Tag Archives: American Counseling Association

CEO’s message: This is your month — celebrate and enjoy

Richard Yep April 3, 2020

Richard Yep, ACA CEO

Each year, it seems like my April column serves as a reminder that  this is Counseling Awareness Month — a recognition that we came up with many, many years ago. I felt there were so many stories to tell, so much to be proud of and so many activities to conduct that a single “counseling awareness week” just would not do. So, we have a full month instead, and even that seems too short at times.

Counseling Awareness Month is designed to increase understanding of the wonderful work that all of you do, day in and day out. As some have heard me say, counselors are great advocates for their clients and students, but not always for themselves. I hope Counseling Awareness Month will be a time when you let others know about one of the world’s greatest professions.

Because we know your time is limited, ACA has this year provided more information on our website to help you celebrate this special month. In addition, we have expanded our event by partnering with key organizations to amplify public attention on counseling and the role of professional counselors. I’m asking you to reach out to organizations with which you are connected to let them know that we would be honored to have them engage in the celebration of Counseling Awareness Month. Our “ask” of our partners is as follows:

I hope all of you will participate in our social media challenges, which will include a photo contest and our #BurnBrightNotOut contest. Another component of our monthlong event will take place Friday, April 10, when we ask people to wear the color teal in a show of solidarity for professional counseling.

We are pushing to make this the best Counseling Awareness Month ever. My hope is that we can count on you to help us increase awareness of the important work that all of you do.
This is a great opportunity to let our various communities know about professional counseling.

I believe Counseling Awareness Month could also be “Counselor Appreciation Month” because that is what I feel about all of you. I hope you will “celebrate yourselves” by recognizing each other in some special way. Please know that your efforts are appreciated and that your work (although grueling at times) really does make the world a better place.

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Finally, I want to recognize so many of you for the work you are doing with clients and students regarding concern over the new coronavirus (COVID-19). I know this epidemic has caused a great deal of anxiety and stress. I also know that we must do all we can to protect ourselves. I encourage you to follow the guidelines from the Centers for Disease Control and Prevention, as well as those from the World Health Organization. ACA has information about COVID-19 on our website too.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800-347-6647 ext. 231 or to email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.

 

Spotlight on: ACA Tomorrow’s Counselors Award winner

April 2, 2020

This award recognizes graduate counseling students with exceptional insight and understanding about the counseling profession and the work of professional counselors in mental health, private practice, community agency, agency, organization or related counseling settings.

 

Winner: Adriana Walsh

Adriana Walsh is a master’s student in the clinical mental health counseling program at Wake Forest University. Before moving to North Carolina for graduate school, Adriana worked in her home state of Maine as a full-time crisis and support line advocate for the statewide sexual assault helpline. Although she is just beginning to explore her clinical populations of interest, she hopes to support people around issues of anxiety, grief and loss, trauma, chronic pain and illness, identity concerns, and life transitions. Adriana is drawn to existential, narrative, and relational-cultural approaches and hopes to incorporate elements of the expressive arts and ecotherapy into her work with clients. She holds a bachelor’s degree in music from Grinnell College. In her free time, Adriana enjoys cooking, traveling, long walks in nature, playing and writing music, and spending time with family.

 

Essay:

To engage fully in the profession of counseling means to understand counseling as both an art and a science. While the “art” of counseling comes intuitively to many, its scientific quality can appear more elusive. Yet, as stated in the 2014 ACA Code of Ethics, measuring therapeutic effectiveness is necessary to ensure that clients’ time, energy, and money are not wasted on treatment that is at best ineffective and at worst harmful. As a first-year counseling student, I find myself facing a delicate conundrum: how can counselors engage in the crucial science of measuring therapeutic outcomes without forgetting the fundamental humanness upon which effective therapy is contingent?

