Tag Archives: Ethics & Legal Issues

No, I didn’t! Denial revisited

By Michael Hubbard July 7, 2014

denialGiven that I thought I’d cultivated my listening skills, it was uncharacteristic of me to so abruptly interrupt a patient who felt compelled to plead his court case of a criminal charge in group therapy. We in group, of course, were experiencing the very common occurrence of denial.

As part of a program in a largely forensic mental institution, our clinicians are primarily working with individuals convicted of some offense and admitted under the “guilty except for insanity” (GEI) determination. More specifically, my team’s sex offender treatment program works with those who have a sex offense conviction in their history and/or have been sexually assaultive or otherwise sexually inappropriate in the hospital.

Yet to take it out of the forensic arena, most counselors will have any number of client cases in which some form of denial may also play a central role. We see denial and so-called “resistance” in couples counseling, in family counseling and when working with any age and circumstance. We witness denial in issues of death and dying or with clients and families dealing with serious or terminal illness. And what counselor working in the drug and alcohol, gambling and other addictions field wouldn’t agree that denial is a hallmark in that client population? Ultimately, whatever level of denial we experience may be perceived as resistance and a barrier to treatment.

 

There are all kinds

While there are multiple types and levels of denial, most are ultimately rooted in avoiding or mitigating responsibility and accountability, generally more along the lines of minimizing or redefining behavior. Yet I have worked with some clients who engage in denial of facts, especially in the initial sessions. This is the classic denial of their offense or some other behavior. It’s also the very common default or impulsive defense mechanism among many of us, especially at a young age (“No, I didn’t break that window”).

In the case of the patient I interrupted, he not only denied the offense (a rape charge), he also denied any transgression in his entire life. Further, he was more focused on pleading his case with the group members and clinicians than on his treatment.

More common, however, are all the other types of denial. Many sex offenders with whom I have worked will engage in denial of impact or harm (“I only fondled her”), even if they admit to their offense. I see this often in cases of attempted rape, wherein the prevailing, and mistaken, attitude is often that there is less trauma if there was no penetration.

Yet we see that same perspective in other forms of rationalization (“Children are resilient; he’ll forget it”), in couples and family disagreements (“It’s always drama with her, so we don’t take her threats of suicide seriously”) and with other situations. Those who work with grief and bereavement will very likely identify with the upset client whose friends, family members or other acquaintances deliver minimizing and rather dismissive statements such as “time to move on,” “don’t dwell on it,” “get over it” and, of course, the trite “time will heal.”

Denial of intent is another common excuse (“It got out of control”). In my work, I’m often subjected to a curious phrase regarding date rape: “There we were … and it just happened,” thus jettisoning the fantasizing, the grooming and all the other behaviors that led up to a life-altering result.

Denial of responsibility, which is related to denial of intent, does not necessarily deny behavior, but is more along the lines of shifting blame. An example most of us have heard, particularly in working with children, is “He started it first.” In a more bizarre example, however, I had a client who was talking about a college female who was raped. His comment was, “Well, it happened in a fraternity. She should have known what was going to happen because that’s what happens at frat houses.”

There are many other types of denial, of course, including a minimizing form — denial of frequency (“It only happened once”) — and denial of fantasy (“I only fantasize about my girlfriend in a healthy way”). That fantasy example was voiced by a hypersexual patient who had molested many young boys over the years. He was engaging in impression management to impart an image of his engaging only in appropriate fantasies.

 

Do I really need this?

One important form of denial affects almost all counselors and other clinicians: denial of treatment need. Many clients with whom I’ve worked say, “I’ve learned my lesson. I’ll never do that again.” While they may genuinely believe that, what they’re overlooking is that they may not have examined the circumstances that led to their offenses, their triggers and risk factors and, thus, what interventions to use. Yet this type of denial isn’t the sole property of those who have engaged in some form of criminal activity.

Many counselors in various settings deal with individuals who have been “coerced” into making appointments. It may be someone with gambling, alcohol or other addictions forced into treatment by families, friends or even a workplace supervisor. It may be someone who had a “dirty” urinalysis at work and was suspended until he or she engaged in some mandatory employee assistance program (EAP) sessions. Few of these individuals show up feeling the need for treatment, especially if it was not their choice.

Often, resistant clients show up in family counseling. These may be teenagers or others with behavioral issues, or a spouse with relationship problems, depression, sexual dysfunction or other presentations. Many of these clients feel that they don’t need counseling, or even if they agree to the need, they are embarrassed to be seeking mental health counseling. Stigma exacerbates a natural tendency to deny.

Many of the individuals pushed into counseling may feel that the problem is with their partner, their parents or with other relatives or friends. Even among those who admit to some level of treatment need or recognize a problem, many prefer to participate in the multibillion-dollar self-help industry of books and videos. Yet is that so very different from those who deny a disease or who think that they can lose weight or otherwise regain some level of health on their own through use of a book or video? The question remains whether an individual who feels confident in self-healing is still engaging in a form of denial. Perhaps so, but with placebo or other effect in place, does it matter if the outcomes are positive?

It may be important to explore why denial occurs in our clients, but a key question is whether denial is a deal killer in treatment. It may seem, for instance, that working with an offender who denies his or her crime is a barrier, but there are many who would disagree with that premise.

 

Does it matter?

In the world of sex offender treatment, most community-based and residential programs in the United States consider taking responsibility for offenses a key component of treatment. That would be defined as a disclosure or admission at least approximating police and victim reports, even if the offender minimizes or engages in other forms of denial. Use of polygraphs is also a common practice. In fact, it is generally a condition of parole.

By comparison, no Canadian sex offender programs require full admission of guilt, and one report indicates that only approximately 26 percent of Canadian community-based programs require any offense disclosure at all (McGrath, Cumming, Burchard, Zeoli, & Ellerby, 2010). That may seem counterintuitive. After all, how can one deal with any situation — whether offense-related or not — if the client denies its occurrence? The answer may rest in what we as clinicians are seeking, both in mining for information helpful in therapy and as an outcome.

