cases Appropriate for Informal Resolution: The director of ethics will make a decision concerning the likelihood that the matter can be resolved fairly without formal disciplinary proceedings. Unsuccessful Informal Resolution: In the event of unsuccessful informal resolution, the director of ethics will refer the case for resolution consistent with these procedures. Section C: Submission of Statement of Ethics Grievance A grievant other than NBCC must complete a Statement of Ethics Grievance, including all information required by the form and submits it to the director of ethics. Section D: Acceptance or Rejection of Ethics Grievance Acceptance of Statement of Ethics Grievance: The NBCC director of ethics will review each grievance presented in the Statement of Ethics Grievance and then determine if it will become the subject of a formal ethics review. Appeal of Grievance Rejection: Within 30 days of the mailing date of a grievance rejection letter, the NBCC Ethics Case Procedures grievant may appeal the rejection. Section E: Initiation of Ethics Complaints and Inquires After a grievance is accepted for a formal inquiry, the director of ethics will issue an Ethics Complaint Notification identifying each term that may have been violated and the basis for each. Inform recipients of the purposes, goals, procedures, limitations, potential risks, and benefits of services and techniques including information about client rights and responsibilities Obtain a legal guardian s consent prior to the provision of distance services if the recipient of distance services is a minor or is unable to provide legal consent. Avoid the use of public social media sources to provide confidential information and provide in writing the appropriate ways to contact them. Provide recipients of distance services with specific written procedures regarding emergency situations. Develop written procedures for verifying the identity of the recipient. Limit use of information obtained through social media sources. Provide information concerning locations where members of the public may access the Internet free of charge. Retain copies of all written communications with distance service clients and limit the use of records to those permitted by law, professional standards and as specified by the service agreement with clients. Retain distance service records for a minimum of 5 years unless state laws require additional time. Develop written procedures for the use of social media and other related digital technology with current and former recipients. Section F: Response to the Ethics Complaint Notification Submitting an Ethics Complaint Response: Within 30 days of the mailing date of an ethics complaint notification, the respondent must submit a written response according to the instructions in the notification. Section G: Preliminary Actions Voluntary Temporary Suspension of Certification: At any time following the issuance of an ethics complaint, the respondent may be asked to agree to a temporary suspension of NBCC certification, pending the final resolution. Involuntary Suspension of Certification: If a respondent fails to agree to and sign a Voluntary Suspension Agreement, the Committee may involuntarily suspend the respondent s certification pending the final resolution of the complaint. Circumstances of Involuntary Suspension Actions: Suspensions are authorized where the respondent has been convicted of a criminal or quasi-criminal act, or the respondent has not contested a criminal indictment under any statute, law or rule or the respondent has been found in violation of any law, regulation or rule by a professional regulatory organization. Section H: Ethics Consultative Committee Ethics Consultative Committee: The NBCC president and CEO shall appoint a committee of individuals who serve as a professional resource for the director of ethics and the president and CEO. Section I: Complaint Resolution NBCC Director of Ethics Resolution of Complaints: The director of ethics will consider the matter under these procedures, resolve the ethics complaint, and issue a final decision and action. Section J: Decisions and Actions Decision of the Director of Ethics: A decision will be prepared by the director of ethics within 30 days of the closing of the case record, or as soon thereafter as practical. Counselors.EliteCME.com Page 11

16 Section K: Disciplinary Actions Disciplinary Actions Available: When a respondent has violated one or more provisions of the Code of Ethics, NBCC may issue a number of sanctions to suspend or revoke NBCC certification. Section L: Board of Directors Ethics Appeals Committee Board Ethics Appeals Committee: The Chair of the Board of Directors shall appoint three or more Board Directors to serve as the Board Ethics Appeals Committee, which shall be responsible for resolving all appropriate appeals concerning decisions of the director of ethics. Section M: Closing Ethics Cases Events That Will Cause Closure of an Ethics Case: An ethics case will be closed and all proceedings ended when the ethics case has not been accepted and the charges have been rejected as the basis for an ethics complaint pursuant to these rules, a final decision has been issued by the Appeals Committee, or an ethics complaint has been terminated or withdrawn by the grievant. Section N: Reinstatement Procedures Reinstatement Requests Following Certification Revocation and Suspension: 5 years after the issuance of a final revocation action issued under these rules, a respondent may submit a Request for Certification Reinstatement to the Board of Directors. A Summary of the ACA Code of Ethics Members are committed to serve all clients and recognize and Autonomy, fostering the right to control the direction of one s life. appreciate multi-cultural diversity. They work across cultures with Non-malfeasance, or avoiding actions that cause harm. the goal of increasing opportunity to maximize the potential of all Beneficence, or working for the good of the individual and society people. The code was not written to mandate how the counselor will by promoting mental health and well-being. practice but serves as a guide for professional behavior and ethical Justice, treating individuals equitably and fostering fairness and practice based on their commitment, values, and dedication to ethical equality. counseling. Fidelity, honoring commitments, and keeping promises, The 2014 revision will be summarized in this section. The complete including fulfilling one s responsibilities of trust in professional ACA Code of Ethics must be studied and can be found at www. relationships. counseling.org/resources/aca-code-of-ethics.pdf. Veracity, dealing truthfully with individuals with whom counselors come into professional contact. ACA Code of Ethics Preamble The American Counseling Association (ACA) is an educational, scientific, and professional organization whose members work in a variety of settings and serve in multiple capacities. Counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals. Mission The mission of the American Counseling Association is to enhance the quality of life in society by promoting the development of professional counselors, advancing the counseling profession, and using the profession and practice of counseling to promote respect for human dignity and diversity (ACA, 2014). Core Values The following are core professional values of the counseling profession according to the ACA, which are detailed in the Code of Ethics: 1. Enhance human development throughout the life span. 2. Honor diversity and embrace a multicultural approach in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts. 3. Promote social justice. 4. Safeguard the integrity of the counselor-client relationship. 5. Practice in a competent and ethical manner. Principles These core values provide the foundation for the ACA ethical principles that will be outlined in this section. The fundamental principles of professional ethical behavior as determined by the ACA are as follows: Purpose The ACA Code of Ethics contains the following: 1. The Code sets forth the ethical obligations of members and provides guidance intended to inform the ethical practice of professional counselors. 2. The Code identifies ethical considerations relevant to professional counselors and counselors-in-training. 3. The Code enables the association to clarify for current and prospective members, and for those served by members, the nature of the ethical responsibilities held in common by its members. 4. The Code serves as an ethical guide designed to assist members in constructing a course of action that best serves those utilizing counseling services and establishes expectations of conduct with a primary emphasis on the role of the professional counselor. 5. The Code helps to support the mission of ACA. 6. The standards contained in this Code serve as the basis for processing inquiries and ethics complaints concerning ACA members. The ACA Code of Ethics includes nine sections that serve as a guide to the counselor in the following areas: The counseling relationship. Confidentiality and privacy. Professional responsibility. Relationships with other professionals. Evaluation, assessment, and interpretation. Supervision, training, and teaching. Research and publication. Distance counseling, technology, and social media. Resolving ethical issues. The counseling relationship Counselors facilitate client growth and development in ways that foster the interest and welfare of clients and promote formation of healthy relationships. This section covers: Client welfare, primary responsibility. Records and documentation. Counseling plans. Page 12 Counselors.EliteCME.com

17 Support network involvement. Informed consent in the counseling relationship. Inability to give consent. Mandated clients. Avoiding harm and imposing values. Prohibited non-counseling roles. Personal virtual relationships with current clients. Managing and maintaining boundaries and professional relationships. Role changes in the professional relationship. Confidentiality and privacy Counselors recognize that trust is a cornerstone of the counseling relationship. This section provides details in the following areas: Respecting client rights. Multicultural diversity considerations. Explanation of limitations and exceptions. Serious and foreseeable harm and legal requirements. Confidentiality regarding end-of-life decisions. Contagious, life-threatening diseases. Note: When addressing HIV status counselors may not know if they are permitted to disclose that a client is HIV positive especially if the client confides that unsafe sexual activity has occurred. Standard B.2.b of the ACA Code of Ethics addresses Contagious, Life-Threatening Diseases and counselors must refer to state laws regarding disclosure because some states allow counselors to disclose HIV-positive status to identifiable third parties though the majority assign this responsibility to medical professionals. Professional responsibility Counselors aspire to open, honest, and accurate communication in dealing with the public and other professionals. The following topics are covered in detail in the code: Knowledge and compliance with standards. Professional competence and boundaries. New specialty areas of practice and qualifications for employment. Monitoring effectiveness. Consultations on ethical obligations. Continuing education. Relationships with other professionals Counselors develop positive working relationships and systems of communication with colleagues to enhance services to clients. This section discusses the following components: Relationships with colleagues, employers, and employee. Different approaches. Interdisciplinary teamwork. Establishing professional and ethical obligations and confidentiality. Evaluation, assessment, and interpretation Counselors promote the well being of individual clients or groups of clients by developing and using appropriate educational, mental health, psychological, and career assessments. Assessment services and security, scoring, interpretation, and reporting results. Competence to use and interpret assessment instruments. Informed consent in assessment. Release of data to qualified personnel. Diagnosis of mental disorders. Roles and relationships at individual, group, institutional, and societal levels. Confidentiality and advocacy. Multiple clients and group work. Fees and business practices. Self-referral. Unacceptable business practices, bartering, receiving gifts. Termination and referral. Court-ordered disclosure. Minimal disclosure and release, sharing and transmission of information. Subordinates and interdisciplinary teams. Confidential settings. Third-party payers. Deceased clients. Groups and families. Clients lacking capacity to give informed. Parents and legal guardians. Records and documentation. Permission to record and observe. Client access, assistance with records. Storage and disposal after termination. Case consultation, privacy, and disclosure. Impairment, counselor incapacitation, death, retirement, or termination of practice. Advertising, soliciting clients, testimonials, or products. Recruiting through employment. Professional qualifications, credentials, educational degrees, accreditation status and professional membership. Public responsibility. Reports to third parties. Media presentations. Personnel selection and assignment. Employer policies. Protection from punitive action. Provision of consultation services and competency. Informed consent in formal consultation. Contributing to the public good (Pro Bono Publico). Referral information. Technological administration. Historical and social prejudices in the diagnosis of pathology. Multicultural issues and diversity in assessment. Forensic evaluation for legal proceedings. Avoid potentially harmful relationships. Counselors.EliteCME.com Page 13

18 Supervision, training, and teaching Counselor supervisors, trainers, and educators aspire to foster meaningful and respectful professional relationships and to maintain appropriate boundaries with supervisees and students in both faceto-face and electronic formats. The Code contains details on the following components: Counselor supervision and client welfare. Supervisor and student responsibilities. Counselor supervision competence. Emergencies and absences. Research and publication Counselors who conduct research are encouraged to contribute to the knowledge base of the profession and promote understanding of conditions that lead to a healthy and just society. Research responsibilities. Roles and relationships between counselor educators and students. Rights of research participants. Student/supervisee participation. Client participation. Distance counseling, technology, and social media Counselors understand that the profession of counseling may no longer be limited face-to-face interactions. They understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how resources may be used to better serve their clients. Counselors understand concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet legal and ethical requirements for the use of such resources. Knowledge and legal considerations. Laws and statutes. Informed consent, security, and disclosure. Confidentiality maintained by the counselor. Acknowledgment of limitations. Client verification. Distance counseling relationship. Resolving ethical issues Counselors strive to resolve ethical dilemmas with direct and open communication among all parties involved and seek consultation with colleagues and supervisors when necessary. Counselors become familiar with the ACA Policy and Procedures for Processing Complaints of Ethical Violations and use it as a reference for assisting in the enforcement of the ACA Code of Ethics (ACA, 2005). This section includes details in the following categories: Standards and the law. Ethical decision-making. Standards for supervisees. Termination of the supervisory relationship. Supervisory relationship, student welfare. Counseling supervision evaluation, remediation, and endorsement. Responsibilities of counselor educators. Evaluation and remediation. Multicultural/diversity competence in counselor education and training programs. Confidentiality of information. Informing sponsors. Research records custodian. Managing and maintaining boundaries. Reporting results. Replication studies, publications, and presentations. Student research. Professional review. Benefits and limitations. Professional boundaries in distance. Effectiveness of services. Access. Communication differences in electronic media. Records and web maintenance. Client rights. Electronic links. Multicultural and disability considerations. Social media. Virtual professional presence. Social media as part of informed consent. Client virtual presence. Use of public social media. Conflicts between ethics and laws. Suspected violations. Informal resolution. Reporting ethical violations. Consultation. Organizational conflicts. Unwarranted complaints. Unfair discrimination against complainants and respondents. Cooperation with ethics committees. The ACA policies and procedures for processing complaints of ethical violations The ACA Governing Council approved these policies and procedures promote sound ethical practices. The ACA does not, however, warrant in 2005 and they were not revised in The ACA process for the performance of any individual (ACA, 2005). resolving an ethical complaint is detailed and extensive. This course Section B: Ethics Committee Members includes a summary and the complete ACA policies and procedures be The Ethics Committee is a standing committee of the downloaded and reviewed at Association and consists of nine (9) appointed members including two (2) Co-Chairs. Section A: General Section C: Role and Function The purpose of this document is to facilitate the work of the ACA Educating the memberships to the ACA Code, Ethics Committee by specifying the procedures for processing cases of Reviewing and recommending changes in the ACA Codes of the alleged violations of the ACA Codes, codifying options for sanctioning Association, Policies and Procedures for Processing Complaints members, and stating appeals procedures. This document is a of Ethical Violations and receiving and processing complaints of supplement to the ACA Codes and not as a substitute. The intent of the alleged violations of the ACA Codes. association is to monitor the professional conduct of its members to Page 14 Counselors.EliteCME.com

19 Section D: Responsibilities of the Committee Members The Committee members have an obligation to act in an unbiased manner, to work expeditiously, to safeguard the confidentiality of the Committee s activities, and to follow procedures established to protect the rights of all individuals involved. Section E: Responsibilities of the Co-Chairs Administering the Complaint In the event that one of the Co-Chairs administering the complaint has a conflict of interest in a particular case, the other Co-Chair shall administer the complaint. Section F: Jurisdiction The Committee will consider whether individuals have violated the ACA Codes if those individuals are current members of the ACA. Section G: Eligibility to File Complaints The Committee will receive complaints that ACA members have violated one or more sections of the ACA Codes from any individuals who have reason to believe that members have violated the Code. Section H: Timelines The time lines set forth in these standards are guidelines only. The Committee may consider complaints against members if the complaint is received less than 5 years after the alleged conduct occurred and deadline extensions may be granted. Section I: Nature of Communication Only legibly printed or typed, signed communication regarding ethical complaints against members will be acceptable within 30 working days of filing the formal complaint. Section K: Notice to Charged Members Once signed formal complaints have been received, charged members will be sent a copy of the complaint by certified U.S. mail, a copy of Policies and Procedures, the Code, and notification of their right to a hearing. Section L: Disposition of Complaints After receiving the responses from charged members, Committee members will be provided copies of (a) the complaint, (b) supporting evidence and documents sent to charged members, (c) the response, and (d) supporting evidence and documents provided by charged members and others. Section M: Withdrawal of Complaints If the complainant and charged member both agree to discontinue the complaint process, the Committee may complete the adjudication process if as determined by the Co-Chair administering the complaint indicates this is warranted. Section N: Sanctions The Committee may stipulate remedial requirements. Permanent expulsion from ACA membership requires a unanimous vote of those voting and may occur if remedial requirements are not met. Section O: Hearings At the discretion of the Committee, a hearing may be conducted when preliminary determination indicates that additional information is needed. Section P: Hearing Procedures A hearing will be conducted to determine whether a breach of the ACA Codes has occurred and to determine appropriate disciplinary action. Section Q: Notification of Results The complainant and charged member shall be notified of Committee decisions regarding complaints within thirty working days after the hearing. Section R: Appeals Decisions of the ACA Ethics Committee may be appealed by the member found to have been in violation based on grounds that the Committee violated its policies and procedures or the decision of the Committee was arbitrary, capricious, or not supported. Section S: Substantial New Evidence In the event that substantial new evidence is presented in a case in which an appeal was not filed, or when a final decision has been rendered, the Committee may reopen the case. Section T: Records The records of the Committee are confidential. Section U: Legal Actions Related to Complaints Complainants and charged members are required to notify the Committee if any type of legal action (civil or criminal) is filed related to the complaint. The ACA offers free confidential ethical/professional standards consultation 5 days a week between 8:30 am and 4:30 pm ET with the Director of Ethics or Ethics Specialist. Contact them at counseling.org/knowledge-center/ethics#sthash.gfkiir1p. Today, most forms of counseling and mental health practice emphasize research-based therapy. Interventions and methods of therapy are moving toward an empirical base, often using integrated therapies that are tailored to the needs of the specific set of clients. The practice of marriage and family therapy continues to be influenced by societal and cultural changes as well as politics and economics, such as the Affordable Care Act, managed care, and the increasing number elderly and disabled citizens who rely on Medicaid or Medicare. The trend toward research-based models that integrate several approaches may be more effective for families than one specific approach. Therapy that involves an integrated model for intervention requires the therapist to match the therapeutic approach to the specific members of the family. This process increases the number of interventions for the therapist to consider and may make the decisions and judgment more complex and dynamic as the therapy Summary of the AAMFT Code of Ethics progresses. The complexity of group therapy increases the ethical considerations for confidentiality and informed consent. The impact of multicultural, generational, developmental, lifestyle, belief set, sexual orientation, race, ethnic, gender, religious, group affiliation, and intrafamilial issues impact the group approach of marriage and family therapy. The nature of the group therapy process involves an infinite number of variables and ethical issues to consider. Complicating this process further is the growing application of technology for distance therapy with multiple clients. Jurisdictional requirements, licensing restraints, state law, and organizational mandates must be reviewed if services are delivered across state lines. Counselors.EliteCME.com Page 15