Fortunately, outcome measurement does not necessitate abandoning therapy’s human quality, but in fact depends upon it entirely. Take, for example, María, a recent immigrant from Mexico. She is in an abusive relationship and presents with debilitating social anxiety. What might effective counseling look like to María? Does it mean gaining the courage to leave her partner? Does it mean addressing her anxiety enough to leave her house and buy groceries? Or does it mean something else entirely?

In truth, the answers to these questions must come largely from María herself. While clinicians depend upon their own professional expertise grounded in empirical research, the cornerstone of effective counseling is the integration of client feedback. Still, traditional means of soliciting feedback (e.g., a post-session conversation or survey) may not always yield accurate evaluations of client outcomes, and the feedback process should be tailored to each client. For instance, María’s social anxiety may render honest face-to-face feedback difficult. She may also hold back critiques because she is not be accustomed to having her voice privileged in relationships. Language and cultural differences must be considered as they, too, may inhibit open and clear communication of feedback.

Counselors can minimize such barriers by cultivating a “culture of feedback,” in which regular client input is normalized and encouraged. To this end, counselors should provide options regarding how clients provide feedback (e.g., verbal vs. written), use language that resonates with and empowers clients (e.g., avoiding psychological jargon), and present opportunities for feedback early and often.

Additionally, counselors must be willing to grapple with potential blind spots, balancing our clinical expertise with an attitude of humility and proactively seeking peer and supervisory input. We must remain critically aware of structural forces that threaten our capacity to objectively assess counseling outcomes, such as insurance policies that prize specific approaches. It is essential that we recognize and resist pressures to fit our evaluations of outcomes into certain molds when other approaches may better suit a given client.

Counselors must strive for long-term effectiveness by advocating against oppressive conditions that pose barriers to seeking or continuing therapy, including discrimination, poverty, insurance costs, and stigma. Finally, adopting an attitude of “scientist practitioner” (e.g., by engaging in action research) can empower clinicians to view the analysis of outcomes not as the sole responsibility of ivory-tower academics, but instead as an integral component of all effective counseling.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Spotlight on: The ACA Graduate Student Ethics Awards for Master’s Degree Students winner

March 26, 2020

This award recognizes exceptional, demonstrable understanding of the ACA Code of Ethics, the foundation of ethical professional counseling practice.

Winners: Samantha Burton, Ingrid R. Pipes, Ben Stoviak and Katie Voorman of Carlow University

Abstract

The essay addresses the ethical dilemmas that counselor Keith faces after deciding to offer distance video counseling to his client, Tina. Before Tina moved to another state, the face-to-face therapeutic relationship between Keith and Tina was trusting and effective. After a few video counseling sessions over FaceTime, Keith experiences poor video connection and some feelings of awkwardness during sessions. Tina has also followed Keith on his private social media pages and contacted Keith on his personal phone number. To review the ethical considerations of this particular issue, this dilemma will be examined through the lens of the American Counseling Association’s foundational principles. Specific ACA (2014) codes are considered and applied in relation to Keith’s dilemma. Relevant court cases, as well as the National Board for Certified Counselors Policy Regarding the Provision of Distance Counseling Services (2016) are introduced to give insight for ethical rational. Using the Forest-Miller and Davis Ethical Decision Making Model (2016), Keith will work through steps to determine a course of action.

 

Essay: Application of the Forester-Miller and Davis Decision Making Model: A Case Study

This case study seeks to evaluate historical activities between a professional counselor, Keith, and individual client, Tina, who has been seeking services related to communication issues she has reported experiencing with her partner and children. In the details provided by this case, Tina has relocated to a rural area, and she and Keith have continued their counseling relationship by FaceTime, an unfamiliar professional distance counseling modality for Keith. Tina and Keith have begun to additionally interact through social media platforms and have experienced multiple technical problems, resulting in Keith developing and acknowledging a sense of discomfort.