But does it matter? While it would seem logical that issues are difficult to address if denied, in the sex offender world at least, data are indicating very little correlation between denial and recidivism. Some, in fact, would point out that denial is an indicator that the offender is well aware, and ashamed, that the act was inappropriate or deviant, in addition to being illegal. In such cases, perhaps our clinical attention is distracted by their denial and should be emphasized elsewhere (e.g., social skills, healthy relationships, etc.).

For those clinicians who believe that client denial does matter, some point to other contributing factors to denial, including the milieu. For instance, in group therapy, it’s reasonable to believe that initial denial would be both common and understandable, particularly with an individual newly introduced to the group. Safety and trust must generally be established. It’s the rare client who is willing to share his or her failures in front of strangers.

Yet one source of help is when the newer clients in group realize that there are others in the same boat, that they’re not alone and that there is support. While this is one of the many advantages of group therapy, a step-up approach with motivational interviewing and alliance-building in individual sessions may be required.

Even in smaller situations such as couples counseling, the sharing may be difficult at first. Yet there are also other dynamics involved in couples and family counseling, such as clients seeking support for “their side,” the fight over “right and wrong,” couples utilizing other techniques (e.g., manipulation) and the perceived or actual issues (even if they aren’t obvious to the clients).

 

Who’s responsible?

It’s far too easy for many of us to say that a client is “in denial” or “resistant.” As stated earlier, many U.S.-based sex offender programs require accountability, including reasonable admission of offenses, with the implication that treatment could be withheld if the offender refuses or resists.

Whether or not it matters may be determined on an individual basis. If it is deemed important, and if there is resistance, might this not be a responsivity issue? And if so, should we not be responsible ourselves as the clinicians?

Our program here is on a risk/needs/responsivity model. Simply put, higher-risk patients receive more intense treatment than those assessed at lower risk. Patient needs, including dynamic risk factors, are addressed as important factors in treatment. Responsivity is an indication of the patient’s response to and/or acceptance and digestion of the treatment approach, as well as a measure of the clinician’s ability to provide the service that will be most accepted.

So while we may feel justified in indicating that a patient’s intransigence is a barrier to treatment, are we not responsible on some level for treatment failure if we are not experiencing a response? And if we assume that responsibility, is it not our task to continue the search for treatment to which the patient may respond? Can we achieve a measurable outcome even in the face of denial? Obviously, some programs believe so. But how?

In a forensic setting, we’re seeking risk mitigation — simply put, to achieve a goal of returning the patient to the community without that individual committing another offense. But can risk mitigation be achieved even if the patient refuses to take responsibility for his offenses? Perhaps so if we’re able to work with the patient to discuss all the circumstances and other factors surrounding the offense. I call this the “backdoor approach.”

For instance, if a patient is willing to discuss what was going on in his or her life prior to, during and even after an offense — even without admitting to an offense — we may be able to identify and point out behavioral patterns and/or circumstances that would be considered potentially contributory to an offense. For example, while not necessarily an excuse for offending, if the patient states that he or she was on methamphetamine or other substances, a risk factor emerges.

I have had patients indicate that their offenses occurred after a break-up or during a rough period in a relationship. Regardless of whether one believes that watching pornography is pre-offense behavior, many have indicated that they turned more and more to porn after a break-up or during a period of no sexual activity, and sought other outlets. Alcohol and drug use has been cited as one of the more common outlets.

Of course, in our setting in a mental institution, there are also contributory situations of a patient going off medication or otherwise decompensating, leading to offense-related behavior. Stress and other situations can be explored, patterns noted and, thus, risk factors identified. Even in cases in which the offense is denied, the patient is often able to see what situations set up as being more risk-related scenarios — and thus their vulnerabilities. Risk mitigation can then be effected on some level by addressing the vulnerabilities through appropriate interventions.

This same approach would be viable in couples counseling, family counseling and other similar forms of counseling. In short, we can examine environmental and other issues that trigger emotions, thoughts and consequential behavior in our clients. This approach relates to a form of mindfulness in which clients can step away and look at external influences, perhaps setting aside blame and personalized issues in the process.

 

Ethical issues

While considering the reasons for denial, and strategies to achieve some outcome, the topic is not without some ethical issues. The preamble of the 2014 ACA Code of Ethics reads in part:

“These professional values provide a conceptual basis for the ethical principles enumerated below. These principles are the foundation for ethical behavior and decision making. The fundamental principles of professional ethical behavior are

autonomy, or fostering the right to control the direction of one’s life;

nonmaleficence, or avoiding actions that cause harm;

beneficence, or working for the good of the individual and society by promoting mental health and well-being;

justice, or treating individuals equitably and fostering fairness and equality;

fidelity, or honoring commitments and keeping promises, including fulfilling one’s responsibilities of trust in professional relationships; and

veracity, or dealing truthfully with individuals with whom counselors come into professional contact.”

In attempts to deal with denial, are there iatrogenic factors present in our demand for disclosure that would constitute maleficence? And where do we stand, and how would we know, if the person indeed did not commit an offense? If, in our cases, a denier passes a polygraph, does that carry any weight, notwithstanding admissibility (or not) in court, police reports or other materials?

Would it be ethical to “treat” someone for something they did not do; or do we treat based upon all the other findings, regardless of the client’s adamant stance? Are we out of our scope of practice if drawn into the legal questions? We must be mindful of these ACA ethics standards:

 

B.1.b. Respect for Privacy

Counselors respect the privacy of prospective and current clients. Counselors request private information from clients only when it is beneficial to the counseling process.

 

B.1.c. Respect for Confidentiality

Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification.

 

B.2.e. Minimal Disclosure

To the extent possible, clients are informed before confidential information is disclosed and are involved in the disclosure decision-making process. When circumstances require the disclosure of confidential information, only essential information is revealed.

 

These questions may all lead to what boundaries we draw regarding working with denial. It is likely an easier decision when there is no denial of fact, but rather the more often expected “lesser” denials. Yet, as in all cases, we must consider potential iatrogenic effects. When we consider how very much we detest denial in our society, and yet forgive confession, it behooves us to explore our goal as counselors when denial is a key factor.