20 The following section is taken from the American Association for Marriage and Family Therapy (AAMFT) Code of Ethics and is only a summary of the major components. Preamble The Board of Directors of the American Association for Marriage and Family Therapy (AAMFT) hereby promulgates, pursuant to Article 2, Section of the Association s bylaws, the Revised AAMFT Code of Ethics, effective January 1, Honoring Public Trust The AAMFT strives to honor the public trust in marriage and family therapists by setting standards for ethical practice as described in this code. The ethical standards define professional expectations and are enforced by the AAMFT Ethics Committee. Commitment to Service, Advocacy, and Public Participation Marriage and family therapists are defined by their dedication to professional and ethical excellence, which includes the following components: Commitment to service, advocacy, and public participation. Participation in activities that contribute to a better community and society, regardless of financial return. Concern with developing laws and regulations pertaining to marriage and family therapy and altering laws and regulations that are not in the public interest. Professional competence in these areas is essential to the character of the field, and the well-being of clients and their communities. Seeking Consultation Therapists are encouraged to seek counsel from consultants, attorneys, supervisors, colleagues, or other appropriate authorities, if they have ethical concerns. Ethical standards Ethical standards are rules of practice upon which the marriage and family therapist is obliged and judged. Standard I Responsibility to Clients Marriage and family therapists advance the welfare of families and individuals and make reasonable efforts to find the appropriate balance between conflicting goals within the family system. This standard includes a discussion of the following categories: Non-discrimination. Informed consent. Multiple relationships. Sexual intimacy with current and former clients is prohibited. Reports of unethical conduct. Abuse of the therapeutic relationship. Client autonomy in decision-making. Relationship beneficial to the client. Referrals. Non-abandonment. Written consent to record. Relationships with third parties. Standard II Confidentiality Marriage and family therapists have unique confidentiality concerns because the client in a therapeutic relationship may be more than one person. Therapists respect and guard the confidences of each individual client. This standard defines the following components: Disclosing limits of confidentiality. Written authorization to release client information. Client access to records. Confidentiality in non-clinical activities. Ethical Decision-Making Therapists must consider the AAMFT Code of Ethics and applicable laws and regulations. If the AAMFT Code of Ethics prescribes a standard higher than the law, therapists must meet the higher standard of the AAMFT. Therapists must comply with the mandates of law, maintain their commitment to the AAMFT Code of Ethics and try to resolve any conflict between the code, the law, and the mandates of their employment organization. The AAMFT supports legal mandates for reporting of alleged unethical conduct. Therapists must remain accountable to the AAMFT Code of Ethics at all times. Binding Expectations The AAMFT Code of Ethics is binding on members of AAMFT. AAMFT members have an obligation to be familiar with the AAMFT Code of Ethics and its application to their professional services. The process for filing, investigating, and resolving complaints of unethical conduct is described in the current AAMFT Procedures for Handling Ethical Matters. Aspirational Core Values These core values are aspirational in nature, and are distinct from ethical standards. Acceptance and inclusion of a diverse membership. Excellence in training in systemic and relational therapies. Excellence in service to members. Excellence in clinical practice, research, education, and administration. A high threshold of ethical and honest behavior. Innovation and the advancement of knowledge. Protection of records. Preparation for practice changes. Confidentiality in consultations. Standard III Professional Competency and Integrity Marriage and family therapists maintain high standards of professional competence and integrity. Maintenance of competency. Knowledge of regulatory standards. Seeking assistance. Conflicts of interest. Maintenance of records. Development of new skills. Harassment. Exploitation. Gifts. Scope of competence. Public statements. Professional misconduct. Therapists may be in violation of this Code and subject to termination of membership or other action if they are: (a) convicted of a felony; (b) convicted of a misdemeanor related to their qualifications or functions; (c) engaged in conduct leading to conviction of a felony, or misdemeanor related to their qualifications or functions; (d) expelled or disciplined by other professional organizations; (e) disciplined by regulatory bodies or have their licenses or certificates suspended or revoked; (f) practicing marriage and family therapy while no longer competent due to physical or mental impairment, abuse of alcohol or other substances;(g) not cooperating with the association throughout proceedings regarding a complaint. Page 16 Counselors.EliteCME.com

21 Standard IV Responsibility to Students and Supervisees Marriage and family therapists do not exploit the trust and dependency of students and supervisees. Exploitation. Therapy with students or supervisees. Sexual intimacy with students or supervisees is prohibited. Oversight of supervisee competence and professionalism. Confidentiality with supervisees. Payment for supervision. Standard V Research and Publication Marriage and family therapists do not exploit the trust and dependency of students and supervisees. This standard includes information on the following areas: Therapists respect the dignity and protect research participants, are aware of applicable laws, regulations, and standards of research. Institutional approval. Informed consent to research. Right to decline or withdraw participation. Confidentiality of research data. Publication. Authorship of student work. Plagiarism. Accuracy in publication. Standard VI Technology Assisted Professional Services This standard addresses basic ethical requirements of offering therapy, supervision, and related professional services using electronic means. Technology assisted services. Consent to treat or supervise. Clients and supervisees must be made aware of the risks and responsibilities associated with technology-assisted services. Confidentiality and professional responsibilities. Technology and documentation. Location of services and practice. Training and use of current technology. Standard VII Professional Evaluations Marriage and family therapists aspire to the highest of standards in providing testimony in various contexts within the legal system. Performance of forensic services. Testimony in legal proceedings. Competence. Informed consent. Avoiding conflicts and dual roles. Separation of custody evaluation from therapy. Professional opinions. Changes in service. Familiarity with rules. Standard VIII Financial Arrangements Marriage and family therapists make financial arrangements with clients, third-party payers, and supervisees that are reasonably understandable and conform to accepted professional practices. Financial integrity. Disclosure of financial policies. Notice of payment recovery procedures. Truthful representation of services. Bartering. Withholding records for non-payment. Standard IX Advertising Marriage and family therapists engage in appropriate informational activities, including those that enable the public, referral sources, or others to choose professional services on an informed basis. Accurate professional representation. Promotional materials. Professional affiliations and identification. Educational credentials. Employee or supervisee qualifications. Specialization. Correction of misinformation. All students must study the entire code, which is available online on the AAMFT website Legal_Ethics/code_of_ethics.aspx. A summary of the AAMFT ethics complaint process The AAMFT Ethics Committee, hereafter the Committee, investigates ethical complaints made against AAMFT members as described in the AAMFT Procedures for Handling Ethical Matters. Initiating a Complaint Complaints must be initiated by someone with personal knowledge of the alleged behavior or by someone in a position to supply relevant reliable testimony or evidence on the subject. Preliminary Review of Complaint AAMFT staff review the complaint materials for jurisdiction and completeness. Complainants must waive therapist-client confidentiality and permit AAMFT to use their name and forward a copy of the allegations to the member, if charged with a violation of the AAMFT Code of Ethics. Determining Whether to Open a Case The Chair, in consultation with AAMFT s legal and ethics staff, determines whether the allegations, if factual, constitute a violation of the Code. Consideration by the Full Committee The case will be submitted to the full Committee at its next meeting. If the Committee determines that a violation has occurred, they will recommend an appropriate sanction based on the severity of the violation. Appeal to Judicial Committee The member will be notified and given the opportunity to appeal the Committee s findings and recommendations to the Judicial Committee. Manner of Judicial Committee Hearing The member may choose either an in-person hearing or a written review process. In-person hearings are typically held in Alexandria, VA before a Judicial Committee Panel. Appeal to AAMFT Board of Directors A member may make a final appeal to the AAMFT Board of Directors if the member believes that a procedural violation substantially impaired the member s ability to defend against the charges. The Board will review the appeal at its next scheduled meeting and will render a decision within 30 days of the meeting. Confidentiality of Ethics Matters All information obtained by the Ethics Committee and all case proceedings are confidential with limited exceptions. Counselors.EliteCME.com Page 17

22 Note: Professional association ethics committees such as the one described above, as well as any peer review, consultant or decisionmaking team, can be viewed as a third party. When disclosing confidential material occasionally, the guidelines from the Code and HIPAA rules regarding confidentiality and disclosure and to third parties is applicable. Counselors, therapists, and other members of professional associations related to the case have the duty to respond as required by the ethics committee, licensing board, courts, or other regulatory agency, but they must always follow basic procedures for confidentiality, privacy and informed consent. If the ethics committee asks for confidential information, or a statement from the practitioner in regard to a client, the practitioner should ask for a copy of the The ethical decision-making model Ethical decision-making is a process and involves the informed judgment of the therapist or counselor. There are many situations where simple answers are not available for ethical questions or the complexity of the situation crosses several standards with different possible interpretations. Ethics related to diversity, discrimination, privacy, confidentiality, privilege, informed consent, dual relationships and duty to warn overlap and these are areas where ethical violations may occur. The practitioner should consider how the issues would be judged in a peer review process where the ethical standards would be applied. In all cases, the practitioner must review all values, principles, and ethical standards that are relevant to the situation. They must have thorough knowledge of the code of ethics for their organization or employer. When codes do not contain information covering a particular issue, the practitioner is still responsible for making correct ethical decisions. If practitioners are faced with ethical dilemmas that are difficult to resolve, they are expected to engage in an established ethical decision-making process. Reasonable differences of opinion can and do exist among individual counselors or therapists in respect to values, principles, directives and how standards would be applied when they conflict. There is no specific ethical decision-making model identified to be most effective. Professionals are expected to be familiar with credible models of decision-making that involve a professional team and will stand public scrutiny. In the absence of a clear answer in the particular ethics code, or conflicts arise among the team concerning interpretation, the team must implement an ethical decision-making model. Through the decision-making processes, in the context of the situation, counselors and therapists can make ethical decisions for the welfare of clients. The models that are most frequently used align with the professional codes of ethics. The decision making process below incorporates a model by Corey, Corey, and Callahan (2004). Identify the problem or dilemma. Identify the potential ethical issues. Look at relevant codes of ethics for general guidance. Consider applicable laws and regulations, and determine how they may have bearing on an ethical dilemma. Seek consultation from more than one source to gain multiple perspectives on the dilemma. Brainstorm various courses of action. Evaluating ethical practice How can a counselor or therapists self-monitor to know if they are practicing in an ethical manner? They may not face an ethical issue in their practice that necessitates the need for a decision-making team process but want assurance that they are following the Code and practicing ethically. consent or waiver of confidentiality from the complainant before responding to the request. The ethics committee cannot conduct a review or require a response concerning client record without signed waiver from the client, which serves as a waiver of the practitioner s duty to maintain confidentiality. A complaint packet may be obtained via to ethics@aamft.org or contact AAMFT by phone at If a therapist needs assistance or information regarding an ethical question, before they make a decision, they can consult with an AAMFT Ethics Case Manager at ethics@aamft.org or Clinical Members may obtain a formal ethical opinion from the AAMFT Ethics Committee (AAMFT, 2014). Enumerate consequences of various decisions. Choose a course of action and review it against ethical standards to see if it presents new ethical considerations. The decision-making model presents a format for balancing risks and benefits of a course of action. In accordance with professional codes of conduct, the model provide a means for the counselor or therapist to consult with others, reflect and evaluate the process, and arrive at an ethical decision, which minimizes the likelihood of an unethical action. The model will assist the counselor in selecting an action that includes the rights, and responsibilities and welfare of the client (Corey, et al, 2004). After the counselor or team has selected a course of action, the plan should be reviewed to see if it presents any new ethical considerations. Stadler (1986) suggests applying three simple tests to the course of action selected to ensure that it is appropriate. The three tests are: Justice This test assesses equity and fairness and asks whether the action would be applied to others in the same way in this situation? Publicity Would the team want the ethical decision or course of action to be reported by the press? Universality Would the team recommend the same decision and course of action to another counselor in the same situation? If the course of action or decision seems to present new ethical issues, then the counselor will go back to the beginning and reevaluate each step of the process. The course of action or decision may be incorrect or the problem, situation, or context may have been identified incorrectly. If the counselor or team can answer affirmatively to Sadler s three tests questions above, and is satisfied with course of action they selected, they are ready to move to implementation. After implementation, the counselor would conduct periodic formative assessments to determine if the course of action had the anticipated effect and consequences for the welfare of the client. Counselors should be vigilant in their practice to identify concerns, areas that require consultation, review effectiveness of the service, and employ the decision making model. This may include the practitioner s self-evaluation and to ensure they are maintaining clarity, objectivity, competence, and appropriate boundaries to prevent ethics violations in their practice. Van Hoose and Paradise (1979) suggested a process for judging professional practice against ethical standards. Their work has stood the test of time and serves as the basis for significant research on ethical practice today. The counselor or therapist is probably acting ethically as evidenced that they: Maintained personal and professional honesty. Can demonstrate they have the best interest of the client as a priority. Page 18 Counselors.EliteCME.com

23 Acted without malice or personal gain. Consulted with other professionals in the field. Can demonstrate fair and just actions. Would be comfortable with a peer review process to evaluate their practice. Would publicly report and defend their action. Can support their actions based on the best practice of the profession. Can demonstrate and document their competency in their area or practice. Employed a sound decision making model. Followed their code of ethics. Current Ethical Issues and Revisions Service delivery through technology and social media The largest area of revision in the ethics codes involves the use of technology in delivering counseling and therapy services. Modern technology has led to many complicated ethical issues in delivering mental health services in and beyond the office setting. Virtually every office and agency has a sophisticated databases designed to contain an infinite amount of sensitive personal information. These systems collect, file, preserve, search, share, tabulate, track, transmit, and store information at incredible speeds from just about anywhere. A review of the literature reveals that even before the Internet mental health professionals expressed concerns about the potential risks to individual privacy and confidentiality inherent in computerized data systems in the 1960s. All of the associations in this course detail their ethical and legal obligation to keep records secure and have developed guidelines specific to technology, social media, and distance service delivery. In addition to the ethics codes, practitioners must comply with the HIPPA Privacy Rule that dictates the who, what, when, where, why, and how when it comes to storage, transmission, disclosure, right of privacy, and the duty to safeguard information under penalty of federal law. Insurance companies may require disclosure of mental health information, which presents additional concerns regarding the privacy of patient records. For example, information is taken over the phone, at an agent s office, or the clients home, such as in the case of application for private health and life insurance. If lab work is required, medical personnel come to the home to collect other vital statistics and questions about medications, previous health conditions, and treatment, including prescribed medications, substance use, and mental health services. This information is recorded and stored on a mobile device, transmitted electronically to the insurance underwriter and ultimately back to the agent with a decision. It is impossible for the client or practitioner to control this flow data. Some ethical questions in this case might include: What happens to the information at each step of the process? How is data transferred, stored and for how long? What happens to the data after a decision is made to accept or decline the application for coverage? How many individuals and agencies have access to the information and what are the safeguards? Who has access and how are they selected or screened? Can others access this data such as employers, law enforcement or the courts or unauthorized viewers? Can the individual ever be sure that the data is secure and will be destroyed? What is the counselor or therapist s role in maintaining confidentiality, privacy, and privilege when disclosing information from the client s record? What can be done to minimize mistakes when using technology in the practice of service delivery? Can data be recovered if lost or stolen? Who has ownership to the mobile digital device used to collect the information and are the devices stored securely at the end of the day? Are the mobile devices used for personal communications? Ethical concerns and potential risks associated with technology cannot be completely avoided in practice today. The ethical codes and case studies will present guidelines for the practitioner and serve as a starting point for the counselor and therapist to deepen their understanding of ethical use of technology and social media in their specific area of practice. Safeguards and ethical warnings Computer networks are used to manage records concerning assessment and evaluation, treatment, billing/payment, and communications between therapist and client. Many practitioners deliver services via real time technology at a distance. The use of these systems may lead to breaches in confidentiality given the ever-expanding use of new technologies, such as mobile media devices, as well as basic computer, , faxes, and cellular phones in practice. Technology in counseling settings requires ongoing security considerations to avoid new risks for unintentional confidentiality breaches. Counselors must carefully review their association s ethical guidelines prior to implementing technology-based therapy or counseling. Numerous articles have been written that provide additional insight into technology use beyond the guidelines provide in the various ethics codes. Koocher and Keith Spiegel (2008) suggest the following safe guards to manage electronic records: Apply encryption software to protect data transmission. Protect stored information with complex passwords. Apply Internet firewalls. Discuss security measures with professionals when storing files with the common server or backing them up on an institutional system. Keep removable data storage systems in secure places or use complex passwords to encrypt them. Protect passwords, changing them frequently and never share passwords with others or use password memory options. Be knowledgeable concerning security measures when using wireless devices. Never reveal confidential information in an ,instant messaging, or social media. Do not follow clients on social media as the ACA advises, counselors respect the privacy of their clients presence on social media, unless given consent to view such information. Always use privacy screens to shield monitors or other screens from view. Protect the physical security of portable devices such as laptops, small computers, personal digital devices, and smart phones. Update virus protection software and other security systems. Remove all information when disposing of computers or other electronic devices because information may remain after delating files. Consult technology specialists when disposing information electronically. Counselors.EliteCME.com Page 19

