This award recognizes exceptional, demonstrable understanding of the ACA Code of Ethics, the foundation of ethical professional counseling practice. Each year, ACA honors top-ranking teams in both Master’s and Doctoral level graduate degree programs.
Supervision, Disclosure and Self-Reflection in Preventing Counselor Impairment: An Ethical Exploration
By: Courtney Griffin, Veronica McMillion, Anya Ross and Angela Sundstrom
Department of Counseling, DePaul University, Chicago
Faculty advisor: Alexandra Novakovic
Prompt: Lila is a Limited Licensed Professional Counselor who, for the past five months has been working in federally-assisted, outpatient mental health and substance abuse counseling agency. For the past month, Lila has been counseling Stephen, a 56-year-old, White male, who has been living with HIV for the past two years. To date, she has had four sessions with Stephen. Stephen started seeing Lila because one month prior to his first session with her, he completed a brief stint in rehab for his cocaine and methamphetamine use disorders. So far, Lila has felt very positive about the progress Stephen has made. He has maintained his sobriety, he has complied with his HIV medications and his viral load is undetectable, and he actively engages in therapeutic work. Lila feels a lot of empathy for Stephen because she has been sober for over five years, but she has started to notice that when Stephen talks about his urges to use, she has felt her own old cravings reemerge. Lila has not discussed this issue in supervision because she has not disclosed her personal addiction history with her supervisor due to fear that it would impact her ability to get her full license.
In a recent session, Stephen shared with Lila that he just started a new relationship with a woman. He expressed that when he has sex with her, it triggers him to want to use coke and meth again. Hearing this, Lila became concerned and asked Stephen if he had disclosed his HIV-status to the new girlfriend. Stephen defensively replied, “That’s none of your business! She doesn’t need to know anyway.” Because it was toward the end of the session, Lila did not pursue the discussion any further. She also realized that she never told Stephen that she may have to report that. In her next session with Stephen, before Lila could bring up the HIV disclosure issue, Stephen stated he was struggling with feelings of guilt about something he did just before he decided to stop using drugs. Lila listened non-judgmentally as Stephen disclosed that about two and a half months ago, to get money to buy drugs, he broke into several houses in the area. In one of the break-ins, the owner unexpectedly walked in on Stephen. Out of fear, Stephen attacked the man who ended up in the hospital in a coma. Stephen was able to get away and was never caught by the police. Lila recalled seeing this story on the local news and remembered that the victim was still in a coma in the hospital. In that moment, Lila felt her strongest urge to drink that she has felt in years, and thought to herself, “I have no idea what to do.”
The supervisory relationship is a foundational tool in preparing recently graduated, unlicensed counselors for independent practice. According to the American Counseling Association (ACA) Code of Ethics (2014), a counseling supervisor’s “primary obligation […] is to monitor the services provided by supervisees” to ensure that all clients receive competent care. A novice counselor’s ability to effectively use counseling techniques, adhere to the ACA ethical code, and seek consultation where necessary impacts the effectiveness of the therapeutic services they provide. Additionally, supervisees must be able to self-assess for possible impairment and commit themselves to regular self-care. This paper will examine a multi-faceted ethical dilemma regarding the importance of the supervisory relationship using the seven steps of the Practitioner’s Guide to Ethical Decision Making (Forester-Miller & Davis, 2016).
Identify the Dilemma
The scenario presents a Limited Licensed Professional Counselor named Lila who has worked for a federally-funded substance abuse facility for five months. Lila has a history of substance use disorder and has been sober for five years. She fears that this could prevent her from obtaining her license, so she has not disclosed it to her supervisor. Lila has had four sessions with Stephen, a middle-aged, HIV-positive, White man with a history of cocaine and methamphetamine abuse. Stephen has maintained sobriety since a recent stay at a rehabilitation facility, and is taking HIV medication to maintain an undetectable viral load. Still, Lila feels concerned that Stephen has not disclosed his HIV status to his girlfriend. Furthermore, she learns that Stephen’s decision to attend rehab was precipitated by a break-in he committed during which he assaulted a man, leaving him in a coma. The authorities have not yet discovered who is responsible for the crime. These revelations, in addition to discussions of Stephen’s urges to use drugs, have triggered intense alcohol cravings for Lila.