We might want to examine whether our goal is an outcome we can achieve by other means, or whether we are so outraged at the “lies” that we become committed to “breaking” someone.

 

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Michael Hubbard is a mental health specialist with the sex offender treatment program at Oregon State Hospital in Salem, Ore. Contact him at Michael.Hubbard@state.or.us.

 

For related reading, see Hubbard’s article from the April 2014 issue of Counseling Today: Sex offender therapy: A battle on multiple fronts

 

A living document of ethical guidance

By Laurie Meyers May 22, 2014

Branding-Box-EthicsAfter three years of work that included 40 conference calls, numerous face-to-face meetings, two meetings at American Counseling Association annual conferences, two town hall meetings and the evaluation of feedback received from more than 100 ACA members, the 2014 ACA Code of Ethics was approved and released at the end of March, replacing the prior ethics code that had been in place since 2005.

“The revised code makes it clear that we have completely made the transition as a profession from focusing on the needs of the counselor to the needs of the client — that our clients are more important than we are,” says David Kaplan, ACA’s chief professional officer and staff liaison to the ACA Ethics Revision Task Force. “The code now states the values of the counseling profession and the basic ethical principles that all counselors — not just ACA members — are expected to use to inform their practice, teaching, supervision and research.”

The 11 members of the ACA Ethics Revision Task Force, chosen for their backgrounds and expertise in ethics, started the process knowing that every area of the code would need scrutiny. Two areas in particular stood out, however — the sticky question of counselor personal values and the ethical use of technology and social media with counseling clients. These areas wound up influencing the ethics code in its entirety because task force members decided it was important to infuse the issues throughout the finalized ethics language.

“A code of ethics is a living document that is meant to change as the profession grows and develops over time,” says Ethics Revision Task Force Chair Perry Francis, a counseling professor in the Department of Leadership and Counseling at Eastern Michigan University (EMU).

The counseling profession has experienced a substantial amount of growth, development and change in the nine years since the release of the 2005 code, and the Ethics Revision Task Force thought it was important for the 2014 ACA Code of Ethics to address the current professional and societal climate. Therefore, task force members carefully considered feedback from practitioners in the field to ensure the revised ethics code would provide guidance for current practices and challenges in the profession, says Francis, who also coordinates EMU’s counseling training facility and sees clients on a limited basis.

“The major sections were, as expected, social media, technology and distance counseling; clarifying the concepts of boundaries in our connected world; [and] addressing the confusion on the difference between values and competence when working with or referring clients,” he says.

Professional values

The committee’s changes started with the ethics code’s preamble. For the first time, specific professional values are delineated at the very beginning of the document.

“We wanted to state the values of the profession,” says task force member Richard Watts, a professor and director of the Center for Research and Doctoral Studies in Counselor Education in the College of Education at Sam Houston State University in Huntsville, Texas. “We didn’t think previous versions had emphasized — to this degree — the values of the profession.”

Specifically, the preamble names these core professional values:

1) Enhancing human development throughout the life span

2) Honoring diversity and embracing a multicultural approach in support of the worth, dignity, potential and uniqueness of people within their social and cultural contexts

3) Promoting social justice

4) Safeguarding the integrity of the counselor-client relationship

5) Practicing in a competent and ethical manner

“While the professional values of counseling have always been in our code of ethics, we clarified and highlighted them to ensure that there was no confusion on the expectation of professional counselors as they interacted with clients,” Francis says.

Task force members pointed to two legal cases that made it clear that not all counselors or counselors-in-training understood the overarching values and expectations of the profession. Ward v. Wilbanks involved an EMU student in the school counseling program, Julea Ward, who, during her practicum at the in-house clinic, refused to counsel a client who stated on the intake form that he wanted help with issues relating to a same-sex relationship. Ward wanted to refer the case to another counselor-in-training because her religious beliefs held that same-sex relationships were immoral. After being informed that referring a client based solely on personal beliefs was unethical, she was offered a remediation program to help her counsel such clients. Ward requested a formal hearing instead and was dismissed from EMU’s program for violating the ACA Code of Ethics. She later filed a lawsuit alleging infringement of her religious freedom.

The other case, Keeton v. Anderson-Wiley, was similar. Jennifer Keaton, a counseling student at Augusta State University in Georgia, declared her opposition to counseling members of the lesbian, gay, bisexual and transgender community and stated that she was a proponent of reparative therapy. After declining to enter remediation, she was removed from the university’s counseling program. She subsequently filed a lawsuit against the school.

“We kind of had this little ‘out’ in the old code,” says Ethics Revision Task Force member Linda Shaw, professor and head of the Department of Disability and Psychoeducational Studies at the University of Arizona. “The standard that allows you to refer when you feel you’re not going to be effective was stated very generally.”

In other words, a counselor who wanted to refer a client based solely on personal beliefs might sidestep the issue of discrimination by claiming he or she would not be effective counseling the client, Shaw explains. “We just didn’t have the clarity [in the 2005 ethics code] saying that there is a difference between a lack of knowledge and referring because of personal values,” she says.

Adds Watts, “There was a lot of discussion about making sure that we treat all clients inclusively — that clients are not discriminated against because of subjective values or class identity.”

“I think we made it more clear that client welfare is the paramount issue in every mental health code,” he continues. “Refusing to see clients because of sexual orientation or any other subjective reason is clearly discriminatory, and we were concerned that competence was functioning as a smoke screen.”

Online without being out of line

The other big change in the 2014 ACA Code of Ethics is the addition of an entire section on the ethical use of technology and social media with clients.

“I think the most glaring omission in the 2005 code was technology,” says Ethics Revision Task Force member Gary Goodnough, a professor and chair of the Counselor Education and School Psychology Department at Plymouth State University in New Hampshire. “We were not as detailed as we should have been. It really needed its own section.”

“I think as a group we were certainly conscious of the need of bringing the code into this decade in terms of addressing new technologies and questions counselors have about social media,” agrees Shaw.

The new section devoted to social media and technology addresses a growing need in the profession, Francis says. Given the transient and ever-evolving nature of technology, the task force tried to write the guidelines as broadly as possible so that the standards will remain relevant to future applications of technology — even those not dreamed of yet.