24 Consult the employer organization s regulations for the maintenance, dissemination, and disposal of confidential client and research data stored or communicated electronically. Technology is continually changing, increasingly varied, and complex in audio/video recording, conferencing, transmitting, storing, and speed capacities. The first and most important part of technology in traditional or distance services is the competency of the practitioner to implement the technology including the following steps: Professional training and practice is required to develop skills in using technology. The practitioner must teach the client how to access the services using technology. The practitioner should have a professional Internet technology specialist on hand to contact if problems occur. The practitioner should not initiate services until they are as competent with this method of delivery as they are in traditional face-to-face services. The practitioner must be sure the client has access to technology and assist them in locating free Wi-Fi zones with the best security possible. They should not proceed unless the client indicates they are confident in technology use and sign consent to begin the technology and distance service. The risks of technology use and distance services, procedures, emergency plans and all other components of the counseling or therapy plan must be explained to the client and signed indicating informed consent. Technology, including Skype, instant messaging, face time, , social media, videoconferencing, mobile media (e.g., ipad and IPhone), and other technology methods for delivering distance practice expands the access to counseling and may make it easier for both client and professional. For counselors or therapists without experience using social media and concerned about privacy on Facebook, Twitter may be a better option (Wade, 2015). Twitter uses have the option to add a photo or video to their message, which must be delivered in 140 characters or less. According to Wade, It s more anonymous than other social media. She explains that there are ways to sign up on Twitter that completely hides identity. Users can sign up with the following: Their real names. The name of the practice if they plan to use Twitter to give information about their specialty area or expertise. A pseudonym or nom de plume. An address that provides anonymity. Any name that does not link back to any identifying information. Practitioners must also be cautious to avoid the negative effects of social media. Linde uses the example of Instagram, which allows users to add photos with the capability of changing the picture. These photos The use of mobile devices HIPAA outlines national standards developed by the Department of Health and Human Services (HHS, 2011) to secure electronic protected health information (ephi) that is created, received, used, or maintained by a covered entity. Security of a client s health information may be at risk when using mobile devices because data is stored on the device in the onboard memory using a SIM card inside a cellular phone, which identifies the owner, stores personal information block use of the device if removed. The device may also have a memory chip, which is a microchip that can be plugged into a computer to provide more memory. Mobile devices may not have the capability to restrict access to data by encryption and authentication so practitioners must be cautious when can be viewed by anyone and viewers may comment which can lead to cyber bullying (Linde, 2014). She cautions that counselors should be aware of this risk, which has reached epic proportions and can cause serious harm to clients. Individuals may seek counseling and therapy because of the devastating effects of cyber bullying. Many clients are more comfortable with online distance services than counseling in person. These individuals may access and continue online counseling when they would not have done so face-to-face which may increase that number of clients receiving services. Technology presents many challenges to the counselor or therapist including: Some of this technology is devoid of visual cues to aid in communication. Frequent system failure may block or interrupts service altogether. During a time of crisis, it can be stressful and dangerous if a connection is lost or service is unavailable causing the counselor to lose all contact with the client. The practitioner may have multiple messages from different clients coming in at once. Communicating at a distance, especially on devices that do not have a video component, may impact the client s response do to anonymity. Others may hear or see interactions, which erodes privacy and privilege. Wade advises counselors to, Think carefully about how to handle the information your client may release. What if a client posts something suicidal? You will have to deal with it. Unless a counselor checks his or her social media networks every 5 to 10 minutes, many of the posts or tweets will not be read in real time, which makes timely crisis intervention unlikely (Wade, 2015). Contingency plans must be developed, written and signed to give consent in the plan of service that outlines procedures to handle technical difficulties and crisis situations. If the counselor or therapist is not in the same location as the client or family, there must be a plan to handle emergency situations in the client s home and employment area. This will require the practitioner to identify and collaborate with professional contacts in facilities immediately available to assist the client. These resources including professional colleague s contact information, crisis hotlines, mental health outreach programs, clinics, hospitals, mental health facilities and law enforcement agencies must be shared with clients and included in the treatment or counseling plan. Procedures that outline when and how to contact these resources, as well as when to call 911, must be written and discussed with the client and crisis contingency plans must be included in the informed consent documents signed by the client. Any informed consent would include the client s understanding of all of the risks involved in technology, long distance service and the implementation of the crisis plan. sharing ephi using mobile devices. Sending or receiving information through publically available Wi-Fi, or cellular networks that are unsecured, risks exposing ephi to anyone. To be sure ephi is not compromised or stolen when using a mobile device the practitioner must use a secure web site or a virtual private networking system (VPN) that encrypts information as it is received and sent from the device. Another risk is that mobile devices are small, light, and portable so they can be easily lost or stolen and theft is the most common form of security breach according to the Center for Democracy and Technology (2015). Page 20 Counselors.EliteCME.com

25 Distance technology includes other challenges when compared to conventional therapy because the professional will have more difficulty assessing body language including facial expression, gesture, voice quality, tone, mood, and other subtle cues that may not translate well or at all depending on the technology being used. The practitioner and client should include in the treatment plan a method to evaluate the effectiveness. Either party may determine that long distance service may be terminated if not effective or the welfare of the client is at risk. Catherine Barrett is a principal consultant with the Federal Working Group in Washington, DC and is a fellow with the e-health Initiative. She provides the following guidelines for securing client information on mobile devices in accordance with HIPAA (Barrett, 2011): Administrative safeguards: Conduct periodic risk assessments of mobile device use to assess exchange ephi and whether proper authentication, encryption, and physical protections are in place. Establish an electronic process to ensure the ephi is not destroyed or altered by an unauthorized third party. Establish processes and procedures to appropriately protect ephi, including encryption and security breach protocols for mobile devices. Train clinicians on the processes and procedures to use when using mobile devices to access ephi and educate clinicians on the risks of data breaches, HIPAA violations and fines. Physical safeguards: Keeping an inventory of personal mobile devices used by healthcare professionals. Storing mobile devices in locked offices or lockers. Installing radio frequency identification ( RFID ) tags on mobile devices to help locate a lost or stolen mobile device. Conversion/reparative therapy The second biggest area of revision and addition to the ethics codes is the opposition by ACA, AAMFT, and NBCC to the practice of conversion/reparative therapy. Many counselors have consulted ACA staff and leaders concerning ethics regarding the practice of conversion, also known as reparative, therapy. Recently many states, as well as federal initiatives, are being proposed to ban the practice completely. The ACA ethics committee shared its formal interpretation of specific sections of the Code of Ethics concerning the practice of conversion therapy which is a practice designed to change an sexual orientation from homosexual to heterosexual (ACA, 2015). The ACA published the following information on their 2015 website: Dr. David Kaplan, ACA s Chief Professional Officer, testified before the Washington, D.C. Committee on Health in support of a bill banning conversion therapy for minors. The American Counseling Association has adopted an unequivocal policy against reparative therapy. Reparative therapy is not congruent with the American Counseling Association s Code of Ethics as the effects of efforts to change sexual orientation have been found to cause damage to individuals who have been exposed to it, Dr. Kaplan said. Additionally, the American Psychological Association has found the practice to be unlikely to be successful and involve some risk of harm. In his testimony, Dr. Kaplan also said the following: The word therapy should really not be used when talking about sexual orientation change efforts. Therapy is a clinical word and refers to a mental health intervention. Reparative therapy is not a mental health intervention since it does not address the diagnosis of a mental disorder. The mental health field has concluded that same-sex attraction is not a deficit and therefore homosexuality is not categorized as a psychiatric disorder in the Diagnostic and Statistical Manual (DSM). President Obama spoke out against this practice and supports the efforts of states to ban conversion therapy. California, New Jersey, and Washington, D.C. have outlawed the use of conversion therapy for Using remote shutdown tools to prevent data breaches by remotely locking mobile devices. Technical safeguards: Technical safeguards, such as encryption, can protect ephi transmitted between healthcare provider and. HIPAA, 2011 defines technical safeguards as the automated processes used to protect data and control access to data. Install and regularly update anti-malicious software also called malware. Install firewalls where appropriate. Apply encryption to ephi and metadata, which describes the format of the information including information on collection. Install IT backup systems, such as off-site data centers and/ or private clouds, to provide redundancy, which insures that information can be duplicated if the system fails, and access to electronic health information. Adopt biometric authentication tools to verify the person using the mobile device is authorized to access the ephi. These tools use physical or voice cues to verify identity such as fingerprint or retinal scans. Ensure mobile devices use secure, encrypted Hypertext Transfer Protocol Secure ( HTTPs ) to provide encrypted communication and secure identification of a network web server. Ethical codes, and the HIPAA Privacy Rule, will be revised but may not keep pace with technology that is constantly changing. Therapists are always responsible for protecting client privacy and information disclosed to them in confidence, which requires sophisticated precautions when using technology. The practitioner should always consult professions in this field to ensure the welfare of clients. minors and eighteen other states are formulating legislation to ban the practice including Arizona, Colorado, Connecticut, Florida, Illinois, Iowa, Massachusetts, Minnesota, Nevada, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Texas, Vermont and West Virginia. Proposed legislation to ban sexual orientation therapy in Virginia failed in committee in January The White House statement by the President was released in response to a WhiteHouse.gov petition that was started on behalf of Leelah Alcorn, a transgender teen who committed suicide after being forced to undergo conversion therapy. The petition has received more than 120,000 signatures. The ACA will assist any parties in their efforts to ensure all Americans are protected from these dangerous and unethical mental health practices and the association commended the White House for speaking out on this topic (ACA, 2015). AAMFT has spoken out against the practice of conversion/reparative that seeks to change a person s sexual orientation. Like the ACA opinion on the topic, AAMFT policy, adopted in 2009 by their Board of Directors, states that homosexuality is not considered a disorder that requires treatment so there is no basis for therapy. AAMFT advises members to conduct therapy based on the best research and clinical evidence available following their Code of Ethics. The following information was obtained from the 2015 AAMFT website and shows the commitment and action of the association to support same-sex couples: AAMFT has joined with the American Psychological Association and other mental health associations in filing briefs in federal court that support the right of same-sex couples to marry under state law. For example, on March 6, 2015, AAMFT, along with the Michigan Association for Marriage and Family Therapy, joined in a brief filed with the U.S. Supreme Court that is in support of parties who are challenging laws in four states that deny the status of marriage to same-sex couples. The Supreme Court is expected to issue its decision in this matter in June The purpose of these briefs, known as an amicus briefs, is to alert a court of issues relevant to the lawsuit that parties in the lawsuit might not adequately address. Counselors.EliteCME.com Page 21

26 Many professional mental health associations file such briefs concerning issues of importance to their members and a number of court cases and amicus briefs will be detailed in this course. The NBCC provides the following directives from their Code in response to this topic: NCCs shall demonstrate multicultural competence and shall not use techniques that discriminate against or show hostility towards individuals or groups based on gender, ethnicity, race, national origin, sexual orientation, disability, religion, or any other legally prohibited basis. Techniques shall be based on established theory. Sexual Orientation Change Content Restriction. The program content of continuing education providers cannot present or include information promoting Sexual Orientation Change Efforts as a therapeutic method (NBCC, 2015). During the third session of counseling, a 30-year-old client reported that he was gay and stated that he no longer wanted to follow this lifestyle. He wanted to participate conversion therapy so that he no longer felt an attraction to men. His goal was to become attracted to a woman to have a traditional marriage with children. At the suggestion of a friend, the client read about reparative/ conversion therapy and researched the approach on the Internet and he is convinced this is the route he wants to take. The counselor listened and asked questions in a clinically appropriate manner. The counselor informed the client that although she felt that Case Study ONE: Reparative/Conversion Therapy she could be effective in counseling with him, she could not ethically engage in reparative/conversion therapy and felt it would not be effective in reaching his desired goals. She explained that she could fine not scientific evidence or support for the approach and even consulted her association who advised her that it was not a supported form of therapy. The client understood but indicated he was disappointed that the counselor could not help him through that type of counseling. He then asks for a referral to another counselor or therapist who will help him to change his sexual orientation to reach his goals. The ethical question is whether the counselor should make a referral for conversion therapy. Analysis The ACA Ethics Committee considered many factors and derived a consensus opinion that addresses several sections of the Code of Ethics and moral principles of practice presented in this scenario. They started with the basic goal of reparative/conversion therapy, which is to change an individual s sexual orientation from homosexual to heterosexual. Counselors who conduct this type of therapy views same-sex attractions and behaviors as abnormal, unnatural, or immoral in need of curing or changing through therapy. The belief that same-sex attraction and behavior is abnormal and in need of treatment is in opposition to the position taken by national mental health organizations, including ACA, APA, and the AAMFT. The ACA Governing Council resolution of 1998 specifically notes that the ACA opposes the portrayals of lesbian, gay, and bisexual individuals as mentally ill due to their sexual orientation. The resolution supports dissemination of accurate information about sexual orientation, mental health, and appropriate interventions and instructs counselors to report research accurately and in a manner that minimizes the possibility that results may be misleading. In 1999, the ACA Governing Council adopted a statement, opposing the promotion of reparative therapy as a cure for individuals who are homosexual. They continued to express their opposition in 2005 and As early as 1973 the American Psychological Association the Diagnostic and Statistical Manual (DSM IV-TR), stated that homosexuality is not a mental disorder in need of being changed. (APA, 2011) The ACA found the majority of the studies on this topic have been expository in nature with no scientific evidence published in psychological peer-reviewed journals that state the effectiveness of conversion therapy. They did not find any longitudinal studies conducted to follow the outcomes of those individuals who have engaged in this type of treatment. They did conclude that research published in peer-reviewed counseling journals indicates that conversion therapy may harm clients. ACA Committee members agreed that it is of primary importance to respect the client s autonomy to request a referral for services not offered by counselor. If counselors determine an inability to be of professional assistance to clients, they avoid entering or continuing the counseling relationship. Counselors act to avoid harming their clients, trainees, and research participants and to minimize or to remedy unavoidable or unanticipated harm (ACA, 2014). Referring a client to a counselor, who engages in a treatment modality not endorsed by the profession, that may in fact cause harm, does not promote the welfare of clients and opposes the basic purpose of the Code. There is no professional training condoned by ACA, ACA, AAMFT, or other prominent mental health associations that would prepare counselors and therapists to provide conversion therapy and all associations and related mental health agencies have spoken against any form of conversion therapy or counseling. Since there is no training, the counselor or therapist would be practicing outside the boundaries of their expertise, which violates the ethics codes. The ACA Code 2014 requires the counselors to recognize history and social prejudices in the misdiagnosis and determination of pathology of certain individuals and groups and the role of mental health professionals in perpetuating these prejudices through diagnosis and treatment. Until the 1980s, some mental health professions viewed homosexuality as a mental disorder. But with the revision by the APA in 1982, it was removed from the Diagnostic and Statistical Manual as a mental disorder. Soon, professional associations for counseling, social work, mental health treatment, marriage and family therapy and psychology followed and same-sex relationships were no longer deemed pathological or indicative as a mental disorder. Today, some religions and segments of the population in the United States continue to view same-sex relationships as immoral sexual behavior that is pathological, sinful, and therefore in need of therapy and counseling. In the past decade, increasing acceptance of same-sex lifestyle choices have been noted including the number of states that recognize same-sex partners and marriage and the accepted inclusion of this lifestyle in all forms of media and modern culture. Referring a client to someone who engages in conversion therapy signifies to the client that same-sex attraction and behaviors are in some way deviant and need to be changed. This would violate the 2014 ACA Code of Ethics, The AAMFT Code of Ethics, the NBCC Code of Ethics, and APA Diagnostic Manual; so, the ethical decision would be to refuse the referral request. Page 22 Counselors.EliteCME.com