Through the employment of a decision making model designed by Forester-Miller and Davis (2016), these counselors-in-training seek to provide recommendations to Keith that are guided by the American Counseling Association’s Code of Ethics (2014), relevant legal cases, and the National Board of Certified Counselors Policy Regarding the Provision of Distance Professional Services. Recommendations are made in alignment with the prescribed steps of this decision making model, in observation and evaluation of the ACA’s six foundational principles: autonomy, justice, beneficence, nonmaleficence, and fidelity (Forester-Miller & Davis, 2016).

Definition and Application of the Forester-Miller and Davis Decision Making Model

These counselors-in-training have chosen to employ an ethical decision making model developed by Forester-Miller and Davis (2016). Initially published in the Practitioner’s Guide to Ethical Decision Making, by the American Counseling Association, this model was designed out of consideration of multiple pre-existing models in use by and developed for professional counselors, calling for decision-making to be grounded in observance of key foundational principles of the helping professions: autonomy, justice, beneficence, nonmaleficence, and fidelity (Forester-Miller & Davis, 2016). Furthermore, this model specifically integrates consideration and application of the American Counseling Association’s Code of Ethics among its mandatory steps, i.e., Step 2 (Forester-Miller & Davis, 2016).

Steps of Decision Making Model

This decision making model progresses through seven steps, beginning with identification of the problem and concluding with implementation and reevaluation of the proposed solution or solutions. Each step is explained and will be addressed and related to Keith’s dilemma.

Step 1: Identify the problem. In Forester-Miller and Davis’ Decision Making model, the problem is identified following a period of information gathering (Forester-Miller & Davis, 2016). Recommended strategies include asking questions and documenting acquired information in an outlined form (Forester-Miller & Davis, 2016).

Step 2: Apply the ACA Code of Ethics. Following information gathering, outlining, and identification of the problem, the ACA Code of Ethics should be applied in a deliberate and rigorous manner (Forester-Miller & Davis, 2016). Legal and professional codes and standards, considerations of multicultural frameworks, and technical pragmatics should be applied to the case alongside the ACA Code of Ethics (Forester-Miller & Davis, 2016). It is the counselor’s responsibility to ensure that they understand all of these critically evaluative and potentially confounding factors (Forester-Miller & Davis, 2016).

Step 3: Determine the nature and dimensions of the dilemma. At this step, the identified problems should be considered in relation to any foundational principles (autonomy, justice, beneficence, nonmaleficence, and fidelity) found to be applicable, and individual applicable principles should be assigned priority values (Forester-Miller & Davis, 2016). Professional literature, peer and expert professional counselors, and relevant professional associations should be consulted for additional perspective and support (Forester-Miller & Davis, 2016).

Step 4: Generate potential courses of action. This step involves brainstorming an exhaustive list of potential courses of action, informed by the previously assigned and ranked applicable foundational values; peer consultation is recommended at this step (Forester-Miller & Davis, 2016).

Step 5: Consider the potential consequences of all options and determine a course of action. By way of careful and well-evaluated elimination of options, the counselor should choose the strongest option or options that meet the criteria of top-rated foundational values (ForesterMiller & Davis, 2016). Possible implications and consequences of and for all involved parties should be considered at this step (Forester-Miller & Davis, 2016).

Step 6: Evaluate the selected courses of action. The selected course of action is reevaluated at this step for any issues that may have arisen or that were not previously considered (Forester-Miller & Davis, 2016). A prescribed test may be employed at this step to confirm the selected course of action; this test involves assessing for three values: justice, or evaluated fairness of choice across the potential population, publicity, or comfort with the possible outcome were it to be made public knowledge, and universality, the likelihood that you would recommend this outcome to a peer counselor (Forester-Miller & Davis, 2016).

Step 7: Implement the course of action. Given that ethical decisions may be realistically challenging to execute, this step exists to remind the counselor to carry out the diligent and thoughtful work completed in the previous six steps of this model (Forester-Miller & Davis, 2016). Follow-up and evaluation after implementation is recommended to ensure that the decision made was successful and positive, as well as if further action, reaction, or re-evaluation should be considered (Forester-Miller & Davis, 2016).