“A major goal was to make sure that technology was focused on not just in a new section but infused throughout, like multiculturalism was infused in the 2005 code,” says Michelle Wade, who was a private practitioner and a student representative to the task force until stepping down in July 2013 to join the ACA Ethics and Professional Standards Department as an ethics specialist.

“The profession is in growth,” Wade notes. “Some counselors are still very traditional and only conduct face-to-face sessions, but others are doing distance counseling, both by phone and online.”

This shift brings with it some significant concerns. “Sometimes, I think a lot of our profession thinks that Skype is all you need [to provide] distance counseling,” Wade says.

In reality, Skype is not compliant with the Health Insurance Portability and Accountability Act (HIPAA). But the ethical concerns don’t end there. Distance counselors need to understand that they may be subject to the rules and regulations of both their state and the state in which the client is located, emphasizes task force member Mary Hermann, an associate professor and department chair of counselor education at Virginia Commonwealth University in Richmond.

Counselors must be aware of these differences for every state in which they have a distance client. “Counselors have to make sure that they have a secure means of connecting and that their encryption standards are current,” Hermann says. “Different states may have different standards.”

“Informed consent and disclosure are important in this area,” adds Goodnough, who is also Plymouth State’s graduate program coordinator for school counseling. “What are the risks and benefits? What do we do if the technology fails or there is a client emergency?”

“Distance counseling definitely starts first and foremost with informed consent,” agrees Wade.

As it states in the new code: “In addition to the usual and customary protocol of informed consent between counselor and client for face-to-face counseling, the following issues, unique to the use of distance counseling, technology and/or social media, are addressed in the informed consent process:

  • distance counseling credentials, physical location of practice and contact information;
  • risks and benefits of engaging in the use of distance counseling, technology and/or social media;
  • possibility of technology failure and alternate methods of service delivery;
  • anticipated response time;
  • emergency procedures to follow when the counselor is not available;
  • time zone differences;
  • cultural and/or language differences that may affect delivery of services;
  • possible denial of insurance benefits; and
  • social media policy.”

But after counselors obtain informed consent and find a secure, HIPAA-compliant method of communication, Wade doesn’t think that distance counseling should differ significantly from face-to-face counseling. For example, she says, counselors should already have a crisis plan in place for their regular clients. Distance counseling just requires that counselors become aware of the resources available in the distance client’s location, she says.

Distance counseling is not for every client or counselor, but in some ways, it can be empowering, Wade says. Because the counselor is less available, the client is encouraged to learn what other resources are available and how to use them.

“For instance,” she says, “say I have a client I treat face to face during the summer who has to return to college in the fall. We can do distance counseling, but I would make her aware that the crisis center at her college is there as a backup resource.”

Social media scrutiny

Some counseling professionals have demonstrated resistance to new technology, but others have jumped right in, especially when it comes to social media, Wade says.

In fact, she notes, counselors have not always looked carefully before leaping into the social media pool, getting caught up in a technological and cultural movement that was not even in its infancy when the 2005 ACA Code of Ethics was released. “People were just doing things — participating in social media — and not thinking about it from an ethical perspective,” she says.

Social media guidance for today’s counselors is critical, says Goodnough, who notes that if counselors are going to be online, they need to present a professional image.

There are other issues that the revised code of ethics addresses as well. For instance: “We don’t follow our clients online. We don’t look at their Facebook,” Goodnough says emphatically. “These guidelines are helpful.”

Specifically, the code states that counselors respect the privacy of their clients’ presence on social media unless given consent to view such information.

Wade adds that although Googling a client online is tempting, especially if a counselor feels like the client is holding back, it is still regarded as an invasion of privacy.

When both the counselor and client are online, distinguishing boundaries can be tricky, Wade says. “I wanted to take a firm stand on ‘friending’ clients,” she says. “Counselors really need to distinguish between their personal online presence and their professional one.”

“You have a professional relationship with the client,” she continues, “and seeing you as a person, not just as a professional, could really change the balance of the relationship.”

As the new code makes clear, counselors who are on Facebook both personally and professionally need to set up distinct, separate profiles for each, Wade emphasizes. “Your personal profile should not have the same email or name as your professional profile,” she says.

“If you have a company name, use it for your professional page. Make the security settings on your personal Facebook page as high as possible so that you cannot be found accidentally,” Wade suggests.

For counselors who are new to social media or concerned about privacy on Facebook, Twitter may be a better option, says Wade. “It’s more anonymous than other social media,” she explains.

Twitter is a social media platform in which users “tweet” their thoughts — which may or may not include a link to an article, photo or video — in 140 characters or less. Signing up requires only a name, a username (such as @ACA_CTOnline) and an email address. Counselors can also sign up with their real names or the names of their practice if they wish to tweet about their areas of counseling expertise. For more personal tweeting, anyone who wishes to remain anonymous can sign up using a nom de plume, an anonymous email address and a Twitter name that doesn’t hint at his or her profession, location or true identity (think @Cyrano not @AdlerDC).

At the same time, counselors must remember client boundaries. For example, a counselor should not follow a client’s tweets without permission. Even if permission is granted, think ethically, advises Wade.

“Think carefully about how to handle the information your client may release,” she says. “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 five to 10 minutes, many of the posts or tweets will not be read in real time, which makes timely crisis intervention unlikely, Wade points out.

If a client asks a counselor to follow him or her on social media, the counselor should sit down and discuss why the client wants to be followed, Wade says. In addition, the counselor should make sure the client understands that social media activity cannot serve as a mode of direct counselor-client communication, she says. If a counselor does decide to follow a client, it is probably best that the counselor and client review the client’s activity in a session so they can discuss the content and address any potential problems.

To respect their clients’ privacy, counselors should not routinely ask them about their social media activity, Wade says. If a client mentions specific activity or incidents on social media multiple times, the counselor might want to ask if there is something the client would like to discuss about his or her online activity.

Ethics Revision Task Force member Lynn Linde, a clinical assistant professor in the school counseling program at Loyola University Maryland, is well aware of the dark side of social media — particularly Instagram, a platform that allows users to upload photos and use a number of filters to change a photo’s appearance. The pictures are public, and people can “like” and post comments to them.