27 Ethical questions These findings bring several questions to the forefront: Is a counseling professional who offers conversion therapy practicing ethically? Since ACA has taken the position that it does not endorse reparative therapy as a viable treatment option, is it ethical to refer a client to someone who does engage in conversion therapy? If the client insists on obtaining a referral, what guidelines can a counselor follow? What are the conditions that allow the professional counselor to refer this case to another counselor? Case STUDY TWO: Discrimination Against Clients Based on Sexual Identity and Inappropriate Referral Julea Ward enrolled in the graduate counseling program at Eastern Michigan University (EMU) in 2006 to obtain a degree and become certified as a school counselor. In 2009, she began her practicum at the clinic on campus that was part of the EMU counseling program. The client assigned to her wrote on an intake form that he was seeking counseling to overcome depression and other problems he was having due to a same-sex relationship. Ms. Ward decided she could not take this assignment based on her religious belief that the Bible teaches homosexuality is immoral, sinful, and that sex should be only between men and women. She believed that individuals could refrain from homosexuality if they were committed to change their immoral sexual behavior. (Ward v Wilbanks, 2009). Her EMU counseling supervisor told Ms. Ward that her refusal to work with the client and her attempt to refer the client to another student counselor has a violation of two standards in the ACA 2005 Code of Ethics. The advisor stated further that Ms. Ward was not allowed to refer the client and needed to accept the assignment. She was offered additional training to assist her in working with clients with diverse beliefs and values and to develop better understanding of the ethics related to this case. Ms. Ward refused and stated she was unwilling to violate her beliefs by affirming homosexual conduct within the context of a counseling relationship. (Ward v Wilbanks, 2009). The University conducted due process hearings and subsequently dismissed her from the counseling program. Ms. Ward contacted the Alliance Defense Fund who filed a lawsuit in U.S. District Court on the grounds that the EMU counseling program, violated Ms. Ward s constitutional rights to free speech, free exercise of religion, freedom from retaliation for exercising First Amendment Rights, equal protection of laws, due process, and freedom from establishment of religion (Ward v Wilbanks, 2009). The University contacted the ACA to obtain an expert witness to address the case based on the ACA Code of Ethics. The expert witness addressed the district court and submitted an amicus brief for the Sixth Circuit. The ACA became involved in the court case to support the standards of the Council for Accreditation of Counseling and Related Educational Programs (CACREP), the EMU counselor education program and because the case challenged the validity and enforceability of the ACA 2005 Code of Ethics Standard C.5 on nondiscrimination. Ms. Ward s complaint responded that ACA s statement of nondiscrimination is vague, overbroad, and allows for unbridled discretion in determining what protected expression and conduct fall under prohibition and thereby limits constitutionally protected speech and conduct (Ward v Wilbanks, 2009,). This case could set a precedent against the ACA Code of Ethics standard written to prevent discrimination on the basis of sexual orientation if the courts ruled in favor of Ms. Ward. The Judge the Eastern District Court of Michigan ruled in favor of EMU in 2010 and Julea Ward decided to appeal the case in the Sixth Circuit Court and Analysis Can services be denied on the basis of sexual orientation or any other value that is counter to the practitioner s values? When is it appropriate to refer a client? When does the profession relationship begin with a client? The District Court presented a ruling on this case related to counseling values and sexual orientation, which addresses the first question. The Judge supported the ACA position in the following statement: The ACA Code of Ethics is the industry standard in the field of counseling. A counselor who cannot keep their personal values out of the interaction has great potential to harm her client. The Dr. Kaplan, explained in his expert report that plaintiff s request to refer clients based on their protected status, sexual orientation, was a clear and major violation of the ACA Code of Ethics as it would have been if she had refused to counsel an assigned African American on the basis that her values would not allow her to provide services to people of color. (Ward v Wilbanks, 2009). On the second questions, Ms. Ward defended her actions by saying that referral is an accepted practice within the counseling profession, including, but not limited to, those circumstances where there is a clash between a counselor s values and a client s values/goals (Ward v Wilbanks, 2009). She also tried to defend her actions by including information from the ACA Code of Ethics, 2005 that states in Standard A.11.b as follows: If counselors determine an inability to be of professional assistance to clients, they avoid entering or continuing counseling relationships. She explained that she could not provide professional assistance to this client because of the client because of the irreconcilable differences between her religious views regarding homosexual behavior and the client s desire for counseling regarding his homosexual relationship (Ward v Wilbanks, 2009). Therefore, she stated that she was obligated by the standard to refer the client to another student counselor. She also attempt to use Standard A.9.b, which refers to End of Life Care for Terminally Ill Clients and allows personal and moral factors to be considered when deciding to counsel a client that is considering physician-assisted suicide. Closer inspection of the ACA Code of Ethics notes that Standard A.11 deals with referral because of the inability of the counselor to deliver services not the unwillingness or discomfort of the counselor when delivering services and no statement speaks of referral based on counselor values. Counselors may refer if they do not have the skill or expertise required to serve the client in their best interest. Counselors.EliteCME.com Page 23

28 Furthermore, Ms. Ward was offered assistance and supervision as a student to help her develop skills to provide ethical quality service, which is the objective of clinical supervision in the practicum program, but she declined the offer. Her actions were also deemed unethical under the ACA Code Standard A.11.a which states that Counselors do not abandon or neglect clients in counseling (ACA, 2005). The ACA included this argument in the amicus brief filed with the Sixth Circuit Court of Appeals as follows: A counselor who drops a client whenever potential values-based conflicts arise violates the prohibition against abandonment. The Code recognizes that a client may suffer harm if the counselor turns away at the very moment that the client s most sensitive issues arise. Because of this risk, termination and/or referral are matters of last resort, to be handled on a case-by-case basis with sensitivity to the facts specific to the client in question (Ward v Wilbanks, 2011). The ACA Code of Ethics allows counselors to terminate a counseling relationship only under specified circumstances, which are as follows: When it becomes reasonably apparent that the client no longer needs assistance. The client is not likely to benefit. The client being harmed by continued counseling. In this case, no evidence could be presented for these conditions; so. Ms. Ward s position that she could not counsel him based on sexual orientation was a direct violation of the ACA Code of Ethics that deals with Termination and Referral and fit the definition of abandonment as outlined in the Code. The argument by Ms. Ward that values were a basis for termination from the ACA Code on End of Life Care for the Terminally Ill was not applicable in this case because The ACA Ethics Revision Task Force wrote this section to give counselors permission in this one specific situation to opt out on the basis of the counselor s personal values. This option allowed the counselor to refrain from assisting a terminally ill client to explore options for hastening death when termination would otherwise be prohibited The Judge agreed with the ACA revision on referral in this case as and stated: If counselors determine an inability to be of professional assistance to clients, they avoid entering or continuing counseling relationships. This excerpt is consistent with the opinion of David Kaplan that there is no statement in the ACA Code of Ethics that referral can be made on the basis of counselor values unless they are counseling terminally ill clients who wish to explore options for hastening their death. Additionally, Dr. Kaplan explained that the provision in the ACA Code of Ethics allowing referrals of clients seeking end-of-life counseling is the exception that proves the rule that values-base referrals based on a client s protected status are not appropriate. That is because the Code permits all counselors, regardless of religious faith, to refer clients seeking counseling for end-of-life issues. The answer to the third question speaks to another argument made by Ms. Ward that she could not have committed an ethical violation because she had not begun to counsel the client. Her lawyers presented the following argument: Ms. Ward never met the potential client. Thus, she could not have imposed her values on the client. In fact, the individual assigned to her was not even her client, since at EMU s clinic the counselor client relationship begins the first meeting, not before (Ward VWilbanks, 2010). The ACA based their rebuttal argument on the book The Counselor and the Law (Wheeler and Bertram, 2008). In this book, published by ACA, the definition of a client begins at the moment individual requests assistance and the client is defined as, Anyone who seeks advice or counseling. In Ms. Ward s case, the individual went to the counseling center at EMU and completed an intake form to seek counseling for depression and other issues so he meets the criterion of a client even if no session had taken place. To care the argument further, since he was a client all of the standards in the ACA Code of Ethics for 2005 could be applied to Ms. Ward s statements of discrimination, her unethical referral that amounted to abandonment. This case cautions that the ACA holds the following considerations to be true in this case: Referral as a last resort to be used only in case of lack of counselor competence or skill, or that addresses the End of Life Terminally Ill standard. The ethical responsibility to clients starts at the first contact whether is be a phone call or intake form. Counselors may not deny services based on sexual identity or any other protected class listed in the discrimination standard. Referrals can never be made based on conflicts of counselor/ client values. There are several areas that may lead to ethical violations and these are addressed in the ethics codes outlined in this course. The case studies Additional Case Studies in Ethics that follow are significant and in some cases have lead to changes in the state and federal law to better protect clients. Dual relationships When reviewing revised codes of ethics, considerable information relates to dual relationships that counselors may have with the client. Mental health professionals must have guidelines, often referred to as boundaries that are designed to minimize the opportunity for therapists to use clients for their own gain and ensure the welfare being of clients who disclosed confidential information to the therapist. Dual relationships are sometimes referred to as multiple role relationships, which occur when the counselor assumes two or more roles concurrently or sequentially which involve the client (Herlihy and Corey, 1997). The dual relationship may include a second role that could be social, financial, or professional. The practitioner may also be a friend, supervisor, teacher, associate, or employer. In all codes of ethics, there are key elements in the guidelines relating to dual relationships as summarized below: A dual relationship exists when the mental health practitioner is in a counseling relationship at the same time they are in a relationship with the client outside of counseling. Guidelines also govern a promise or agreement to enter into another relationship in the future with the client or a person associated with the client. The mental health practitioner should not take on a dual role with the client if it would impair their assessment, objectivity, competence, effectiveness, communication, or confidentiality as a therapist. The mental health practitioner should not enter into a dual relationship if the possibility exists that it could exploit or harm the client. Page 24 Counselors.EliteCME.com

29 Mental health practitioners are responsible for establishing clear, appropriate, sensitive, and ethical boundaries prior to entering into any dual relationship with the client. If the mental health practitioner becomes aware that potential harm may occur, or unintentional harm has occurred due to a multiple relationship, the practitioner must take immediate action and show evidence that they have attempted to remediate the harm. Kitchener and Harding (1990) identified three risk factors that may result in harm to the client who is involved in multiple relationships, or dual relationship with their therapist: The more incompatible the expectations the greater the potential harm. The greater divergence of responsibilities and obligations the more potential for divided loyalties and loss of objectivity. The larger power and prestige differential between therapist and client greater potential for client exploitation due to the power differential, which most often favors the therapist. Herlihy and Cory (1997) outlined four problematic and complicated characteristics of dual relationships: 1. Dual relationships can be difficult to identify because they develop in a subtle fashion without a clear danger sign alerting the therapist that the behavior in question might lead to an unprofessional relationship. 2. The potential for harm broadly ranges from extremely pernicious to neutral or even beneficial. Sexual dual relationships can be extremely harmful to the client whereas attending a client s graduation may be benign or therapeutic. 3. Excluding dual sexual relationships, there is little consensus among mental health practitioners concerning the appropriateness of dual relationships. 4. Some dual relationships cannot be avoided, such as clinicians living in rural areas and small towns. Herlihy and Corey (1997) developed a decision-making model for therapists faced with a potential dual or multiple relationship. It would be wise to include a team of professionals in this process. Their model gives following guidelines: Determine whether the dual relationship is avoidable. If unavoidable, the practitioner should explore potential problems and benefits with the client. The practitioner must judge whether benefits outweigh the risk of potential harm. The differences in the client s expectations of the therapist in the two roles must be examined. The therapist s divergent responsibilities in the two roles must be determined. The power differential in the therapist and client relationship must be considered. If the practitioner s assessment concludes that client risk of harm is greater than the potential benefits, the counselor should not enter the dual relationship. The client should be informed of the rationale for not participating in the dual relationship. If the team decides that client benefits are substantial and the risk of harm is small, or the dual relationship is unavoidable, then the dual relationship can exist with the following safeguards: 1. Obtain clients informed consent after discussion and agreement on the potential for risk and methods of resolution. 2. Seek ongoing consultation to maintain objectivity in managing a dual relationship to avoiding for harm to the client. 3. Maintain ongoing communication and monitoring with the client regarding potential risk and resolutions. 4. Document the dual relationship and self monitor throughout the process, providing evidence of vigilance toward client risks, benefits, and protection. 5. If the dual relationship becomes a complaint before a licensure board or court of law, those adjudicating the complaint will expect an open reporting of all information. 6. Obtain ongoing supervision, beyond simple consultation, during the dual relationship if risks are high, the relationship is complex, or if practitioners are concerned about maintaining objectivity. Ethics violations related to dual relationship comprise the majority of ethics complaints and licensing board actions (Montgomery and Cupits, 1999; Neukrug, Milliken, & Walden, 2001). Lawsuits and the cost of defending licensing board complaints led to increased liability insurance rates, which affect everyone in the mental health professions. One ethical responsibility that counselors must take very seriously is tied directly to the position of power they hold in the counseling relationship (Remley, 2007). He cautions: When clients seek counseling services, they are vulnerable. There is very little oversight of the interactions between counselors and clients, and clients could easily be abused in counseling relationships because of the power counselors have. Therefore, it is very important for counselors to practice in an ethical manner that results in their clients being helped and never being harmed or taken advantage of. Barnett corroborates this position and adds: Clients come to counselors in need, seeking assistance for important issues and difficulties. They come to counselors needy, dependent on us, and trusting us to only act in ways that are in their best interests. A failure to act ethically in our professional roles can lead to direct harm to clients and can undermine the public s trust in counselors in particular and in mental health professionals in general. This could result in people who are in need of help not accessing the help they need. The public is trusting us to help them, not to harm them (Barnett, 2011). Current revisions focus on the nature of the dual relationship in order to determine if it is harmful or beneficial to the client rather than completely avoiding all dual relationships outside of the counseling setting. Jeffrey Barnett an authority in this area, and co-author of The Ethics Desk Reference for Counselors with W. Brad Johnson, states: The most recent thinking is that there is a big difference between crossing a boundary and violating a boundary. Certain multiple relationships are now ethically acceptable; such as counseling your child s teacher if no other counselors are available in the area. Sometimes it s us or nothing. The 2005 revision of the ACA Code of Ethics on multiple relationships contains the following statements: Counselor-client nonprofessional relationships should be avoided, except when the interaction is potentially beneficial to the client. Standard A.5.d. States the counselor must document in case records, prior to the interaction when feasible, the rationale for such an interaction, the potential benefit and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. The standard provides examples of potentially beneficial interactions outside the counseling office, include, but are not limited to, attending a formal ceremony, a wedding/commitment ceremony or graduation; purchasing a service or product provided by a client or former client, except unrestricted bartering, hospital visits to an ill family member, mutual membership in a professional association, organization or community. According to Barnett, the counselor or therapist must always be mindful when deciding whether to cross a boundary of the potential for impairment of objectivity. Barnett explains, If it s a conflict-ofinterest situation or if I can t remain objective, it s probably not a good idea. Barnett recommends that the counselor or therapist keep the dual relationship roles separate or compartmentalized. Using the situation of services provided to the counselor s child s teacher, it would be inappropriate to ask the teacher about the child s school Counselors.EliteCME.com Page 25