Identification of the Dilemma (Step 1)

Keith is a licensed professional counselor who had been seeing a client, Tina, for communication issues she was having with her partner and children. After building a comfortable and effective therapeutic alliance, Tina revealed that she had to move out of state. A few months later, Tina contacted Keith when she was feeling unsuccessful with her new therapist. She explained that the nearest alternative service provider is a long drive away from her rural area and requested that Keith consider tele-counseling over video chat. Keith admitted that he did not have experience with this method of counseling, but he attempted its use nonetheless. After a few sessions over FaceTime, Keith experienced several frustrating dropped calls and reported feeling awkward in offering a new medium of counseling. Keith used his personal cell phone for their FaceTime sessions and Tina began texting this personal number when she had questions. Tina sent Keith a Facebook friend request and has also followed him on Instagram and Twitter, stating that she appreciates having so many avenues to be connected to Keith since they no longer have faceto-face sessions. Keith understands that the relationship with Tina is potentially no longer therapeutic, but does not know what steps to take next.

Ethical Codes and Relevant Considerations Identification and Applications (Step 2)

According to the prescribed steps in Forester-Miller and Davis Ethical Decision Making Model, Keith’s actions during the course of and related to the counseling relationship he established with his client, Tina, should be evaluated in relation to pertinent individual codes from the American Counseling Association’s (2014) Code of Ethics. Because this document is the de facto guide for ethical professional counseling practice responsibilities, these counselorsin-training have sought to exhaustively and collaboratively identify and apply any codes which may be valuable during the proposed course of decision-making and implementation. Keith’s dilemma, and others like it, are complex and multi-faceted, and the identified codes may not perfectly encapsulate all dimensions of the dilemma.

A.4.a Avoiding Harm. This code recognizes that counselors work to reduce or avoid situations that can cause unexpected harm to their client (ACA, 2014). Although Keith acknowledges that he has never used tele-therapy with a patient before, he fails to establish boundaries or guidelines around service delivery and instead gives his personal phone number to Tina to conduct sessions. This is a boundary crossing which impacts the therapeutic relationship and is potentially harmful for Tina.  Blumer, Hertlein and Mihaloliakos (2014) conducted a mixed methods study involving part and full time counselors as well as students enrolled in marriage and family therapy programs to assess their views on ethical issues and online counseling. One theme that emerged was the impact tele-therapy has to the therapeutic relationship, particularly boundary concerns. Participants were concerned that boundaries become blurred when clients are given access to personal contact information. For example, clients may perceive that the counselor is available at any time or the client may be able to gain access to the therapists’ social media platforms, both of which can negatively impact client care (Blumer, et.al, 2014).

A.5.e Personal Virtual Relationships with Current Clients. Code A.5.e states that counselors are not permitted to enter into personal virtual relationships with current clients; this includes social media and other media sites (ACA, 2014). Kolmes (2017) explains that multiple relationships between client and therapists are occurring more regularly and exist whether the therapist is aware or not. In this case, Keith became aware that Tina was following him on Instagram and Twitter after he received a Facebook friend request from her. Although it does not state whether Keith acknowledges these attempts by Tina to “stay connected and interact” it can be implied that her actions are the beginning stages of multiple role development in their therapeutic relationship. Multiple roles can impede on the counselors primary role as a therapist (Kolmes, 2017). A recommendation for Keith on how to navigate multiple roles when social media is involved comes from Kolmes. He suggests consultation and documentation with an expert who is proficient on the inner workings of the internet and social media (Kolmes, 2017).

A.7.a Advocacy. Code A.7.a declares that a counselor must take opportunities to advocate for clients when there is a potential barrier that may impact their development (ACA, 2014). The client now resides in a rural area, more likely with low mental health access and higher levels of suicide than other geographical areas (Cohn & Hastings, 2013). One aspect of this low access relates to high burnout among counselors in the area (Cohn & Hastings, 2013). Without proper supervision and better support from the community, mental health practitioners in rural areas will continue to struggle – and clients will continue to suffer under the lack (Werth, Hastings, & Riding, 2010). As the counselor of a client in this population, Keith should not only advocate for his client to seek out additional support in her area, but for the mental health community to show greater support for rural counselors.