“Cyberbullying is an epidemic on Instagram,” says Linde, who is also a past president of ACA. “Kids don’t understand that once they take a picture and [post it or] send it to someone, it’s there forever. … Cyberbullying can happen anywhere, with anyone.”

For this reason alone, ethically, school counselors must have a basic understanding of social media so they are aware of the issues students may be facing, Linde emphasizes.

Counselors also need to know where the boundaries are. “I’ve gotten a lot of questions from school counselors about whether they can look at a client’s Facebook page,” she says. Linde’s response is that the school itself may have the legal right to access the student’s Facebook page, but, ethically, counselors should always respect their clients’ virtual privacy.

With all the new technologies available, Linde also thinks that counselors need to reconsider one technology that has become old hat — email. Because it is a method of communication that has become ubiquitous, counselors can get lazy about putting the proper safeguards in place. Particularly at schools, she says, everyone emails everyone else — counselors to teachers, counselors to parents, counselors to counselors and so on. “People forget that anything that is put in an email can go anywhere to anyone,” Linde says.

Other changes

The definition of relationship has expanded in the 2014 ACA Code of Ethics. Language has been added that prohibits counselors from having personal virtual relationships with clients, Goodnough notes. In addition, the prohibition on counselors having a relationship with a former client has been brought back after an inadvertent omission in the 2005 code, Hermann says.

Certain types of nonsexual, yet still problematic, counseling relationships are prohibited as well, such as counseling a family member or friend if the counselor will be unable to remain objective, Goodnough says.

Again, however, task force members assert that lack of objectivity should not be confused with the imposition of personal values.

The revised ethics code has also removed the end-of-life exception to the referral rule. Counselors may no longer refer a client because he or she is terminally ill and considering either physician-assisted or self-inflicted suicide. If the client wants to discuss the decision, counselors should check the laws in their state. If a counselor’s state has legalized physician-assisted suicide, then any discussion is legally covered. If the state does not allow physician-assisted suicide, counselors should consult an attorney to see if that ban includes discussing the issue, Kaplan says.

The 2014 code has also clarified “duty to inform.” If a client has revealed a diagnosis of a life-threatening disease and the counselor is concerned that a third party may be at risk, the counselor does not have to confirm his or her client’s diagnosis but should check state laws to see if it is legal to inform the third party, Kaplan explains.

Another area that has been clarified in the revised code is providing pro bono services. “The pro bono issue was one we kept coming back to, deciding what we meant by ‘pro bono,’” Shaw says. “Did pro bono mean reduced rate, or in some way addressing unmet needs?”

The task force also discussed whether it was fair to ask counselors who might be struggling financially to offer free or reduced rate counseling, Shaw says.

“We wanted to broaden the notion of what pro bono means,” Goodnough says. The revised code says that counselors should make a reasonable effort to engage in pro bono activity, but this can include public speaking, putting free professional information on their websites or volunteering counseling services in the wake of a disaster, Kaplan explains.

“The pro bono requirement is in many ways related to social justice,” Shaw says. “It is an attempt to do what you can as a counselor to improve access to services or information. It means sharing your knowledge and expertise in ways that benefit others, without posing an unreasonable burden on you.”

The revised ethics code also attempts to clarify counselors’ responsibilities with mandated clients. As Goodnough points out, these clients may be mandated, but they don’t really give up their autonomy. “Let them know what the reporting requirements are, the type of [information] we might be sharing, who we might be sharing it with and what the consequences are for not participating,” he says. “But they can still refuse counseling services.”

Another ethics issue the task force addressed was where client confidentiality starts and where it ends. Under the revised code, the responsibility to protect confidentiality begins even before a counselor takes on a client and continues after the client’s death.

“A good example comes from college counseling centers,” says Francis. “It is not uncommon on a college campus for a dean of students or a member of the faculty to refer a student for counseling services. In some cases, the referring agent may follow up to see if the student has sought services.”

“The ethics code now point out that a prospective client — someone who has an appointment but has not yet come in for services — is afforded the same privacy and confidentiality as a regular client,” he explains. “We do not release information without permission or sound ethical or legal justification.”

The 2014 ACA Code of Ethics also includes updated requirements for counselor educators. “The code now makes it their ethical obligation to teach classes within their areas of competency, provide current information and provide students with direct assistance with
field placements and career assistance,” Kaplan says.

Educators and researchers will find some significant changes in the area of ethical research as well. “The emphasis on anonymity of persons and case studies was strengthened,” Watts points out. “If you are going to use a case study, you should get permission. … The use of clients, students or research participants is appropriate only if the person has seen and agreed to it or details are obscured enough that they cannot be identified.”

Thinking and acting ethically

The 2014 ACA Code of Ethics requires counselors to use a problem-solving model when confronted with an ethical dilemma, Kaplan says.

“There are a number of models out there,” Shaw adds. “Which one [to use] is not as important as that we ensure that counselors are familiar with one, have working knowledge of it and use it to sort out some of the thornier issues.”

But the Ethics Revision Task Force members also hope the entirety of the code, including its tone throughout, will guide counselors when they are in doubt.

“I felt that we needed to work at making the code more than just specific guidance for specific situations,” Shaw says. “We needed to create a context for counselors’ ethical conduct by having a mindful, thoughtful approach to practicing ethically.”

“The whole code of ethics needs to be looked at in its entirety. It’s all connected,” adds Linde. “I hope the message comes across that we want people to be thoughtful.”

Concludes Shaw, “If you asked me what the most important change was — technology is going to keep changing, but I think the values issues questions … are really fundamental to who we are as counselors. To me, it is the most profound change in the code.”

 

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The five most common ethical concerns

American Counseling Association members receive free confidential ethics consultations as a benefit of their membership. Michelle Wade, an ethics specialist in the ACA Ethics and Professional Standards Department, handles many of these calls and emails. She provided Counseling Today with a list of the five ethical concerns that ACA members seek guidance on most frequently.