30 performance during counseling or to bring up questions related to the teacher s counseling issue at the parent teacher meeting. A thorough informed consent document should be developed and signed if the practitioner makes a decision to cross a boundary and engage in a dual relationship with a client. Barnett advises, Informed consent clarifies up front the working agreement between the two parties. Many clients may not know what their rights are, what appropriate professional behavior includes, and what behaviors are not appropriate. Part of the informed consent is to educate the client. It is also to clarify our responsibilities and obligations. A professional artist complained to an ethics committee that the therapist did not carry out her promises. The therapist had treated the artist for over 1 year, during which time the therapist complemented the client s art work, attended art shows with him, and promised to introduce her art gallery contacts to her client. The client stated he began to feel so self confident that he terminated therapy and expected Case Study THREE: Dual Relationships the therapist s interest in his career to continue. The therapist stopped returning the ex-client s phone calls, which left the client frantic. An ethics committee contacted the therapist to whom she explained that she always provided unconditional positive regard to her clients, but since this particular individual was no longer a client she felt no further obligation to him. Analysis The ethics committee found in favor of the client. The therapist maintained a dual relationship by their combining their professional and private lives outside of counseling together and caused confusion and harm to the client. The therapist did not resolve the potential consequences of the dependency she established and maintained with the client Koocher and Keith Spiegel, 2008). The therapist and her ex-client decided they would become friends because the past therapeutic relationship was very harmonious. Unexpectedly, the ex-client perceived the therapist to be controlling and overbearing in the new relationship. She then questioned the therapist s over all competence to the point of distancing herself from Case Study FOUR: Dual Relationships the post-therapeutic friendship. The ex-client decided that the therapist was incompetent causing her to feel exploited and confused. She then consulted another therapist who told her to press charges against the previous therapist. Analysis An Ethics Committee determined that incompetence could not be conclusively proven but both the complainant and respondent were surprised at the findings on the dual role violation. The investigation uncovered that the therapist mistakenly planned their developing relationship and its longer-term continuation while the client was still in active therapy. The therapist had actually presented these facts as a defense against the client s accusations. This case shows how personas may change from one context to another and the change may be viewed as negative. The client responded well in therapy to the therapist s authoritative personality in therapy but not in a social context. Also, ex-clients may choose to reenter therapy and a neutral relationship is advised. (Koocher and Keith-Spiegel, 2008). The current revisions summarized in this code advise against bartering, but give exceptions, as long as it causes no harm. Therapist generally enter bartering arrangements with clients with the good intention of offering services to those with limited finances, however, potential problems exist. If the intent is to help a client with limited funds, delivering services Pro Bono may be an option. Though bartering with the client for goods or services is not directly prohibited, it is not recommended as a customary practice. The reader should carefully review the ethics code for their association, which includes major sections on regulations surrounding bartering or inappropriate relationships with clients that refer to trading or exchanging services in lieu of payment but do not use the term bartering. There is much disagreement among practitioners regarding whether bartering is ethical. Often, client services do not equal the monetary value, on an hourly basis, to that of therapy (Kitchener and Harding, 1990). Therefore, clients fall further behind in the amount owed and may feel trapped or resentful. The quality of barter services might also become problematic as therapist or client may feel shortchanged resulting in resentment and therapeutic damage. The exchange of goods instead of payment may elicit the same quality issues inherent service exchange, and negotiating the equivalent number of therapy sessions for the bartered goods can become an issue. Bartering: A Common Boundary Issue The following list provides general guidelines that are summarized and held in common from the various codes of ethics for mental health practitioners: Bartering arrangements create the potential for conflicts of interest and inappropriate boundaries with clients. Bartering should occur only in limited circumstances and if it is an accepted practice in the community. The mental health practitioner assumes the full burden of demonstrating that this arrangement will cause no harm to the client Bartering arrangements should not put the mental health practitioner at an unfair advantage. Bartering agreements should be discussed and the counselor and client should sign a clear written contract. Establishing a friendship, or social relationship, when bartering with clients may produce a conflict of interest that impairs the objectivity necessary for professional judgment (Pope and Vasquez, 1998.) The friendship dual relationship forms a new set of interests for the counselor or therapist beyond the professional one. For example, a therapist may hesitate to raise a certain issue with the client who is also a friend due to concerns of damaging the friendship. Page 26 Counselors.EliteCME.com

31 A counselor provided services to a man with anxiety, which affected his work and personal life. He eventually lost his job and health insurance due to his anxiety. The counselor agreed to hire the client to do maintenance on his house and yard work to help him earn some money while he looked for a job. The counselor paid him minimum wage but continued the counseling sessions at no charge. A month later, the man attempted suicide Case Study FIVE: Bartering and was admitted to an inpatient mental health facility. He was assigned to a psychiatrist who learned of the exchange of work for counseling services. The psychiatrist questioned the ethics of the relationship and considered it a boundary violation and inappropriate dual relationship that caused harm to the client. He reported it to the state licensing board and they opened an investigation. Analysis The therapist was not paying the fair market value for the labor being performed so the relationship was not a beneficial one for the client, though he was able to continue counseling for free. The quality and effectiveness of the counseling services would be called into question in light of the firing and subsequent suicide attempt. Most professional liability insurance policies exclude coverage pertaining to business relationships with clients (Bennett et al., 2007). Sexual dual relationships One of the oldest ethical mandates in the healthcare profession is the prohibition of sexual intimacies with clients and predates the Hippocratic oath. The ethics codes of mental health professions, however, did not address his behavior until research revealed its prevalence and harm to client (Pope and Vasquez, 1998). Their research, and others that followed, provided evidence that clients may suffer reactions similar to victims of rape, spouse abuse, incest, abandonment, and posttraumatic stress disorder. Feelings of guilt, rage, isolation, confusion, and impaired ability to trust may occur. Harm from sexual relationships with the practitioner is universally accepted and easy to prove and there are no credible opinions in the profession that defend sexual relationships with clients. The codes of ethics for all mental health organizations include established moratoriums, timeframes, and strict regulations concerning sexual contact with clients. The mental-health practitioner must review the sections of their organization s code of ethics that governs sexual contact with clients in their entirety. The following list contains information held in common among major codes of ethics regarding regulations for sexual contact between mental health practitioners and clients: Mental health practitioners do not engage in sexual intimacies with current therapy clients/patients. Mental health practitioners do not engage in sexual contact with former clients according to the limits set in their organization s code of conduct. Sexual intimacy with former clients is likely to be harmful. Even after the appropriate time period allowed in the professional s code of conduct, the burden shifts to the therapist to demonstrate there has been no exploitation or injury to the client or the client s immediate family. Whether such contact is consensual or forced, under no circumstances the counselor will engage in sexual activities or sexual contact with current clients. Mental health practitioners should not engage in sexual activity with anyone associated directly with the client, such as friends, family members, or colleagues. Liability insurance carriers may construe bartering arrangements between mental health professionals and clients as business relationships and therefore refuse to defend covered therapist if bartering complications arise. Koocher and Keith-Spiegel (2008) believe that bartering arrangements have the propensity to be problematic, whether actually or perceived, exploitive, unsatisfactory in outcome to both parties, and should be used sparingly. The indecency of sexual conduct with clients is widely acknowledged and clients who sue for damages have an excellent chance of winning their lawsuits if allegations are true. Jorgenson (1995) lists the broad array of causes of action that victimized clients may allege in their civil lawsuits: Malpractice. Negligent infliction of emotional distress. Battery. Intentional infliction of emotional distress. Fraudulent misrepresentation. Breach of contract Breach of warranty. Spousal loss of consortium. Some state legislators have passed laws that automatically make it illegal for certain categories of mental health professionals to engage in sexual relationships with their clients which encourages victimized clients to sue. Client who sue must still prove the sexual relationship harmed them, but harm is broadly defined as mental, emotional, financial, or physical. Feeling sexually attracted to a client is not unethical, but acting on the attraction is unethical. On feeling a sexual attraction to a client, Remley and Herlihy (2007) recommend various measures, including: Consulting with professional colleagues. Considering client welfare issues. Obtaining supervision. Self-monitoring feelings. Seeking counseling to help the practitioner resolve their issues. Referring the clients to another therapist. Sexual dual relationships will always be clear ethical violations, but nevertheless continue to occur. Ted Remley, as a former executive director of ACA, served over 20 years on four counseling licensure boards. He reports that he presided over many license revocations and saw many counseling practices close due to inappropriate sexual relationships with clients. As a former co-chair of the ACA Ethics Committee, Gary Goodnough agrees that sexual boundary crossings may involve professors, students, counselors, and clients and are a serious topic of concern in the counseling field. He does not believe that this type of boundary Counselors.EliteCME.com Page 27

32 violations results from lack of training and believes counselors aware of the guidelines in the ethics code that forbid sexual contact. His explanation is, I think it has to do with unmet needs that counselors have as human beings that cause them to behave in ways in which they meet their needs at the expense of others (Goodnough, 2011). Remley believes that ethical violations related to sexual relationships occur when counselor cannot separate personal feelings and needs that grow from the counseling relationship. In order to solve these problems, Remley points to the counselor education programs to address this ethical issue directly and prepare students with strategies to identify and prevent sexual relationships with clients. He believes that counselors must learn how to identify feelings and find appropriate resolution when they are sexually attracted to clients through consultation with professional colleagues. He explains, because attraction to clients is an uncomfortable topic in our profession, it often is not talked about in counselor preparation programs. In addition, counseling practitioners are often reluctant to admit being attracted to clients. Counselors have to create a professional environment where this topic is welcomed and honestly addressed so that future abuses of clients will not occur. Goodnough believes counselor education programs have the responsibility to be vigilant for cues in student behavior that may indicate the potential for sexual misconduct. He believes that professors in counseling programs are in the unique position of working closely with students for 2 years, including time to observe them during their practicum. Goodnough believes that, in that time period, professors should identify students with personality issues or unmet needs as a precursor to sexual ethical violations. He believes the professors role includes monitoring student progress, growth and development and a deep knowledge of ethical and legal issues. During the counselor education program, problematic ethical issues can be identified, assessed, and a correction plan can be written for remediation. The student at this point has the faculty to supervise, teach, mentor, and coach them to assist in resolving personal issues that will interfere with ethical practice in a supportive manner. At the end of the program if the student has not been able to successfully complete the remediation plan or is still not able to control or resolve personal issues related to sexual attraction to clients they should be dismissed from the program for their best interest and the welfare of clients. Goodnough concludes, We need to pay attention to our gut as counselor educators, as well as to indicators that we set up for students to meet. Ethical boundaries can be crossed within the traditional counseling setting (Barnett, 2011). Barnett explains that there are situations where ethical boundary lines are crossed but not violated. On first inspection, these actions may appear to be appropriate for the counseling setting and plan, professionally allowable, culturally accepted, and in the best interest of the client to do no harm. Barnett cites the example that with a grieving client he might show support by touching the client on the shoulder or even giving him a hug. He explains that seemingly innocent action of reaching out to show support might be totally inappropriate and harmful for a client who has been sexual abused. Barnett makes the distinction that boundary crossing may be allowable is certain situations when it is helpful and allowed by the client in the counseling relationship but becomes an ethical boundary violation if it is harmful or rejected by the client or determined to be the result of the counselor s personal needs. A therapist had delivered services to a client for 2 months and felt an attraction to her. He decided to invite her to go with him to a presentation on autism because her nephew had been recently diagnosed with the disorder. The client believed that it was not a date but rather an educational event so she accepted. After the lecture, they went to dinner at the invitation of the therapist and again she agreed. When the client went to the next therapy session, she was given a DVD for the nephew that was produced by the speaker from the presentation. Following a subsequent therapy session, they again went to dinner and after a few drinks they returned to the client s house Case STUDY SIX: Sexual Boundary Violation where they engaged in sexual intercourse. The relationship continued for a month and ended when the therapist started dating a previous girlfriend again. The client was hurt and angry so she ended the therapy sessions and brought a malpractice suit against the therapist on the ground that he was unprofessional, the relationship violated professional boundaries, and caused her mental distress that left her unable to sleep which affected her work. The client won a large damage award as a result of her civil malpractice complaint (Koocher and Keith- Spiegel, 2008). Analysis The therapist has the burden of proving that no exploitation took place in relation to the client s mental status and severity of her presenting issues, ability to comprehend the risk, level of independence, and autonomy to act in their best interest. Therapists may have difficulty in defending themselves against a claim of harm as the professional with inherent power in the relationship to coerce or influence the client. Confidentiality and duty to warn Anyone familiar with the previous 1995 ACA Code of Ethics will notice the omission of clear an imminent danger and the substitution of serious and foreseeable harm in the revisions. This was a direct outcome from the legal case Tarasoff v the University of California. This case from 1969 concerned a counselor working with the client who confessed that they intended to murder their partner. (Grant, 2011). The study of confidentiality in the mental health field must Any diagnosis such as depression, previous abuse, or various personality or emotional disorders suggest vulnerability or susceptibility to exploitation and would influence the case against the therapist. The therapist or counselor must all ways put he client s welfare above his or her own. Sexual relationships with current, former or potential clients are always an ethical violation. include a thorough review of Tarasoff v Board of Regents of the University of California. Analysis of the legal case has been the subject of much historical literature in the field of mental health ethics and a brief summary will follow. Page 28 Counselors.EliteCME.com

33 In this case study, Prosenjit Poddar, a student from India, born into the Harijan, untouchable caste. He came to UC Berkeley as a graduate student in September of 1967 and he briefly dated a fellow student named Tatiana Tarasoff. She was not interested in a serious, exclusive, relationship, and during the summer of 1969 she went to South America. Poddar felt betrayed, became depressed, and went to a psychologist for counseling at UC Berkeley University s Health Service Department. During counseling, Poddar confided his intent to buy a gun and kill his former girlfriend and his psychologist concluded Poddar posed a significant danger. His conclusion came not only from Poddar s statements, but also included assessment results of pathological attachment to Tarasoff. The psychologist consulted with professional colleagues and notified police orally and in writing of his belief that Poddar posed a significant danger to Tarasoff and that he believed he was suffering from paranoid schizophrenia, acute and severe. He also told the police of Poddar s plans to shoot and kill her. The psychologist requested that the campus police detain Poddar and requested that the police take Poddar to a facility for hospitalization and an evaluation under California s civil commitment statutes to be committed as a dangerous person. Poddar was detained, but shortly thereafter released, as he appeared rational and police believed he was not a significant danger to his girlfriend. Poddar agreed that he would stay away from Ms. Tarasoff. Poddar then befriended Tatiana s brother and even moved in with him. In October, after Tatiana had returned home, Poddar stopped seeing his psychologist. Neither Tatiana nor her parents received any warning of the threat he revealed to the psychologist. October 27, 1969, Poddar carried out his plan, killing Tatiana Tarasoff by stabbing her with a kitchen knife. Case Study SEVEN: Duty to Warn Poddar s original sentence was overturned and he was allowed to avoid a second trial by agreeing to return to India. Some reports indicate he is married and living happily in India today. Tatiana Tarasoff s parents sued the psychologist, the University of California, health center staff who were involved in the consultation and the police. Initially, both trial and appeals courts dismissed the case because at that time no legal basis existed under California law concerning the duty to warn. The Tarasoff family appealed their case to the Supreme Court of California on the grounds that the defendants knew of the danger prior to the tragedy and had a duty to warn Ms. Tarasoff or her family of Poddar s potential for significant danger due to his severe mental illness and stated plans to kill their daughter. The family believed that the mental health professionals should have insisted on Poddar s confinement and should have taken steps to ensure he was hospitalized to protect their daughter. The court ruled in 1974 that the therapists did have a duty to warn Ms. Tarasoff. The defendants and several organizations responded and petitioned the court for a new hearing, which was granted. The second hearing in 1976 resulted in the ruling that released the police from liability, but established that mental health therapists were responsible and obligated to warn by imposing a duty that they use reasonable care to protect third parties against dangers posed by a patient. The ruling set forth that if a therapist concludes, or according to the standards of his profession should have concluded, that the client represents a serious danger of violence to society, the therapist has an obligation to use reasonable care and has a duty to warn in order to protect the intended victim against such danger. Depending on the specifics of the case, the therapist may have to make numerous contacts to notify and warn the potential victim(s), notify law enforcement, contact medical or psychiatric facilities, or persist in taking all steps necessary to warn and protect (Tarasoff v Regents of University of California, 1976). Ethical questions This case brings several ethical questions to mind: Should the counselor have informed the police or Tarasoff or her family? Does the counselor have a duty to warn or to protect? What information concerning cultural contexts existed and should they have been reviewed? Was the counselor competent to deal with the cultural aspects and the mental health diagnoses? Was the counselor competent to deal with dangerous or violent clients? If confidentiality is center of patient counselor relationships can the counselor violate this ethical standard if he is no longer seeing the client? Analysis Resulting court opinions form the basis for general acceptance of the notion that treating professionals have a duty to protect if they know there are intended victims. This is important and relates to the general principles of beneficence meaning, strive to benefit and nonmalfeasance or takes care to do no harm. In Tarasoff v Regents of the University of California, it was ruled that if the patient poses a significant risk of violence to another party, the therapist bears a duty to exercise reasonable care to protect the In what circumstances is breaching confidentiality necessary or allowed? What happens if clients who pose a significant danger to others and needs therapy do not return to therapy, which places the client and society at increased risk? What if clients in need of therapy avoid it because they feel the therapist may disclose information they share to law enforcement? What if clients are not forthcoming with their true feelings and intentions because they believe the counselor will disclose them to law enforcement or mental health facilities? What was the responsibility of the therapist or counselor to follow up after Poddar was released and for how long? foreseeable victim of the danger. States differ in their requirements for identifying foreseeable danger or intended victims and the scope or degree of possible danger. These are important factors to be considered and acted on to protect individuals and society. Counselors.EliteCME.com Page 29