There are multiple dilemmas in this case: Lila’s concern about Stephen’s HIV status in relation to his partner, Stephen’s admission of guilt in the assault case, and Lila’s reluctance to disclose her increasingly urgent cravings to her supervisor. This paper will apply the ACA Code of Ethics (2014) and legal standards to each dilemma before selecting a recommended course of action.
Apply the ACA Code of Ethics and Determine Dimensions of the Dilemma
HIV is not considered transmissible if there is no viral load, according to the Centers for Disease Control and Prevention (2021). Legally, there is little federal oversight in regard to HIV transmission, and the state of Illinois, where the authors of this paper will practice, repealed the Illinois Criminal Transmission of HIV Statute on July 27, 2021 (The Center for HIV Law and Policy, 2021). Therefore, no laws compel Stephen to disclose his HIV status to his partner. Additionally, Lila works for a federally-funded agency which is subject to Substance Abuse and Mental Health Services Administration (SAMHSA) laws, including Standards for Privacy of Individually Identifiable Health Information (HIPAA) (2004) and the Confidentiality of Substance Use Disorder Patient Records (2017). Here, it would be wise for Lila to seek legal consultation for clarification of these and all laws pertaining to the case.
Ethically, Lila did not discuss the potential limits of confidentiality with Stephen, which she must do immediately in order to maintain transparency and honesty in the therapeutic relationship (ACA, 2014, Section A.2.). Perhaps the most significant aspect of the counselor- client relationship, Lila must protect Stephen’s confidentiality, including the release of his records (ACA, 2014, Sections B.1.c., B.6.b.). Lila has no proof that Stephen has a communicable disease nor that he is putting his partner at risk; thus, she has a legal and ethical duty to maintain Stephen’s confidentiality (ACA, 2014, Section B.2.).
Past Crime Disclosure
Lila must be aware of Stephen’s legal rights and any legal mandates for disclosure of his crime. The Illinois Mental Health and Developmental Disabilities Confidentiality Act (1994) allows disclosure at the therapist’s discretion when there is a specific threat of violence “where there exists a therapist-recipient relationship or a special recipient-individual relationship.” In this case, Lila has no legal duty to warn because there is no threat of future violence, nor a special relationship with the assault victim. Additionally, according to the Professional Counselor and Clinical Professional Counselor Licensing and Practice Act, privileged communications are still protected because the crime was already committed and there is no new imminent risk of injury (2012). Finally, the confidentiality of Stephen’s records is federally protected (Confidentiality of Substance Use Disorder Patient Records, 2017).
Ethically, Lila must have ongoing conversations with Stephen about potential limits to confidentiality (ACA, 2014, Section A.2.a.). Lila should consider possible negative outcomes of disclosure, such as harm to the therapeutic relationship, legal repercussions for Stephen and herself, and value imposition (ACA, 2014, Sections A.4.a, A.4.b.). Ultimately, Lila must maintain client confidentiality because there are no conditions under which disclosing a previous crime is ethically or legally mandated (ACA, 2014, Section B.1.c.). Lila should focus on clinical work with Stephen regarding the past crime, while prioritizing consultation, documentation and self-care.
Examination of Moral Principles
Lila must examine Kitchener’s moral principles (1984) in relation to the personal conflicts she experiences while working with Stephen. Nonmaleficence, or the concept of doing no harm to her client, should be considered in relation to Stephen’s confessions regarding his HIV status and past crime. Lila feels a strong negative reaction to these admissions, but must consider the possible harmful consequences of breaking client confidentiality, such as jail time for Stephen or the dissolution of his personal relationship. Beyond preventing harm, Lila has a duty to uphold beneficence, or work for the good of her client and greater society. Lila could achieve this goal by assisting Stephen in processing the effects of his crime, thereby reducing the likelihood of a recurrence. However, Lila’s negative reaction to his confessions could signal internal conflict between honoring fidelity to her client versus protecting his partner and bringing justice to the man that he gravely injured. She must examine the conflict between these impulses and explore her resulting emotional response and urge to use alcohol. In doing so, she will honor the principle of veracity; honesty with herself, her supervisor, and her client about professional impairment she may be experiencing.