Although she here suggests applicable areas of the revised ACA Code of Ethics for each of the five concerns, she cautions that none of this should be taken as official ethical advice. To receive assistance with a specific ethical dilemma or question, contact the ACA Ethics Department at 800.347.6647 ext. 314 or ethics@counseling.org.

Subpoena questions/release of information

There are several ethical standards within the 2014 ACA Code of Ethics that need to be considered regarding the release of client information: A.1.a., A.2.a., A.4.a., B.1.c., B.1.d., B.2.d. and B.2.e.

Breaking confidentiality/mandated reporting

Note that the ACA Code of Ethics does not address mandated reporting directly because every state has its own regulations. Therefore, it is important to understand what your state’s regulations are regarding reporting. With regard to ethics, Wade refers counselors to standards B.2.a. and B.2.e. as well as A.2.a., B.1.b., B.1.c. and B.1.d.

Extending professional boundaries

Navigating the relationship between counselor and client can be difficult at times. The ethical standards that address this situation within the 2014 ACA Code of Ethics are found in A.6.

Distance counseling/social media/technology

There is a brand-new section within the 2014 ACA Code of Ethics that addresses distance counseling, technology and social media. That section (Section H) provides some guidance and considerations when working with technology and distance counseling as well as social media.

Personal values

“ACA celebrates that our members are all different and would never ask anyone to change who they are,” Wade says. “However, ACA would ask counselors to put themselves second to their clients. In the 2014 ACA Code of Ethics, A.4.b. was expanded to include the necessity of obtaining training and multicultural competency as a counselor. A.11.a. and A.11.b. were also added to suggest that referrals need to be based on competency, not values, and the reasoning for that was, again, the client comes first.”

 

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Getting familiar with the revised ACA Code of Ethics

In addition to the hard copy of the 2014 ACA Code of Ethics that was packaged with this issue of Counseling Today, ACA members can access the code online at counseling.org/ethics.

To familiarize themselves with the differences between the 2005 and 2014 ethics codes, counselors may also wish to listen to a podcast, “The NEW 2014 Code of Ethics: An Overview,” also available at counseling.org/ethics.

Additional resources, including a six-part webinar series (worth a total of six CEs), can be found at counseling.org/continuing-education/webinars.

Also, beginning next month with the July issue, Counseling Today will feature a new column series that highlights the most significant changes in the revised ethics code.

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

 

Letters to the editor: ct@counseling.org

 

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Equality: The only value acceptable in session

By Quinn K. Smelser May 8, 2014

“Counselors do not condone or engage in discrimination against prospective or current clients, students, employees, supervisees or research participants based on age, culture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital/partnership status, language preference, socioeconomic status, immigration status or any basis proscribed by law.”

 

The above is not an excerpt from a political speech. It is not a suggestion from a more liberal-minded counselor. It is not a tagline from a book. It is Standard C.5., titled “Nondiscrimination,” of the ACA Code of Ethics. As licensed professional counselors (LPCs), we agree to this statement as part of our practice.

 

Recently, counselors, activists and others gathered for the first Human Rights Campaign Time to Thrive Conference to promote inclusion and safety for LGBTQ youth. The past year has seen several states adopt same-sex marriage laws or overturn outdated bans, including a ruling by a federal judge in my own state of Texas. LGBTQ allies are standing up for equality all across the country. Our ACA president, Cirecie West-Olatunji, sent a letter to Arizona Gov. Jan Brewer in late February asking her to veto legislation that would have allowed LPCs to refuse treatment to members of the LGBTQ community based on a counselor’s religious values.

 

equalityOf the many theories and ideas I learned in graduate school, a belief in equality is one that guides me not only as a new professional, but also as a citizen of the world. I thought that other counselors shared in this conviction, but I was recently proved wrong.

 

Shortly before I graduated my master’s program, I attended a training approved for CEUs on marriage and family therapy at a faith-based counseling agency. I was pursuing a job that was offered to me as an LPC-intern, and this training was a requirement for me to qualify for the position.

 

The training presented a relational model to help couples remove pain and condemnation from past and present relationships in an effort to feel deeper love and connection with one another. Because I believe we are relational beings and I agree that pain caused by one person can get projected onto other relationships, I began the first hour of the workshop wearing some thick rose-colored glasses.

 

The presenter reiterated that these principles were biblically based, but applied to anyone. I am a practicing Episcopalian, but I was concerned about the plethora of biblical passages quoted throughout the workshop manual. I thought these passages might invite a counselor to impose values onto a client, thereby limiting the therapy’s use with diverse populations. But like I do in every session with my clients, I sought to view the training from the presenters’ perspective, enter their world and see what their model was about.

 

I learned this model was built on how a husband and wife can love each other better as Jesus Christ would want. There were breakout sessions on applying the therapy to single adults and married couples experiencing infidelity, but that was the breadth of the diversity presented. There were no examples of divorced couples, cohabiting couples, newly bereaved widows or widowers, single parents or same-sex couples. I started questioning the motivation behind this therapy. At the end of the first day of the workshop, we were asked to write any questions we had on a note card. Questions were to be answered the following day. So, I began jotting down some thoughts.

 

At the end of that second day, I asked how to apply this model to single parents, or to the newly bereaved or with same-sex couples. And I asked if the agency where the training was being held saw same-sex couples that might want to strengthen their relationship with each other and with God or their higher power.

 

The presenter took quite a few deep breaths before answering. He started off by saying that he couldn’t see why this model couldn’t be applied to same-sex couples. I breathed a sigh of relief. But then he continued his answer. For him, individuals “choosing” to act on those “kinds of urges” would not be seen at his agency. In fact, he said, he had a lesbian couple come to him once, but he referred them out because he was “not an expert on that kind of thing.” However, he said, he also had a client who told him he was having thoughts and urges about having a same-sex relationship. The presenter continued to talk about how he most certainly helped that client rid himself of those “kinds of sins.”

 

ACA’s website states that “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.” Conversion or reparative Therapy is a deplorable practice that approaches same-sex attraction as a mental disorder and attempts to change the client’s sexual orientation. What this presenter seemed to state was that he practices conversion therapy.