34 Ethical decisions Key points resulting from the Tarasoff case (Grant, 2011): Belief that therapists have special knowledge, which, when coupled with the special relationship of therapist and client, gave rise to the duty to protect in this case. The Tarasoff case, and the line of cases that followed, do not stand for that proposition that psychotherapists have a duty to warn unknown, intended victims, instead they have a duty to protect the intended victim. Counselors must keep current in methods and procedures to handle violent clients and evaluate the level of danger. If a patient poses a significant risk of violence to another party, the therapist bears a duty to exercise reasonable care to protect the foreseeable victim of danger. One standard by which the breach confidentiality and the duty to warn will be judged is the standard of what a reasonable professional in the community under the circumstances would do. Counselors must be competent to work with clients with those diagnoses that may include violent behavior. Subsequent cases A number of cases, called progeny cases, followed in the path of the Tarasoff case including VandeCreek and Knapp, 2001 and Quattrocchi and Schopp, Elements from the Tarasoff ruling can be seen in numerous cases involving confidentiality, disclosure, informed consent, and duty to warn and protect as follows: Some cases have recognized the duty to warn all foreseeable victims, not just those clearly identified. Legislative and regulatory bodies have attempted to clarify and define this duty across numerous states. In child abuse cases, parents must be notified despite client confidentiality rules. All 50 states have mandatory reporting requirements for child abuse. In cases of communicable diseases, such as HIV, the counselor may attempt to diffuse the risks before making an exception to the confidentiality rule if the level of risk or level foreseeable harm allows it. Thorough records are critical to document that the therapist understood the nature of the situation in relation to the client s diagnosis. Counselors must take reasonable steps in light of the facts. Counselors should consult with colleagues if they unsure of how to proceed according to their code of ethics and the law of their state. A therapist is liable for a negative outcome if their actions fall below the expected level of care. Therapist liability either to the client for slander or defamation, or to the person warned for intentional infliction of emotional distress is extremely unlikely under the doctrine of qualified privilege (Grant, 2011). Elements of this doctrine are: Good faith. Legitimate interest in their duty to protect from harm to be furthered by statement or action. Statements limited in its scope to that purpose. Proper location and communication in a proper manner and to proper parties. Examples would be to: 1. Have the client present when the partner is notified. 2. Include this in part of the therapy. 3. Have the partner or client voluntarily divulge the disclosure. 4. Have the parties participate in other partner notification programs. States differ in their requirements concerning the identifiable victim versus the scope of the danger. As stated throughout all codes of ethics, the counselor must be familiar with their state statutes. Other circumstances dictate the counselor must legally report information in the following cases as outlined by law: Counselors believe a client younger than 16 years of age is a victim of incest, rape, or some other crime. Counselors believe the client needs hospitalization to prevent harm to self or others. When information is required as an issue in a court action. When clients request that their records be released to themselves or to a third party. (HIPAA, 1996). M.K. was a 15-year-old client of a New Jersey psychiatrist for 2 years. The client was open with the therapist about his use of illegal drugs and his violent thoughts about a fantasy to threaten people with a knife to control and rob them. He also told the therapist about his sexual relationship with a 20-year-old neighbor and it was clear that he had a strong emotional attachment to the young woman. M.K. often expressed his anger and jealousy that the woman was dating other men. The therapist observed that M.K. showed symptoms of severe anxiety when he spoke of the woman.in a subsequent session M.K. told the therapist that he once fired a BB gun at her car as she drove by his house. M.K. stole a prescription pad from the therapist, and attempted to forge his signature and attempted to purchase 30 xanax pills. The pharmacist noticed that M.K. was acting suspiciously and, because of his age, called the therapist who told the pharmacist to disregard the prescription and M.K. went home. He later stole a gun and shot the young woman to death. Case STUDY EIGHT: Duty to Warn The therapist had attempted to reach M.K. by phone to discuss the stolen prescription forms, but did not reach him before the woman was shot. The woman s father had heard of the Tarasoff case and the family hired an attorney to bring a civil suit against the therapist.the suit charged him with the wrongful death of their daughter and his failure to warn and protect her. The therapist hired an attorney who argued to dismiss the suit claiming that the Tarasoff principle should not apply in New Jersey for based on the following: The ability to predict danger is unreliable. Violating the client s confidentiality would have interfered with effective treatment. Instituting the Tarasoff principle might deter therapists from treating potentially violent patients. A ruling on the Tarasoff principle could lead to unwarranted commitments to institutions. Page 30 Counselors.EliteCME.com

35 Analysis The court rejected all these arguments and declined to dismiss the case, McIntosch v Milano, in The court instead ruled that the duty to warn is a valid concept under New Jersey law. The court decision stated that even though the therapist cannot be expected to be accurate in their predictions of danger or harm in 100 percent of the situations, they have the ability to make a professional judgment in the relationships of client with others. The therapist observed several warning signs and the client s own statements and actions of a violent nature should have provided the therapist with enough evidence to make a decision that a warning concerning danger was in order. The court made an analogy comparing the situation with the responsibility to warning communities and individuals about carriers of a contagious disease, and stated that client/therapist confidentiality must be secondary to the greater welfare of the community. In cases of imminent or potential danger, the therapist has the duty to warn. The therapist faced the jury and was not held liable for damages, but the Tarasoff principle of duty to warn and protect was adopted in New Jersey. A Ph.D. and MFT therapist had treated a client, who was a former policeman, for 3 years. Therapy centered on work related injuries and the break up of a 17-year relationship with a women who began to date someone else. On June 21, 2001 the client allegedly told the therapist that he was having suicidal thoughts. The therapists recommended hospitalization and he asked for permission to speak with the client s father. The father told the therapist that his son was deeply depressed, had lost his desire to live, and had mentioned harming the new man his former girlfriend was dating. The client checked himself into the hospital as a voluntary patient on the evening of June, 21, The therapist received a phone call from the client s father the next morning stating that the hospital would soon release his son. The therapist then called the admitting physician and urged him to maintain the client s hospitalization for further observation through the weekend. The psychiatrist disagreed Case Study NINE: Duty to Warn and released the client who did not contact his therapist after he was released from the hospital. No one from the hospital contacted the therapist after releasing the client. On June, 23, 2001 the client shot the boyfriend of his ex-partner and then killed himself with the same handgun. The parents of the new boyfriend filed a wrongful death lawsuit naming the therapist as one of the defendants (Ewing v Goldstein, 2004), claiming he had a duty to warn their son of the risk from the client. A judge dismissed the case against the therapist who asserted that his client did not disclose a threat to the new boyfriend directly to him. Ultimately, the California Court of Appeals reinstated the case, explaining, When the communication of a serious threat of physical harm is received by a therapist from the patient s immediate family, and is shared for the purpose of facilitating and furthering the patient s treatment, the fact that the family member is not technically the patient is not crucial. Analysis The court expressed that psychotherapy does not occur in a vacuum and that for therapy to be effective, therapists must be aware of the context of a client s history and their personal relationships. The court advised that communications from clients family members in the context comprised a patient communication. Mental health professionals however must use caution when taking the warnings from third parties such as parents or spouses who are emotionally involved or may have ulterior motives. This ruling requires the therapist to determine if individuals, who are non-professionals they do not know, have credible information that constitutes patient communication and necessitates the duty to warn. Case Study TEN: Third-Party Access: Insurers and Managed Care Blue Cross and Blue Shield of Massachusetts (BCBSMA) implemented a program in 2007 to measure outcomes related to subscribers who had accessed mental health services programs under their plans. They selected Behavioral Health Laboratories Treatment Outcomes Package (BHL-TOP) for the program that would be conducted as part of the delivery of service. Counselors and therapists would ask clients to voluntarily complete a survey form prior to beginning service and at set intervals until service was terminated. The therapist or counselor would electronically transmit the completed forms to the BHL personnel to be scored and stored. Reports on the results would be sent to the practitioner and BCBSMA for the purpose of monitoring and documenting ongoing progress during service delivery. BHL and BCBSMA provided assurance that data security was at the highest standard throughout the process. Counselors and therapists would receive an incentive for the number of surveys completed in the form of higher reimbursement.the surveys included questions of a personal nature including alcohol and drug use, income, religion, sexual orientation, and criminal history. Many clients took issue with the type of sensitive information on the form and felt pressured from the therapists and counselors in this program. They feared that if they did not complete the form the practitioner would not treat them the same way as clients who had completed the forms and felt as if they were being coerced. They threatened to bring a malpractice suit against the counselor and therapists in the program. Analysis Professional mental health associations expressed numerous ethical concerns and questions about the use of the surveys, electronic transmissions, and the incentive plan for the practitioner. The practitioner would be asking clients to voluntarily compromise their privacy in completing these forms putting the practitioner in an uncomfortable and ethically vulnerable position while receiving a financial incentive to obtain the data.in addition to a potential breach of privacy the practitioner was not in control of the data or the process used to transmit, share, and store data. They could not be certain that the disclosure of information would be to appropriate individuals that could ensure security. Clients personal and sensitive data would remain in electronic databases with no plans for future security or protection from further disclosure beyond the termination of the program. Increasing numbers of security breaches of electronically stored information and data theft from major companies, medical facilities, and governmental agencies raises serious ethical concerns Counselors.EliteCME.com Page 31

36 about confidentiality and privacy as well as violations of the HIPAA Privacy Rule. BCBSMA did not have a provision to give informed consent about the potential risks to subscribers of the plan who were receiving mental health therapy or counseling. As a result of the concerns of the professional associations and the pressure from subscribers, including possible legal and legislative contact, BCMSMA made significant changes to the program and assumed the responsibility of informing clients about the program, privacy issues, date storage and future use of information. They also removed the financial incentive structure based on the number of clients who complete the forms. Clients may be unaware that when they make a claim to an insurance company for reimbursement for mental health services, or allow a provider to do so, they will have information disclosed concerning the service that was rendered. The insurance company may ask for information concerning the date(s) of service, type of service provided, and the diagnosis, level of disability in work compensation cases, diagnosis, medications, and the projected length of service or number of session. The counselor or therapist can follow the ethical guidelines to be sure only the minimum information that relates directly to the request is shared and that all consent forms have been signed giving the provider the authority to disclose the information. The HIPAA Privacy Rule was designed to address client s privacy and the procedures for disclosure under the law. The client must be informed and give consent for all information that is shared and the recipients. The counselor must be sure all legal and ethical standards and procedures are followed though they cannot control the information once it has left their office. HIPAA penalties are a serious matter and all companies should handle documents following security procedures in order to avoid HIPPA violations and potential legal action if client privacy in breached. Misunderstanding and the stigma of mental illness still continue in society today. A documented history of mental health counseling or therapy often triggers a denial of coverage by underwriters of health and life insurance plans. All mental health providers and their staff should have received training in the HIPAA law as it affects their practice. The client however may not read or understand the forms they sign which allow their information to be shared. The provider is bound by the ethics codes to be sure they have the informed consent from their clients. This means the practitioner has done everything according to procedure, to the best of their ability to insure the client understands their rights including the forms they sign. This includes the risks they face when applying for insurance benefits to cover mental health services. D.C. battled cancer for many years and received assistance of a counselor on several occasions. She did not have regularly scheduled sessions but D.C. would consult the counselor when she faced medical issues and treatments that intensified her anxiety and depression. During a planned surgery there were complications and she had to be resuscitated which left her in a coma on life support. Her physicians informed her family of the possibility that she would remain on life support and her prognosis for recovery was bleak at best. Members of her family decided to approach the court for authorization to take D.C. off life-support. Case STUDY ELEVEN: Records Access by Family Members The family was instructed by the court to locate any information they could find that would shed some light on D.C. s wishes concerning end of life issues. The family asked the counselor if any of the records from counseling sessions might provide some guidance to the court concerning D.C. s end of life plans and help them make decisions about her treatment. The counselor refused and decided to consult a colleague. The family turned to the court for an order to compel the counselor and colleague to release all information and communication concerning D.C. wishes at the end of her life. The courts issued a subpoena for all records and communications concerning D.C. end of life decisions and the counselor eventually complied to avoid sanctions by the court. Analysis Family members have many reasons to seek access to the records of family members. Some are legitimate and others have the potential to harm the client and lead to an ethical violation if mistakes are made in disclosing information to the wrong party. In this situation, the client is incapacitated and cannot make her wishes known. In these cases, the courts recognize a surviving line of consent as follows: The first in line in the chain to grant consent is the spouse. This is true even if they are estranged and living apart, but not divorced. Next would be the children of legal age, giving each child equal weight in the decision. Next are parents or grandparents, followed by siblings, each having equal weight. If there are no family members the courts may appoint the next closest relative or close friend. The ethics codes are clear that in cases with minor clients, or clients meeting criteria as legally incompetent, that parents or legal guardians are given full access to records. Therapists must understand the complex nature of confidentiality, informed consent, and privacy when serving minors and their families. Even if a client is a minor or incompetent to understand at the expected level, the therapist should make every attempt to communicate in a way that they can understand at their developmental or cognitive level. The practitioner must be sensitive to the needs and feelings of these clients who may understand more than is readily apparent or they may have an inability to respond. At the beginning of any counseling or therapeutic relationship each member should receive information about confidentiality in the treatment relationship. The legal parent or guardian must be established before services begin the practitioner knows who may be contacted, consulted, and involved in the client s treatment. Counselors and therapists may be reluctant to provide access to records and notes to clients, parents, and guardians because they may believe they will not understand or misconstrue the information, which could cause harm to the client, impede the treatment plan or result in a lawsuit. The ethics codes of the NBCC, AAMFT, and ACA provide guidelines concerning the rights of the client and the obligation of the provider in this area. When information is shared, the practitioner must take the time to be sure the client understands the information, which involves interpretation and explanation. Records should never be turned over to the client or guardian without a conference, with all parties that have legal authority to review the information, so that the therapist or counselor can explain the contents and answer questions. Page 32 Counselors.EliteCME.com