Lila’s Sobriety and Impairment
While Lila fears unfair treatment due to her substance use disorder, her status is protected by federal law. According to the Americans with Disabilities Act (ADA), which includes substance abuse disorders as a protected disability, “No covered entity shall discriminate against a qualified individual on the basis of disability in regard to job application procedures, the hiring, advancement, or discharge of employees, employee compensation, job training, and other terms, conditions, and privileges of employment” (1990). Furthermore, while the ADA applies to state and local governmental units, the Rehabilitation Act protects federal employees of organizations that receive governmental grants, such as Lila, from discrimination based on “information learned about an individual’s disability” (1973). Per the ACA Code of Ethics (2014):
Supervisors must endorse supervisees for certification, licensure, employment, or completion of an academic or training program only when they believe that supervisees are qualified for the endorsement. Regardless of qualifications, supervisors do not endorse supervisees whom they believe to be impaired in any way that would interfere with the performance of the duties associated with the endorsement. (Section F.6.d.)
According to the ACA Task Force on Impaired Counselors, “Therapeutic impairment occurs when there is a significant negative impact on a counselor’s professional functioning which compromises client care or poses the potential for harm to the client” (Lawson & Venart, 2005). Vicarious trauma (VT), or emotional and psychological symptoms experienced by counselors that work with clients addressing trauma, may contribute to Lila’s impairment in this case (Lanier & Carney, 2019). Vicarious traumatization can be viewed as “a cumulative process of personal change in helpers that happens through empathic connection with clients” (Lawson & Venart, 2005). Novice counselors like Lila are at elevated risk for experiencing VT for several reasons. Lila may have limited experience and training in helping clients to process trauma, and she may not have established appropriate boundaries with her clients in this early stage of her career development. Furthermore, her inexperience may affect her ability to recognize her own symptoms of VT as they develop (Lanier & Carney, 2019).
At the core of Lila’s dilemma lies her failure to inform her supervisor of her previous substance use and her current challenges treating Stephen. Lila should be involved in ongoing consultation with her supervisor, especially when ethical or professional questions arise (ACA, 2014, Section C.2.e.). Not only does she risk making poor, uninformed ethical decisions, she could possibly harm her client by providing incompetent treatment. Furthermore, Lila’s supervisor is obligated to monitor services she provides to clients (ACA, 2014, Section F.1.a.) in order to assess her professional development and performance. She risks her own professional growth and relationship with her supervisor in withholding key information about her triggers and substance use disorder. In time, she could face remediation, as it is her supervisor’s ethical duty to monitor her competency and effectiveness (ACA, 2014, Section F.6.b.).
Lila’s dynamic with her supervisor, termed “supervisee intentional nondisclosure,” is common, with one study indicating that of 107 prelicensed counselors, 95.3% reported withholding some degree of information from their supervisors, while 53.3% completely withheld a concern from their supervisors (Cook et al., 2020). This is significant in that supervisors are legally responsible for the services rendered to their supervisees’ clients (Magnuson et al., 2000, as cited in Cook et al., 2020). The same study noted that several factors contribute to the likelihood of nondisclosure: self-directed supervision, a more evaluative supervisory relationship tied to professional progress, reduced access to supervisors compared to university settings, and less direct monitoring of supervisees’ work. These considerations may shed light on Lila’s hesitance to discuss negative triggers she experiences in her sessions with Stephen.