 

When our clients hold a discriminatory belief, we are obligated to respect them, but it becomes a totally different issue when professional counselors conduct therapy with a biased and discriminatory mindset. Professional counselors are in a position of power, and with power comes the possibility of causing serious harm. Putting the word Christian in front of your title as a licensed counselor does not give one free rein to impose values. While someone may feel it is just to pick and choose what parts of the Bible to quote as fuel for hatred, choosing bits and pieces of the ACA Code of Ethics is not an option. Licensed professionals must uphold ethical standards.

 

After the training, I talked to the supervisor at the agency where I was pursuing the job. She told me that there is a “real world” and the world I was taught in graduate school, that the two are different, and that her agency would likely hold the views of the presenter at the training. Needless to say, I didn’t take the job.

 

In the face of this type of discrimination, what are we supposed to do as licensed professionals? What is our responsibility to our clients? What is our responsibility to our profession? What is our responsibility to humanity?

 

When we choose to simply accept this cynicism and hate as a reality, we are not being true to our five moral principles as prescribed by Kitchener — autonomy, nonmaleficence, beneficence, justice and fidelity. We are also not being true to our Rogerian foundation of providing our clients with unconditional positive regard.

 

Professional counselors must work to uphold our ethical standards to promote the best care for our clients and work against discrimination. By not standing up to other counselors who are holding these discriminatory views, we as a profession are contributing to the oppression of the LGBTQ community. We cannot just say that our code of ethics aims for multicultural competence; we must act on this. If our profession is going to attain the respect and value it deserves, we must as members of ACA truly “[embrace] a multicultural approach in support of the worth, dignity, potential and uniqueness of people within their social and cultural contexts,” as the preamble to the ACA Code of Ethics states.

 

When we become counselors, we are agreeing to constantly re-evaluate our own views, avoid imposing our beliefs onto our clients and expand our own self-awareness. This reevaluation of ourselves as counselors should be a never-ending process. Putting faith-based, biblically based or Christian in front of the title counselor doesn’t warrant that process to stop, nor does it entitle the counselor to discriminate.

 

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Quinn K. Smelser, a national certified counselor and licensed professional counselor-intern, is a counselor in Austin, Texas, and a graduate of Texas State University and the University of Texas at Austin. She counsels families and at-risk youth in central Texas.  She is also a member of the Human Rights Campaign’s Federal Club and the Austin-area gala committee. Contact her at qksmelser@gmail.com.

2014 ACA Code of Ethics approved by governing council

March 26, 2014

The 2014 ACA Code of Ethics was approved by the ACA Governing Council this week at its meeting at the ACA conference in Honolulu, Hawaii.

The 2014 ACA Code of Ethics replaces the 2005 edition.  The new edition is the first code that speaks to the ethics of using social media with clients.  It also presents new or expanded Branding-Box-Ethicsguidelines for preventing the imposition of counselor personal values, distance counseling, confidentiality, dual relationships, multiculturalism and diversity, the use of technology, record keeping, diagnosis, end-of life care and the selection of interventions.

The 2014 ACA Code of Ethics is posted on the ethics section of the ACA website at counseling.org/ethics

ACA conference attendees can be the first to hear about the new code by attending the six-hour Learning Institute, “Hot Off the Press – The New 2014 ACA Code of Ethics: An In-Depth Review of Critical Changes” on Thursday, March 27, or the 90 minute education session, “A Town Hall Meeting on the New 2014 Code of Ethics: What You Need to Know” on Saturday, March 29.

A podcast focusing on the updates in the 2014 ethics code with Perry Francis, chairman of ACA’s Ethics Revision Task Force, is available at counseling.org/knowledge-center/podcasts

More resources focusing on the 2014 ACA Code of Ethics will be soon be posted on the ACA website, including a six-part webinar series, a ten-part interview series with the Ethics Revision Task Force, updated ACA books such as the bestselling ethics casebook and branch presentations.

 

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See the June issue of Counseling Today for an in-depth cover story on counseling ethics.

In July, Counseling Today will begin a column series highlighting significant changes in the new Code of Ethics.

 

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For more information on the 2014 Code of Ethics, see counseling.org/knowledge-center/ethics

 

ACA has developed a six-part webinar series to navigate the changes in the new Code of Ethics. Each Wednesday between May 14 and June 25, 2014, from 1 to 2 p.m. ET, a new topic will be discussed including ethics, competence, values and referrals; gatekeeping and relationship boundaries for counselor educators; resolving ethical issues/ethical decision-making; technology, social media and distance counseling; professional responsibilities of the counselor; fees, fee splitting, bartering, gifts and other billing issues.

Details: counseling.org/continuing-education/webinars

 

A Kindle edition of the ACA 2014 Code of Ethics also available: amazon.com/2014-Code-Ethics-Erin-Martz-ebook/dp/B00L5T9QUU/ref=sr_1_2?ie=UTF8&qid=1404312268&sr=8-2&keywords=ACA+Codes+of+Ethics

 

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Resolution of EMU case confirms ACA Code of Ethics, counseling profession’s stance against client discrimination

Heather Rudow January 9, 2013

(Photo:Flickr/krossbow)

(Photo:Flickr/krossbow)

In December, after years of litigation, the court case Julea Ward v. Board of Regents of Eastern Michigan University was resolved. The resolution upheld the university counseling program’s policies and confirmed the ACA Code of Ethics as the guide for defining ethical behavior for professional counselors. The case also reiterated that equal rights and social justice remain key pillars of the counseling profession.

“The resolution of the lawsuit leaves the university’s policies, programs and curricular requirements intact,” said Walter Kraft, vice president for communications at Eastern Michigan University (EMU), in a press release. “The faculty retains its right to establish, in its learned judgment, the curriculum and program requirements for the counseling program at Eastern Michigan University. EMU has made the decision that it is in the best interest of its students and the taxpayers of the state of Michigan to resolve the litigation rather than continue to spend money on a costly trial. The matter has been resolved in the amount of $75,000. The university’s insurance company, M.U.S.I.C. (Michigan Universities Self-Insurance Corporation), will pay the cost of the settlement.”