37 B.R., age 15 years, receives therapy for behavioral problems at home and in school. She told the therapist that she does not feel close to her parents or comfortable talking to them about her problems. She also confided in the therapist that she is sexually active with multiple partners that are her age. At an annual physical exam, she was diagnosed with genital herpes that could only be acquired through sexual contact. During an argument with her parents B.R. screamed that she wished Case STUDY TWELVE: Access to Information by Parents they would listen and care as much about her as her therapist. This angered the parents and they concluded that the therapist probably knew B.R. was sexually active for months. They were enraged that the therapist knew their daughter was sexually active and did not notify them. The parents threatened a lawsuit and pulled B.R. out of therapy, which caused her problems to escalate further. Analysis This case may appear simple but actually addresses some complex issues related to confidentiality, the duty to protect the client from harm, and the issue of parent access of information and consent for services for their minor child. The law is clear that young minors cannot give consent for treatment, but, in this case, the parents did give consent and with that comes the right to see information in the client record. However, when the child becomes an adolescent, the situation of confidentiality and access to confidential information is not so clear and many exceptions can be found. Individual state laws are a major factor because some states do not permit minors to receive birth control information or receive treatment for sexually transmitted diseases without parental consent. It is conceivable that B.R. might have initiated a discussion with the therapist or raised questions about birth control issues, symptoms, or treatment she was having. Depending on how the therapist handled these inquires, the state license she held, and state of practice, she may or may not have crossed a boundary, or violated it during these discussions, depending on state law. California Consent Law is an example of state law that would give B.R. the right of consent to her own treatment. Of course, with consent she would control her records as well. They two statutes read as follows: If a minor meets the criteria under either statute, the minor may consent to his or her own treatment. If the minor meets the criteria under both, the provider may decide which statute to apply. The statutes are as follow: Family Code 6924 A minor who is 12 years of age or older may consent to mental health treatment or counseling on an outpatient basis or to residential shelter services, if both of the following requirements are satisfied: The minor, in the opinion of the attending professional person, is mature enough to participate intelligently in the outpatient services or residential shelter services. The minor (A) would present a danger of serious physical or mental harm to self or to others without the mental health treatment or counseling or residential shelter services, or (B) is the alleged victim of incest or child abuse (Cal. Fam. Code 6924,2010). Health & Safety Code A minor who is 12 years of age or older may consent to outpatient mental health treatment or counseling services if, in the opinion of the attending professional person, the minor is mature enough to participate intelligently in the mental health treatment or counseling services (Health & Safety. Code ,2010). This consent law limits parental access in the following: Parent Access/Confidentiality Obligation If the minor consents or could have consented to care, the provider only may share the minor s medical information with parents or guardian with the signed authorization of the minor. Cal. Health & Safety Code (a), (a); Cal. Civ Code 56.10(b)(7), 56.11(c); 45 C.F.R (g)(3); 45 C.F.R (a) 2010). Other considerations for this case include the following: One goal of therapy and counseling with adolescents is to help them develop autonomy and independence. Part of independence involves increasing levels of privacy as the child matures from childhood to adolescence and adulthood. The therapist must review the initial consent and confidential boundaries to be sure they are appropriate in the interest of client welfare and delivering the best therapy. The therapist or counselor must understand the importance of an adolescent s privacy as it relates maintaining the client-therapist relationship and delivering effective treatment. In adolescent treatment, nothing is more important when building trust and maintaining relationships in treatment as the client s belief that information given in confidence will not be shared without their consent. Clinically and ethically it is prudent to discuss with the adolescent in advance what information will be shared, and when. The ethics of duty to harm and imminent danger apply here. When the therapist or counselor believes that disclosing information to a parent would cause harm, disrupt, or end the treatment the decision to refuse the parent s request to access records may be supported by law. The professional faced with this situation should consult professionals, implement the decision making model and consult legal counsel concerning the specifics of the case and state law. Therapist and counselors must always know the laws for mandated reporting in their state. It is likely that if the therapist had reported B.R. s sexual activity to the parents she would have destroyed the trusting relationship they had built and violated B.R. s confidentiality. By not telling the parents, B.R. may have concluded her behavior was acceptable to this adult, though the therapist was simply trying to be non- judgmental, value free, and keep the lines of communication open. The therapist should help B.R. to see all the consequences of her behavior and help her develop decisionmaking and critical thinking skills to inform her actions. The parents are understandably upset and worried that her sexual behavior at a young age, with multiple partners they do not know, may cause irreparable physical and mental harm to their daughter. The parents may also be experiencing sadness that their daughter will not confide in them and would tell intimate details to the therapist. They may feel disappointed in their daughter or blame themselves as parents. In this case the parents were not in family therapy which would be advisable to help them cope with their feelings and to build the relationship with their daughter. At the age of 16 years, B.R. is capable of understanding her behavior and the consequences, barring any cognitive or developmental challenges, and can benefit from therapy to understand her feelings and develop appropriate coping strategies. In addition, she may come to realize that her sexual behavior puts her at risk for many negative consequences as a result of therapy with an adult she trusts. When all members are amenable and ready to communicate, a meeting with B.R. and her parents may be appropriate. The therapist will have to be sure she is able to maintain her relationship and level of Counselors.EliteCME.com Page 33

38 confidentiality with B.R. and provide support to both parties so they can heal and move forward. One apparent problem in this case is that that the parents did not understand their daughter s right to privacy and the confidential nature of the therapeutic relationship between their daughter and the therapist. It is likely that the parents made the first contact to ask for assistance so the therapist should have held a conference with the family to discuss issues of confidentiality and access to records. This may have prevented the misunderstanding concerning the disclosure of information shared in confidence. The parents are likely paying for the services and after the conference they could have made the decision Privilege and confidentiality Practitioners and clients may not be clear on the meanings of these terms though they have great importance when studying a number of ethics violations. Privileged communication describes certain specific types of relationships that enjoy protection from disclosure in legal proceedings. The term privilege was first noted in case law and is conveyed to the client in the therapeutic and counseling relationship. Privilege protects the client when the law would normally require all case material be delivered to the court and admitted into evidence. Clients have the ability to waive their right to privilege and, if they do, the counselor or therapist will be compelled to disclose all privileged material and communications relevant to the case. to not continue with the therapy once they understood that they would not have access to sensitive information shared by their daughter. The questions about the law in their state may still need to be considered but on face value in light of the ethics, the therapist did not commit an ethical violation in this case. Access to records sought by family members of an adult should be denied unless the client is incapacitated. Even though B.R. is 16 years old, 18 years is the age of consent in most states, her sexual activity with a partner of her age, unless she did not consent, would not be a illegal and does not initiate the duty to warn. The herpes would not hold up as serious danger, nor was B.R. incapacitated at the time according to her statements to the therapist. Prior to 1996, privilege involved only a limited number of relationships including: Attorney-client. Husband-wife. Physician-patient. Clergy relationships. Psychologists, psychiatrists, and social workers. Counselors, marriage and family therapists, all other mental health therapists, and psychiatric nurses were omitted. In 1996, the U.S. Supreme Court decided to review the case of privilege because there were so many rulings in the federal appellate court districts that were contradictory. The next case presented changed and extended privilege to licensed mental health professionals (Jaffe v Redmond, 1996). Mary Lu Redmond was a police officer in a suburb of Chicago. On June 27, 1991, she responded to a fight in progress call where she found Ricky Allen, Sr., chasing and man with a butcher knife in his hand. Mr. Allen caught the man and was about to stab him when Redmond fired her gun and killed Mr. Allen. Officer Redmond went to counseling after the shooting and worked with a clinical social worker. The administrator of Mr. Allen s estate, Carrie Jaffee, brought a law suit in the Federal District Court against Ms. Redmond based on U.S. civil rights statutes and Illinois tort law on the grounds that Officer Redmond violated Mr. Allen s constitutional rights because excessive force was used. During the process of discovery, Jaffee learned that the Ms. Redmond had 50 counseling sessions and requested the social worker be called to testify in the case and he wanted to review all of the notes and client records. The social worker and Ms. Redmond stated that they would not give Jaffe access to the records because that would be a violation of therapist-client privilege. The district judge ruled against Ms. Redmond and the social worker and allowed the discovery information to be part of the case, but they refused to turn over the information to Case STUDY THIRTEEN: Client Privilege the court. The Judge told the court, and instructed the jury, that the refusal to provide the record could be held against Ms. Redmond. He noted that the refusal leads to the presumption that contents of the notes could provide evidence against Ms. Redmond s case. The jury awarded the Petitioner $45,000 on the federal claim and $500,000 on her state-law claim. The Court of Appeals for the Seventh Circuit reversed the ruling and the case was scheduled for a new trial. On June 13, 1996, the Supreme Court overturned the previous decision in the lower court with a verdict supporting privilege to clients of licensed psychotherapists under Federal Rules of Evidence. Justice John Paul Stevens wrote privilege is rooted in the imperative need for confidence and trust, and that the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment (Jaffee v Redmond, 1996). Today all 50 states and the District of Columbia have past legislation allowing psychotherapist-client privilege. The Supreme Court supported the belief that privilege is good public policy that addresses and promotes confidence in mental health treatment. Analysis The U.S. Supreme Court decision affirms that confidentiality in psychotherapy takes precedence other important societal goals, laws, and statutes. A precedent was set allowing privilege to other mental health professionals. The decision aligns with client privacy, confidentiality, consent standards, and directives in all the major mental health association s ethics codes. The ruling will encourage, not discourage, individuals and families to seek assistance with mental health issues by protecting them from release of sensitive information. The new Health Insurance Portability and Accountability Act (HIPAA) privacy rule developed by the Department of Health and Human Services uses the findings of Jaffee v Redmond as a way to provide additional legal protections for confidential in the field of psychotherapy and covers all licensed mental health providers. Both the US Supreme Court Jaffee v Redmond ruling and the HIPAA Privacy Rule support the protection of confidentiality between therapists and clients. Page 34 Counselors.EliteCME.com

39 Case STUDY FOURTEEN: Privilege Applied to Child Safety and Custody The laws that govern mandatory reporting of child abuse will always take precedence over client privilege laws in all states. In cases of child abuse or neglect the therapist or counselor may be compelled to testify in court for the welfare of the child. The following case from the 2005 Alabama Supreme Court (Marks v Tenbrunsel) demonstrates these important facts: Client Marks consulted a psychologist, Dr. Tenbrunsel, for psychological services. It was the client s understanding that anything he shared with the therapist would be confidential information that would never leave the office. He believed the therapist told him there would be protection under client privilege when they met initially. During a subsequent therapy setting, Marks confided that he had sexually abused two girls under the age of 12 years. The therapist consulted a professional colleague and made the decision to tell Marks that as a mandated reporter he was compelled to report the incident to child protective services and the confidentiality agreement would be void in this case. Marks alleged malpractice, hired an attorney, and filed a civil case against the therapist and the colleague he consulted. He also claimed in the lawsuit that the therapist caused him to be prosecuted, lose his job, suffer mental anguish, and ruined him financially. The therapist s counsel filed a motion to have the case dismissed, which was granted. Marks then appealed the judgment of dismissal but the Alabama Supreme Court upheld the dismissal. Analysis The court, after reviewing rulings in other cases, found when a person issues a report of child abuse or neglect in good faith, or is called to testify in the judicial process related to the report, the person would have immunity from any liability, civil or criminal, that might otherwise be incurred or imposed. The court stated, because Marks admitted to the abuse of the two children the psychologists had reasonable causes to suspect that children were being abused and therefore were acting in good faith when they determined that a report should be made. In the review of other cases, the court found decisions that the psychotherapist-client privilege was second to the child abuse reporting statute and that child abuse statutes, vitiated the privilege and the therapist could be compelled to reveal the alleged sexual abuser s medical records in a civil action for damages. The court found in most cases the child abuse reporting statute abrogates a privilege that may otherwise be applicable with respect to proceedings involving child abuse or neglect. Some states allow all information in the report of child abuse to be disclosed along with all other privileged information, and others simply act on the fact that the report was made and substantiated in these cases of privilege brought against the therapist or counselor. For prosecution of the alleged abuser all privileged information would be discovered. In situations of child custody, there are a number of positions on privilege taken by the courts depending on the jurisdiction. Some courts will deny privilege to allow every piece of information to be reviewed to make the best possible custody decision. Some courts will strictly adhere to the Jaffee ruling of privilege. The courts will have to resolve any conflicts that may result based on these two positions and the circumstances of each case. In cases of custody disputes, the mental health of one or both parents, and the effects that may have on the child, may come into question. The court will make a decision based on the particular evidence regarding the mental health of the parents or the child. Again, states vary on their position of privilege in these cases depending on the severity of the mental health issues of the parents or child. Today states recognize privilege in the relationships of clients and mental health practitioners. Counselors and therapists should consult state statutes or case law in the state of their licensure and or jurisdiction of practice to be familiar with the concept of privilege in their state. Case STUDY FIFTEEN: Privilege and Confidentiality in Divorce and Child Custody The case, New Jersey Supreme Court Kinsella v Kinsella involved claims brought by both parties against each other in a divorce and child custody case. Spousal abuse claims and client privilege are included. This case began when Mr. Kinsella filed for divorce and sought custody of his three children alleging cruelty by Mrs. Kinsella. The wife in turn filed a counter claim that denied any cruelty on her part and alleged that her husband was extremely cruel, used drugs and alcohol, and was verbally and physically abusive to the children and her. Mrs. Kinsella sought divorce and custody of the children also. She noted that his drug and alcohol abuse led to a change in his personality and was so extreme that she required several surgeries. In order to make the best decision for the custody of the children the judge requested a psychologist to inform the court on the fitness of Mr. Kinsella to simply have overnight visitation at the onset of the case. The psychologist began by meeting with all members of the family and she consulted with another psychologist who worked with the family in the past. She discovered that Mr. Kinsella had continued to see the other psychologist for individual therapy as well. After conducting her evaluations, she informed the court that she would recommend overnight visitation be granted twice a month on weekends and for dinner in the middle of the week. She also told the court that both parents should receive therapy and a mediator would assist them in formulating a plan for co-parenting and supervised visitation. The appointed mediator was not able to achieve any consensus on a co-parenting plan with the parents and informed the court that the case would go to trial. Mr. Kinsella s legal counsel sought a court order to access Mrs. Kinsella s medical and psychological records to prepare for the trial and Mrs. Kinsella requested the order be modified so that each party could receive all psychological records for the other and she requested the records from the previous psychologist as well. Mrs. Kinsella said that the records from Mr. Kinsella s previous therapy would contain conversations with his therapist and admissions that he had been abusive toward the children and her, which was important in the custody decision. Mr. Kinsella s team sought protection for the records based on client privilege under New Jersey s rules of evidence and objected to the request for release of records. Mr.Kinsella and his attorney stated the information in the mediator s report gave enough information concerning his mental state to make custody and visitation decisions. Counselors.EliteCME.com Page 35

40 The Judge ordered the release of psychological records for each party be given to opposing counsel. He also directed that the parties would be allowed to read the records but they would not be released to them. Mr. Kinsella appealed the order to the intermediate appellate court citing that the records were privileged information and could be reviewed using other means. The psychologist submitted the following statement from: In my professional opinion, forcing me to produce my treatment notes and records, and possibly testify regarding my therapy sessions with the father, will cause him to suffer severe anxiety and humiliation. Additionally, I am extremely concerned that such disclosures could damage my relationship with him, causing regression in his progress and undermine the therapeutic process. I am specifically concerned if the substance of our conversations are revealed, and used in the divorce proceeding, he will be more cautious and less candid with me in future therapy sessions out of fear that whatever he says may be revealed to the outside world and used against him. The Kinsella case proceeded to the Supreme Court who issued the following statement about privilege in this case, Privilege runs counter to the fundamental theory of our judicial system that the fullest disclosure of the facts will best lead to the truth. The court continued with the following interpretation of common law that recognizes privilege for some specific types of information, and provided the following rationale statements: Privileged communications originate in confidence. Confidentiality is an essential element of the proper relationship between the parties. The relationship is one that the community wishes to encourage. The injury caused by damaging the relationship through disclosure of the communications would be greater than the benefit gained. Jaffee case Rule 501, concerning the perception of confidentiality, was referenced by the court, which noted that every state had some form of psychotherapist-client privilege. The court noted that Jaffee s Rule 501 was part of the Federal Rules of Evidence and that privilege serves the public s interest. The mere possibility of disclosure could impede successful treatment, and that an uncertain privilege was little better than no privilege at all. The Kinsella case also referenced the Tarasoff principle and its impact on exceptions in client litigation cases that include information and access to records exposing mental or emotional health in malpractice cases. When records are included in the case it is the same as waiving client privilege. The court suggested that the judge may review all records and decide what will be disclosed which preserves client privilege in part. To address the custody issues the court would have the obligation, to conduct a best-interests-of-the-child analysis in a child custody dispute. This would include a review of the results and testimony by the court-appointed psychological expert but would exclude the therapy records of a treating psychologist. Due to the importance of a correct decision in custody cases, the client privilege complicated difficult issues for the court. The trial court had to make a decision on privilege, while meeting their obligation to protect and promote the interests of the child. This case affirmed that courts must rely on mental health professionals to achieve the best-interest-of-the-child standard and each party should be allowed to use expert witnesses to this end as follows: Information from psychological evaluations could be more helpful to the court than the parents prior treatment records. Evaluations provide information on ability to parent, which can inform the custody decision and prior therapy may not relate to parenting. Evaluations include meeting with parents and the children but are conducted over a limited period of time giving the opportunity for family members to conceal issues. In conclusion, this court noted, evaluators in most cases are able to detect serious issues of unfitness, and they can consult with any psychologists or psychiatrists who have been treating the parents or children. Cases used to make decisions in this case include California, Florida, Connecticut, Idaho, and Missouri. These courts upheld claims of privilege in custody cases and concurred with the above statements on court-ordered evaluations. The New Jersey Kinsella court ruling can be interpreted as supporting client privilege but the court had the ability to breach the privilege in circumstances such as the welfare of a child. The court cited rulings of a New York court that implemented a test to balancing the interest of both sides of the issue and determined the following important factors in making decisions on privilege: Opening protected communications for review was critical to reach a decision in a custody case; a court s duty to protect the child would prevail. Furthermore, in light of the potentially chilling effects psychotherapist-patient privilege should not be ignored or lightly cast aside. Instead, there first must be a showing beyond mere statements that resolution of the custody issue requires revelation of the protected material. Courts, after careful review of all information, may disclose only the parts of the records directly related to the custody issue. When privilege was breached, it was due to discovered information that provided evidence of recent mental illness or continuing mental illness that was serious and therefore may be used to judge the fitness of the individual related to custody decision. Disclosure of privileged information may be indicated if that evidence cannot be found in any other source. Material from the court ordered evaluations is not enough to for a custody decision so disclosure of privileged information is warranted. Meeting the standard of the best interest of the child is the driving factor in disclosure. J.D. is a licensed Marriage and Family Therapist (MFT) who found herself in an ethical dilemma when faced with a court order to release certain client records from her files. J.D. refused to release treatment notes as ordered by the courts as part of a custody dispute involving a young client. She believed that there were two exceptions to the confidentiality and client privilege, including knowledge of child abuse or if the client threatens suicide or homicide. J.D. stated that the notes were sometimes just phases of her interpretations, thoughts, and topics to refresh her memory and would not be understood by anyone but herself. She believed that it was unethical to disclose Case STUDY SIXTEEN: Court Access to Records her notes and decided to provide only a general summary. The attorney brought the summary to the Judge who issued an order for the complete set of notes but J.D. decided to defy the court order. J.D. was arrested, and fined $2,000 on the contempt charge, which cost her $900 in bail in lieu of being incarcerated. In the end. J.D. decided to disclose the notes to the court. Page 36 Counselors.EliteCME.com