A.12 Abandonment and Client Neglect. Code A.12 accredits that it is the responsibility of the counselor to ensure their client has access to treatment, even in times of the counselor’s absence (ACA, 2014). This may mean arranging a connection with another professional. Though the professional relationship between the client and counselor was ended before the client moved, the client has now faced a different environment with less resources. The counselor does not appear to have sought supervision for this new situation – wherein the client has asked for continued counseling services. It seems likely that the counselor was concerned about neglecting the mental health needs of the client due to her current struggle in a rural community. The ethics code regarding neglect and abandonment, however, applies to appropriately caring for the client and counselor relationship during the specific course of treatment – or during breaks within that treatment such as for vacation. Because the relationship between the counselor and the client ended out of necessity, if Keith appropriately closed out services, then he would have been within ethical boundaries to deny furthering services regardless of the client’s new environment.

C.2.a Boundaries of Competence. Code C.2.a states that a counselor must only offer services that are within their competency, or develop competencies to meet client needs (ACA, 2014). If offering a new service, counselors must prevent harm to their clients. As mentioned under other codes, the rural communities in America face a struggle with mental health resources. In studying ethical solutions for counselors in that area, Werth, Hastings and Riding (2010) recommend that some rural counselors refer clients to video conferences with specialists, or even tele-psychotherapy. In those recommendations, however, the counselor accepting the referral is a specialist or expert. The counselor in the proposed case, while specializing in one area of the practice, appears to have little experience with both tele-therapy and with rural culture. By not seeking greater understanding of either aspect, he is likely missing important parts of both – and will need to seek additional education or refer the client.

C.2.b New Specialty Areas of Practice. Code C.2.b contends that a counselor offers a new specialty or modality of therapy only after obtaining the specific training and supervision needed (ACA, 2014). One of the counseling concerns with rural populations relates to the cultural differences in rural and urban environments. Though the client has moved to the rural environment from a more urban space, she now faces a completely different set of resources and community supports. As Rollins (2010) points out, the cultural differences can be stark when it comes to recommendations and coping mechanisms. Urban counselors, for example, may not understand what is or is not available for clients in a rural community – where businesses, social gatherings, and accessibility may be very different than what the counselor wants to recommend. There is little indication that the counselor in the case has an understanding of these differences. As he moves forward with the client, he must seek additional education or training in virtual counseling those in rural areas. If he cannot find it, he may need to refer the client.

C.2.d Monitor Effectiveness. Code C.2.d explains that counselors should be continuously monitoring their effectiveness, as well as making appropriate relationships with other professionals for supervision (ACA, 2014). Apart from not having adequate competency about technological aspects of distance counseling, the counselor, Keith, also appears to have no knowledge of the legal consequences. His license may not be adequate for the state where his client is operating.

Alternatively, there are states where the licensed counselor doesn’t require a license for the state where the client resides, but must seek additional education and supervision under specific rules to practice there. By not mentioning this to the client, or seeking any of those additional measures, the counselor has both opened himself to legal issues, and is ignoring the basic ethics code regarding licensure and long-distance counseling.

C.7.b Development and Innovation. Code C.7.b states that counselors must explain the boundaries and risks of new areas in the field to clients before using such tools or methods (ACA, 2014). Counseling via technology poses increasingly great risks to clients, depending on the state where their licensed counselor is operating. According to Hughes (2000), “A client who obtains counseling services via the Internet from a counselor licensed in the same state has recourse to that state’s regulatory board for any violations against either the state code or standards of practice.” By not having adequate competency, the counselor has failed to give the client adequate warning about the issues related to his license and her options should malpractice or harm occur.