The case began in 2009, when then-student Ward began her practicum at EMU. Upon reading the file of a client to which she was assigned and finding he had previously been counseled about his same-sex relationship, Ward, a conservative Christian, notified her supervisor that, in accordance with her religious beliefs, she would not be able to counsel the client and needed to refer him to someone else.

Ward’s supervisor canceled the counseling session and scheduled an informal review, during which EMU faculty members explained to Ward that she needed to abide by the university counseling program’s policies and curricular requirements, which adhere to the ACA Code of Ethics. The ACA Code of Ethics states that “counselors may not discriminate against clients on the basis of age, culture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital status/partnership, language preference, socioeconomic status or any basis proscribed by law.” This meant Ward was required to set aside her personal beliefs and values when working with clients during practicum.

Given the choice of completing a remediation program, leaving the EMU counseling program or requesting a formal hearing, Ward chose the hearing. As a result of the formal hearing, she was dismissed from the program for violating the ACA Code of Ethics.

Ward sued EMU for her dismissal with the backing of the Alliance Defending Freedom (ADF) — formerly the Alliance Defense Fund — an organization of Christian lawyers that also assisted in another counseling student’s case at Augusta State University that revolved around counseling clients who are lesbian, gay, bisexual or transgender (LGBT).

According to the EMU press release, “The ADF lawsuit sought to stop [EMU] from enforcing its policies prohibiting discrimination and requiring the students in its counseling program to counsel students in conformance with the code of ethics of the American Counseling Association.”

ACA provided expert testimony for the case, which the judge quoted when granting the summary judgment in the decision.

On July 27, 2010, the U.S. District Court for the Eastern District of Michigan granted summary judgment in favor of EMU, which Ward appealed. She made her oral arguments on Oct. 4, 2011, and on Jan. 27, 2012, the 6th Circuit Court of Appeals sent the case back to district court for a jury trial. ACA Chief Professional Officer David Kaplan spent a morning being deposed for the scheduled trial.

In December, Ward officially left the program.

“Personally and as a department, we are pleased that the lawsuit is settled,” says Perry Francis, counseling professor and counseling clinic coordinator at EMU. “It has taken a great deal of time and energy to defend ourselves, and now we can continue to focus on educating our students to become excellent clinicians in the mental health profession.”

Francis believes implications from the court case are clear, showing that counseling is “best accomplished by entering into the world of the client, valuing that client as a worthwhile individual who deserves [our] nonjudgmental care and concern. That has been what we teach to our students; it drives our policies and is a reflection of the professional values and ethics of the counseling profession. To accomplish this, we teach our students how first to become aware of their own values and issues, how to bracket off those values and issues that would interfere with client care and then to enter into the client’s world to help him or her develop into the best person he or she can be.”

Kaplan echoed those sentiments. “ACA is pleased that the settlement leaves intact the district court ruling that fully supported Eastern Michigan University’s gatekeeping function in dismissing a student who refused to counsel an [LGBT] client, the right for CACREP to require adherence to the ACA Code of Ethics and the nondiscrimination statement within the ACA Code of Ethics,” Kaplan says.

Pete Finnerty, president of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling, a division of ACA, says the case was especially relevant for LGBT individuals, who are often marginalized and discriminated against.

“Eastern Michigan stood strong for nondiscrimination and should be applauded for doing so,” Finnerty says. “When Julea Ward refused to counsel a gay man, she was discriminating against an individual for religious reasons. This not only shows a refusal to move past her own values but also creates an environment where it is impossible for all persons to have equitable treatment under policies long in effect at university and community levels.”

Because of the lawsuit, EMU has also come under fire from Michigan legislators, Finnerty adds.

“Two bills within the last few years, including the recently shelved SB 975 …  sought to make it illegal for Eastern Michigan and all other educational institutions in the state to enforce its nondiscrimination policies by allowing medical and mental health professionals to refuse service based upon ‘conscience,’” he says. “This bill nearly made it to the governor’s desk but was not voted on in the House before the end of the legislative session. There was specific language in this bill that targeted educational institutions [that] utilize a nondiscrimination policy. The language noted penalties and fines for enforcing nondiscrimination clauses.”

Finnerty notes the likelihood exists that similar legislation could still come about, however, because other freedom of conscience bills were passed into law in states such as Arizona.

In 2011, Arizona passed HB 2565, which prohibits schools from disciplining a student in a counseling, social work or psychology program if the student refuses to counsel a client about goals that conflict with the student’s “sincerely held religious belief.” In 2012, the state passed SB 1365, prohibiting the denial, suspension or revocation of a person’s counseling license or certification for “declining to provide any service that violates the person’s sincerely held religious beliefs, expressing sincerely held religious beliefs in any context, as long as services provided otherwise meet the current standard of care or practice for the profession, providing faith-based services that otherwise meet the current standard of care or practice for the profession, making business-related decisions in accordance with sincerely held religious beliefs, including employment decisions, client selection decisions and financial decisions.”

In Michigan, SR 66, a resolution to enact legislation protecting the rights of conscience of students seeking counseling degrees and licensed professional counselors, calls out ACA directly: “Whereas, the American Counseling Association, a private organization that promulgates a code of ethics widely used by university counseling programs and state licensure boards in training for and regulating the counseling profession, has publicly supported universities that have punished or dismissed students for adhering to their sincere religious convictions.”

However, says Finnerty, “The conclusion to [Julea Ward v. Board of Regents of Eastern Michigan University] is a win for the LGBTQQIA community, as those who serve this population were activated to defeat the legislation and not allow anti-gay groups to press their agenda upon the counseling profession that holds equitable and fair treatment as paramount to counseling. LGBTQQIA clients can be sure that counselors will continue to be trained through a multicultural lens where nondiscrimination and personal growth, not a counselor’s personal values, is pertinent to the counseling relationship. For counselors and educators, this shows that believing in a world that values nondiscrimination and diversity is still very much a plausible reality and must be continually strived for.”

Says Francis, “We as a profession must continue to teach these professional values to our students so they can have a positive impact not only on our clients’ lives but on the society as a whole.”

To learn more about the case, visit emich.edu/aca_case

  Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.