Impairment and Self-Care
Above all, this case highlights the importance of vulnerability awareness, wellness monitoring, self-care and supervision in preventing counselor impairment, especially in prelicensed counselors. The ACA Task Force on Counselor Impairment promotes these exercises as a means of increasing counselor resiliency in the face of professional stressors (Lawson & Venart, 2005). Lila meets the standard of impairment as defined by the Task Force; her personal crisis regarding alcohol use and possible VT compromise her effectiveness as a counselor. Counselors should regularly perform self-assessments such as The Professional Quality of Life (ProQOL- III) to measure their vulnerability to burnout, as well as the Self-Care Assessment, which provides examples of various self-care techniques (Lawson & Venart, 2005). Lila must monitor her reactions and emotions, obtain consultation and process her triggers in treatment. Ultimately, “counselors engage in self-care activities to maintain and promote their own emotional, physical, mental and spiritual well-being to best meet their professional responsibilities” (ACA, 2014). Lastly, the Task Force maintains that “An active supportive relationship with supervisors and peers is an especially important component of self- care for counselors” (Lawson & Venart, 2005).
Generate Potential Courses of Action
Legal and ethical codes pertaining to Stephen’s HIV status and his past crime demonstrate that Lila should maintain confidentiality in these areas. Therefore, possible courses of action outlined here will focus on Lila’s sobriety and resolving impairment. One possible course of action is exclusive consultation with peers, which may provide Lila with a sense of confidentiality and safety outside of the supervisory relationship. Having recently finished her graduate studies, Lila may have a robust network of counselors with whom to consult. However, other inexperienced prelicensed counselors may not advise Lila with the same level of insight and expertise as her supervisor. Furthermore, Lila does not have legal or ethical basis to resist disclosure to her supervisor, so this course of action is not a comprehensive solution.
Another potential course of action is to refer Stephen to a different counselor. The immediate benefit of this solution is that Lila’s triggers may be reduced or altogether eliminated, but this is not a long-term solution. Removing the source of stress does not constitute an in- depth understanding of the dilemma, and will not help Lila maintain confident sobriety going forward. Additionally, referring Stephen to another counselor may be detrimental to his recovery and mental health. Stephen may experience feelings of rejection or abandonment if he is invested in the support he receives from his therapeutic relationship with Lila. Referral should be a final resort if all other paths fail.
Select Recommended Course of Action
The recommended course of action is that Lila disclose her sobriety status to her supervisor and speak candidly about her compromised mental health, sobriety, and ability to provide competent care. She is legally protected from discrimination due to her substance use disorder, but may not receive her license if she remains impaired due to non-disclosure. Lila will be honest with her supervisor about how sessions with Stephen trigger cravings, and how she fears being judged for her substance use history. Additionally, she will prioritize her mental health and sobriety, possibly calling on resources such as personal counseling, 12 step programs and support groups that previously helped her reach and maintain sobriety. She will also perform regular self-assessments such as the Professional Quality of Life (ProQOL- III) to check for signs of burnout and impairment. By pursuing this chosen course of action, Lila takes steps to resolve impairment and ensure that Stephen and other clients receive quality care.
Evaluate Recommended Course of Action
Before implementation, the chosen resolution must be evaluated for appropriateness using Stadler’s tests of justice, publicity, and universality (1986, as cited in Forester-Miller & Davis, 2016). The justice test examines whether the counselor would take the same action in parallel situations; the publicity test judges if she would deem it acceptable for her choices and actions to be reported by the news media; and the universality test asks if she would encourage counselors in similar situations to follow this course of action. The proposed solution adheres to recommendations from the 2014 ACA Code of Ethics and meets the conditions of all three tests.
As has been discussed in this analysis, the supervisory relationship is fundamental to the education and growth of new counselors. Counselors will encounter various challenges and ethical questions as they work toward licensure. It is their responsibility to apply relevant laws and ethical codes to their dilemmas, as well as consult their supervisors. In this case, Lila’s fear of personal disclosure isolated her from a fount of support, insight, and guidance that could have prevented her impairment. No counselor is an island, and from novice prelicensed counselors to experienced practitioners, all members of the counseling profession benefit from seeking new perspectives and networks of support.
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