41 Analysis J.D. s personal views and her misinterpretation of the AAMFT Code of Ethics points to a lack of understanding in many areas. Here are the key features: If J.D. had referred to the Code she would know that she was wrong to defy the courts in this case. She made a mistake by not seeking assistance from other professionals, or her administrator, when faced with a situation as serious as a court order in a child custody case. In fact, she viewed her own opinion, not based on sound decisions following the Code, as more significant than the opinion of the court. She was not focusing on the best interest of her client by delaying the case and refusing to turn over her notes to inform the court s decision. The delay added to the stress and fear felt by her young client who was unable to give consent or waive the obligation of confidentiality to disclose the notes. If a subpoena duces tecum, subpoena for production of evidence, is issued that requests all files documents, notes, reports, photographs, and recordings in any form, it is clear that case notes are part of that request. The subpoena in this case would have a release signed by the parent in cases with a minor child. A court order is issued as the result of a hearing before a judge and demands a set of records be disclosed and delivered to the court representative unless there is an appeal to a higher court. It is the court, not the practitioner that will ultimately decide what qualifies as protected information. If the therapist is ordered to testify, and the client requests that they do not disclose privileged information, therapists may explain to the court the possible harm to the therapeutic relationship if a disclosure is made. If the judge requires the therapist to testify they disclose only the information related to the request. Under court order, the counselor or therapist is not in violation of privacy rules or privilege because they are complying with the judge s order. The court order is defense against any charge of ethical wrongdoing if the counselor is later sued over a breach of confidentiality. Summary of the Health Insurance Portability Accountability Act HIPAA Privacy Rule Standards for Privacy of Individually Identifiable Health Information establishes a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services (HHS) issued the Privacy Rule to implement the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The Privacy Rule standards address the use and disclosure of individuals health information called protected health information by organizations under the Privacy Rule called covered entities. According to the Privacy Rule, as well as all of the Administrative Simplification rules, the term covered entities applies to health plans, health care clearinghouses, and to any healthcare provider who transmits health information in electronic form in connection with services or transactions. HIPAA also includes standards for individuals privacy rights to understand and control how their health information is used. A major goal of the Privacy Rule is to assure that individuals health information is properly protected while allowing sharing of health information to provide high-quality health care and to protect to public health. The Rule permits the use of information, while protecting the privacy of people who seek care and treatment. Psychotherapy notes are treated in a different way from other records under the HIPAA Privacy Rule. These notes include: Details about the topics covered, process and methods used in the session. Details that extend beyond the typical documentation in medical records. The therapist s observations written for their use only. These notes may be written and maintained in any format at the discretion of the practitioner. The healthcare marketplace is diverse, so the Privacy Rule is designed to be flexible and comprehensive to cover the variety of disclosures that need to be addressed. The entire HIPPA document and Privacy Rule is extensive with more than 800 pages. Covered entities regulated by the rule are obligated to comply with all of its requirements and should not rely on this summary as the source of legal information or advice. Counselors should be aware that 2013 brought important changes to HIPAA and that September 23, 2013, was the compliance deadline for many of these regulatory requirements. Any counselor or therapist who is not sure if they are considered a covered entity under HIPAA should immediately access the online decision-making tool available at the website of the Centers for Medicare and Medicaid Services. All counselors who are covered entities should move quickly to come into compliance or risk very stiff monetary penalties (ACA, 2014). To view the entire Rule, and for other information about how it applies, review the website at Counselors.EliteCME.com Page 37

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Tag Archives: Ethics & Legal Issues. Retrieved April 14, 2015 from ct.counseling.org/tag/ethics-legal-issues/ 30. Montgomery, L.H., and Cupit, B.E. (1999) Complaints, Malpractices, and Risk Management: Professional Issues and Personal Experiences. Retrieved April 20, 2015 from psychpage.com/ethics/pfstand1.html Resources for Information References Association for Multi-Cultural Counseling and Development HIPAA Privacy Rule International Association of Marriage and Family Counselors (IAMFC) National Association of Mental Health Counselors National Board for Certified Counselors Neukrug, E., Milliken, T., and Walden, S. (2001). Ethical complaints made against credentialed counselors: An updated survey of state licensing boards. Retrieved April 14, 2015 fromhttp://www. counseling.org/search-results?q=23+dec doi%3a %2f+j tb01268.x american+counseling+association.+issue National Board for Certified Counselors. (2015). Retrieved April, 13, 2015 from org/interactivecodeofethics/ 33. National Center for Youth Law. (2010). California Minor Consent Laws Mental Health Services: Minor Consent Services and Parents Access Rules. (2010). Retrieved April 11,2015 from CaMCConfMentalHealthChart Pope, K.S. (2001). Sex Between Therapist and Client. Retrieved on April 16, 2015 from kspope.com/sexiss/sexencyc.php 35. Pope, K.S. and Vasquez, M.J.T. (1998). Ethics in psychotherapy and counseling: A practical guide for psychologists (2nd Ed.). Retrieved on April 23, 2015 from Paniagua, F.A. (2001). Assessing and Treating Culturally Diverse Clients. Retrieved on April 24, 2015 from Pedersen, P.B. (2007). Ethics and Professional Issues in Cross-Cultural Counseling. Retrieved April 25, 2014, from Remley, T. and Herlihy, B. (2007). Ethical, Legal, and Professional Issues in Counseling (2nd Ed.) New Jersey: Pearson Education, Inc. 40. Remley, T. and Johnson, B.W. (2014). Ethics Desk Reference for Counselors, (2nd Ed.) Alexandria, A.: American Counseling Association. 41. Ridley, C. (2005). Overcoming Intentional Racism in Counseling and Therapy. Thousand Oaks, CA: Sage Publishing. 42. Sadler, H.A. (1986). Making Hard Choices: Clarifying Controversial Ethical Issues. Counseling and Human Development, 19, Shallcross, L. (2011) Do the Right Thing. Retrieved April 20,2015 from org/2011/04/do-the-right-thing/ 44. Superior Court of Los Angeles County (2004). Cal Ewing et al., Plaintiffs and Appellants, v David Goldstein, Ph.D., Defendant and Respondent, No. BC267552, Retrieve April14, 2015 from forensicpsychiatry.stanford.edu/files/ewing%20v%20goldstein.htm 45. Supreme Court of Alabama. (2005). David Kenneth Marks v Dr. Thomas W. Tenbrunsel et al April 22, Retrieved April 17, 2015 from Supreme Court of New Jersey. (1997). John Kinsella, Plaintiff-Respondent and Cross-Appellant, v Mary Kinsella, Defendant-Appellant and Cross Respondent. Decided: July 10, Retrieved on April 17, 2015 from Supreme Court of the United States (1996). No Carrie Jaffee, special administrator for Ricky Allen, Sr., deceased, Petitioner v Mary Lu Redmond et al. 48. On Writ of Certiorari to the United States Court of Appeals for the Seventh Circuit. Retrieved on April 14, 2015 from Tarasoff v Regents (1976). 17Cal.3d 425,551 P.2d 334,131 Cal.Rptr.14.Retrieved April 15, 2015 from Trimble, J.E. and Fisher, C. (2006). Handbook on Ethical Considerations in Conducting Research with Ethnocultural Populations and Communities. Thousand Oaks, CA: Sage Publishing. 51. United States District Court Eastern District of Michigan (2010). Case 2:09-cv GCS-PJK Document 139Filed 07/26/10, Julea Ward, Plaintiff, vs. Roy Wilbanks, et al., Defendants. Retrieved on April 15, 2015 from Van Hoose, W.H. and Paradise, L.V (1979). Ethics in Counseling and Psychotherapy: Perspectives in Issues and Decision Making. Cranston, RI: Carroll Press. 53. Wade, M. (2015). Ethics and Social Media. Retrieved April 16, 2015 from org/knowledge-center/podcasts/docs/default-source/aca-podcasts/ht Welfel, E.R. (2002) Ethics in Counseling and Psychotherapy: Standards, Research, and Emerging Issues. Retrieved April 18, 2015 from Wheeler, A. M., Bertram, B. (2008). The Counselor and the Law: A Guide to Legal and Ethical Practice, Sixth Edition. American Counseling Association. Retrieved April 14, 2015 from Whitman, J.S., Glosoff, H.L., Kocet, M.M. and Tarvydas, V (2011). Retrieved on April 21, 2014 from Yelamanchili, A. (2015). President Obama Calls for End to Conversion Therapy. Retrieved April 15, 2015 from Page 38 Counselors.EliteCME.com

43 Ethical Practice for Marriage and Family Therapy and Professional Counseling Final Examination Questions Select the best answer for each question and mark your answers on the Final Examination Answer Sheet found on page 43, or for faster service complete your test online at Counselors.EliteCME.com. 1. Ethics in counseling and therapy focuses on which of the following: a. Mandatory rules that must be followed. b. Ideals rather than obligatory rules. c. Jurisdictional law. d. Compliance rules. 2. The ACA suggests that counselors seek consensus and document in writing the confidentiality agreements among which of the following? a. The primary client. b. The adult client. c. All parties involved in the group counseling setting. d. The client that contacted the office for services or assistance. 3. The 2014 ACA revision states that additional considerations to confidentiality apply to address which of the following areas? a. Premature birthrights. b. Sexual orientation. c. Gender transition. d. End-of-life and child welfare issues. 4. What can be said about the non-traditional family today? a. The therapist must try to help these families assimilate into today s culture. b. It is impossible to be competent with the changes in family composition to adequately counsel them. c. Today there is no typical family group and each person in the family may face issues related to their unique family composition. d. There is little training for counseling these groups. 5. The three tests for a course of action to be sure it is appropriate are which of the following? a. Honesty, integrity, and legality. b. Truth, justice, and peer review. c. Confidentiality, privilege, and justice. d. Justice, publicity, and universality. 6. Serious and foreseeable is which of the following concepts? a. It is impossible to accurately predict harm or danger. b. It protects the counselor or therapist from liability in most states. c. It warns clients of risk in distance therapy using technology. d. A concept used in negligence tort law to limit the liability of a party to those acts carrying a risk of foreseeable harm. 7. According to the NBCC, when should a counselor seek professional assistance or withdraw from practice? a. If mental or physical conditions render the counselor unable to provide services. b. When they do not share values or believe the client is acting immorally. c. When they strongly disagree with the client s beliefs. d. When they feel that the client is a danger to themselves and others. 8. NBCC developed a process to review alleged ethics violations by their NCCs and administer discipline if warranted. Which of the following statements are true? a. NCCs are not bound by decisions by the NBCC. b. NCCs are governed by their own state laws of practice only. c. NCCs are bound by the decisions by NBCC, which are governed by the laws of North Carolina. d. NCCs are bound by their professional association s ethics codes only. 9. Concerning distance counseling, technology, and social media, the ACA Code of Ethics states which of the following? a. Counseling should be limited face-to-face interactions. b. Distance counseling is in the experimental stage and should be avoided. c. Social media is not a resource for counselors. d. Counselor understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how resources may be used to better serve their clients. 10. One part of the AAMFT binding expectations is as follows: a. When the AAMFT standards and the law conflict, the law must be followed. b. AAMFT members have an obligation to be familiar with the AAMFT Code of Ethics and its application to their professional services. c. The AAMFT members are not bound by their Code of Ethics. d. The AAMFT does not have a binding commitment to process ethical complaints or resolve them but defers to the law in these cases. 11. The ACA advises which of the following about social media? a. Never follow clients on social media, even with consent. b. Social media is public so it should be followed to learn more about clients with or without consent, it is a violation. c. Social media is allowed is potentially too dangerous and should be avoided. d. Do not follow clients on social media as the ACA advises, counselors respect the privacy of their clients presence on social media, unless given consent to view such information. 12. Linde uses the example of Instagram to warn against social media that may lead to which of the following? a. Stalking and privacy violations. b. Anxiety over self-concept when pictures are unflattering. c. These photos can be viewed by anyone and viewers may comment which can lead to cyber bullying. d. Increased narcissism in teen girls. Counselors.EliteCME.com Page 39

44 13. According to the Center for Democracy and Technology (2015) what is the most common form of security breach with mobile devices? a. Hacking is the most common form. b. Theft is the most common form. c. System failure is the most common form. d. Interception is the most common form. 14. Which view is held by ACA, AAMFT, and NBCC to the practice of conversion/reparative therapy? a. No opinions are held in common. b. Two associations oppose the practice. c. All are conducting research. d. Opposition to the practice of conversion/reparative therapy. 15. ACA Code of Ethics allows counselors to terminate a counseling relationship only under specified circumstances. Which of the following is not one of these circumstances? a. When it becomes reasonably apparent that the client no longer needs assistance. b. When counselor values conflict with the client s values. c. The client is not likely to benefit. d. The client being harmed by continued counseling. 16. Which statement is true about dual relationships? a. They should always be avoided. b. They are always unethical. c. The mental health practitioner should not enter into a dual relationship if the possibility exists that it could exploit or harm the client. d. There is no support from the codes at all. 18. The ethics codes provide what information concerning release of information to parents of guardians? a. In cases with minor clients, or clients meeting criteria as legally incompetent, that parents or legal guardians are given full access to records. b. They do not give clear guidance on the topic. c. Legal guardians must have a court order. d. Parents must obtain a court order. 19. Which statement is not correct concerning privilege? a. The term privilege was first noted in case law. b. It is conveyed to the client in the therapeutic and counseling relationship. c. Privilege protects the client when the law would normally require all case material be delivered to the court and admitted into evidence. d. Clients do not have the ability to waive their right to privilege. 20. The term covered entities applies to all of the following except: a. Health plans. b. Any healthcare provider who transmits health information in electronic form in connection with services or transactions. c. Only the employing organization not the counselor or therapist d. Healthcare clearinghouses 17. The counselor must legally report information in the following cases as outlined by law except in one of the following: a. Counselors believe a client younger than 16 years is a victim of incest, rape, or some other crime. b. Counselors believe the client needs hospitalization to prevent harm to self or others. c. When information is required for research. d. When clients request that their records be released to themselves or to a third party. PCUS06ETE16 Page 40 Counselors.EliteCME.com

45 NOTES Counselors.EliteCME.com Page 41

46 2016 CE Course for Professional Counselors $4 ONLY per credit hour Customer Information Three Easy Steps to Completing Your License Renewal Step 1: Complete your Elite continuing education courses: What if I Still Have Questions? No problem, we have several options for you to choose from! Online at Counselors.Elite. CME.com you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or us at office@ elitecme.com or call us toll free at , Monday - Friday 9:00 am - 6:00 pm EST. 99 Read the course materials and answer the test questions. 99 Submit your final exam and course evaluation along with your payment to Elite online, by fax or mail. Step 2: On-Line Submission: Go to Counselors.EliteCME.com and follow the prompts.you will be able to print your certificate immediately upon completion of the course. 99 Fax or Submission: Fax to (386) , be sure to include your credit card information. All completions will be processed within 2 business days of receipt and certificates ed to the address provided.* 99 Mail Submission: Use the envelope provided or mail to Elite, PO Box 37, Ormond Beach, FL All completions will be processed and certificates issued within 10 business days from the date it is mailed.* *Please note - providing a valid address is the quickest and most efficient way to receive your certificates when submiting via fax, or mail. Submissions without a valid address will be mailed to the address provided at registration. Step 3: Once you have received your certificate of completion you can renew your license with your state board, or mail in your renewal. You should receive your renewal notice within 90 days of the expiration date in most states. Elite Continuing Education Page 42 Counselors.EliteCME.com