H.1.a Knowledge and Competency. This code demands that counselors develop adequate knowledge and competency surrounding use of technologies, distance counseling, and social media, as well as related to regulations and laws surrounding use of these kinds of technologies (ACA, 2014). Keith proceeded with using technologies for which he did not indicate he had any formal training and did not express that he was seeking the development of competencies related to using these technologies. Keith did not identify that he had knowledge of any laws surrounding distance counseling, social media, or telebehavioral health and counseling.

H.1.b Laws and Statutes. Code H.1.b. asserts that if counselors are engaging in telecounseling, they must be aware that they are held to the laws and statutes of their state and the state where their clients reside (ACA, 2014). The client’s resident state has jurisdiction over that therapeutic relationship and to protect the client. Since regulations on counseling across state lines varies from state to state, it is Keith’s duty to contact the state board in which his client, Tina, now resides to ensure the legality of temporarily counseling from a different state. A number of potential issues exist for telebehavioral health practitioners who practice across state lines, especially when state laws are notably different in the states where the client and counselor live, respectively (Maheu, 2018).

H.2.c. Acknowledgment of Limitations. Code H.2.c states that it is the counselor’s responsibility to inform the client of the limitations regarding confidentiality within technology (ACA, 2014). The counselor must ensure that the client understands the boundaries of security within the programming the counselor and client communicate on. By being clear and concise with the client about these limitations, the client is fully informed when giving consent to distance counseling. Keith acknowledged that he had never offered distance counseling, but he was not thorough in considering what steps need to be taken to protect his client’s confidentiality and security. Keith should explain the implications and boundaries of tele-counseling to Tina, including the extent of security of sessions and personal information.

H.2.d. Security. Code H.2.d requires counselors to ensure the programs they use host their website or communicate with clients have secure encryption that meet legal requirements (ACA, 2014). The client’s confidentiality must be ensured when using any digital programming by the counselor. Keith did not research or implement the use of encryption programing or HIPPA compliant tele-medical software to administer tele-counseling. The FaceTime tool that Keith used to host their video calls does not have privacy protection and although may potentially be implemented in ways that are HIPAA-compliant, for example, may not be a safe tool (O’Grady, 2011). To promote the security of his client, Keith would have to choose an encrypted program to host video sessions and communicate with the clients to whom he offers distance counseling.

H.3 Client Verification. When engaging in tele-counseling, or any form of digital communication, code H.3 states that counselors must continually verify the identity of their client (ACA, 2014). This can be done using nondescript, collaboratively chosen identifiers such as code words or phrases. No evidence was provided that Keith took appropriate and effective steps to verify Tina’s identity once the counseling modality had changed from in-person to video conference; additionally, no evidence was provided that Keith took steps to verify that social media accounts purporting to belong to or represent Tina were owned or stewarded by her.

H.4.b Professional Boundaries in Distance Counseling. Code H.4.b suggests that integrating technologies into the counseling relationship may effectively create a dual relationship, and it is important that Keith consciously maintain professionalism and professional boundaries, as well as clearly discuss these boundaries related to technology use with Tina (ACA, 2014, section H.4.b). Evidence was not provided that suggests that Keith met these professional responsibilities.  

H.4.d Effectiveness of Services. Code H.4.d confirms that if the tele-counseling sessions are ineffective, the counselor consider face-to-face sessions or referring the client to other services (ACA, 2014). Keith has experienced multiple instances of poor technical execution of the distance counseling sessions initiated with Tina. One substantial shortcoming was the ability to effectively address technology failures, e.g., dropped calls, a necessary step in the provision of distance counseling (Stolsmark, 2015). He has felt frustrated as a result of these technical issues and his own lack of competency to deliver counseling effectively via FaceTime. Keith has suspected that this new counseling modality may be ineffective, and because he can no longer provide face-toface counseling to Tina due to geographic constraints, Keith is therefore responsible for assisting

Tina with identifying appropriate, competent counseling. According to Meilman and Weatherford (2016), counselors unclear about communications using online counseling modalities might risk inaccurately assessing or overlooking potential signs or symptoms, resulting in further client harm, danger, or potentially suicide. Use of the FaceTime modality for counseling may negatively affect client disclosure or the client’s ability to speak clearly and comfortably about emotions (Mishna, Bogo, & Sawyer, 2015). Additionally, because professional counseling interactions may have taken place within the boundaries of social media platforms, anti-therapeutic communications may have occurred (Navarro, Sheffield, Edirippulige, & Bambling, 2019).

H.6.b Social Media as Part of Informed Consent. Code H.6.b states that counselors must clearly define the limitations, boundaries and advantages of social media during the informed consent process with their client (ACA, 2014). Before engaging in distance counseling with Tina, Keith did not explicitly discuss any usage of social media. As a result, Tina attempts to friend Keith on multiple social media accounts. One way Keith could have addressed social media prior with Tina is by establishing a social media policy during the informed consent process. Kolmes (2017) states that having a social media policy allows for the therapist to share their views on friending, following and other messaging which could potentially threaten counselor- client confidentiality and boundaries.

H.4.f Communication Differences in Electronic Media. Code H.f.4 ascertains that verbal and non-verbal cues occur differently while tele-counseling and that the counselor is responsible to address issues and nuances within digital communication as they arise with the client (ACA, 2014). Keith identified that he experienced the professional interactions between he and Tina as awkward. Yet, he did not proactively or reactively address these communication issues by providing information about voice inflections, a lack of visual cues, and other potential differences that may manifest in online, virtual, and video-conferencing communications.

Conflicting Factors, Dimensions, and Variables (Step 3)

Following the Forester-Miller and Davis model, the identified problems are to be considered in relation to the ACA foundational principles, which are then prioritized. Consultation of professional literature and relevant professional organizations occurs at this step, as well. Each of six foundational principles is considered, as is The National Board for Certified Counselors’ Policy Regarding the Provision of Distance Professional Services and relevant legal cases, in consultation for further best practices, perspective, and restrictions for Keith in working with Tina.

ACA Principles

In the presented case, the counselor has violated or potentially violated multiple codes under the ACA Code of Ethics. The description of the case indicates that he has begun to notice these conflicting practices and the need for an ethical assessment an action plan. If he had followed the basic principles upon which the code is written, however, he may have been more careful with both the client and the counseling relationship. The six principles (autonomy, beneficence, fidelity, nonmaleficence, justice, and veracity) are discussed here as they apply to the case. Their merits in the situation vary, but each ideal has a place in the dilemma this counselor now faces – and how his practice has reached this point.

Autonomy. The principle of Autonomy within the counseling relationship is the ideal that the therapist acknowledges and respects the client’s right to make their own decisions and actions based upon their value system, when appropriate (Davis & Forester- Miller, 2016). In the case of Keith and Tina’s counseling relationship, Tina makes new, continued, and repeated assertions of her needs, desires, and expectations, demonstrating autonomy, and Keith attempts to respect and acknowledge her autonomy therapeutically. However, as a counselor, it is Keith’s due diligence to also address when his client’s choices and actions may negatively impact the therapeutic relationship. For example, although Tina prefers to continue her services with Keith online, Keith fails to establish any guidelines or boundaries of informed consent about how the online service will be carried out. Additionally, the lack of boundaries leads to Tina finding and friending Keith on multiple social media accounts.

Nonmaleficence. This principle refers to the therapist’s duty to not inflict intentional harm nor participate in actions that could cause harm to others (Davis & Forester- Miller, 2016). Keith’s actions, though seemingly unintentional, still carry the potential risk of harming his client. At the moment in time at which Tina and Keith’s case has presented for evaluation, obvious issues exist, but client satisfaction or therapeutic effectiveness are unclear. The first action Keith should have made, in observance of the ACA Code of Ethics, would be to discuss a termination plan with Tina after she shares that she is moving. Along with the termination discussion could be information and guidance about possible in-person or distance counseling referrals for Tina to continue counseling. Not completing these steps could result in Tina being unable to receive proper care, as well as experience limitations in access to services.

Another instance where Keith did not consider the welfare of his client was in his decision to agree to provide online counseling services, without having any competence in this area and without seeking consultation prior to making this arrangement with his client.  As a consequence, frustrations develop between Keith and Tina due to dropped phone calls during sessions. Additionally, Keith is not comfortable during their sessions due to his lack of knowledge about online distance counseling. In either case, there is a risk of harm for Tina since she may no longer trust or feel safe with a counselor who appears incompetent. Also, her frustrations due to service issues are infringing on her ability to progress in therapy.

There is also a major risk of a dual relationship developing between Keith and Tina which could negatively influence Tina. As mentioned, Tina finds Keith on social media and decides to formally connect with his online account presence. She also has access to his personal phone number, which she texts whenever she has an issue. Since Keith did not establish any guidelines with Tina on how these forms of communication would be addressed, he has potentially made Tina vulnerable to harm. Whether intended or not, Keith is giving the impression that he is accessible anytime which can cause role confusion in their client- therapist relationship.

Beneficence. This value concerns itself with the acknowledgement and prioritization of work for the well-being of both the individual and society (ACA, 2014). In order to promote better mental health and wellbeing, counselors must follow ethical practices and manage their own part of the counseling relationship. By allowing boundaries to become confusing, and mishandling new professional tools, the counselor has set a poor standard for both mental health and the profession of counseling as a whole. Though he showed consideration for issues such as isolation and lack of mental health in rural areas, he also did not seek to understand what is needed in those rural areas.

Justice. This principle addresses the responsibility of the counselor to address clients fairly and equitably and to seek out means to ensure that clients experience fair and equitable care (ACA, 2014). This means that Keith, as a counselor, should be promoting accessibility for his clients. Though he has done this by treating his client when she is in need of assistance, he has ignored the complex dimensions of a relationship between client and counselor. In a counseling relationship, boundaries and expectations must be maintained and met. The boundaries of professional spaces assist clients in understanding where they have rights and independence. It is the counselor’s professional responsibility to explain these boundaries and help maintain them as the counseling relationship moves forward. Without clear communication and professional boundaries, both people in the counseling relationship are in danger, and cannot act with appropriate agency or advocate for their part of an equal relationship.

As Keith moves forward in the counseling profession, he should also spend more time understanding the cultural differences in communities. By better pursuing multicultural understanding across different cultures and environments, he can reduce the harm and inequality in his professional relationships. Currently, he has acted with an assumption that he understands an entirely different culture and does not need to work on his perceptions of environments. This may demonstrate an exercising of privilege, and denies his clients in different situations the appropriate help and resources they need – as well as setting inappropriate standards of care.

Veracity. Veracity deals with being honest or truthful with one’s clients (ACA, 2014). Keith does mention to Tina that he has never facilitated online counseling sessions before. Still, Keith should have disclosed more information about his lack of competency and sought advice from an expert in this area. In addition, Keith was not honest with Tina once issues with service connection and boundary crossings arose. In distance counseling, clients need to be made aware of the risks to their confidentiality as part of the informed consent process. There is a greater risk of clients’ personal information being accessed if technical measures are not established to secure client identity.

It is also the responsibility of the therapist to address and be honest about boundary crossings and boundary violations with their client. Keith realizes that Tina gaining access to his social media accounts is problematic. Ideally, this is another issue that should have been addressed during the informed consent process prior to engaging in online sessions. During which time Keith could have communicated his views and boundaries for social media with his client.

Fidelity. This good faith principle holds the counselor responsible to their promises, thereby increasing the profession’s holistic trustworthiness. Keith may be operating under the assumption that he must continue working with this client to fulfill a responsibility to her, or to honor a commitment to their professional relationship. However, the trust placed in Keith assumed that he would operate with appropriate competence and understanding. By disregarding supervision, education, legal concerns, and the need for informative consent between himself and the client, he has placed the client’s private information in danger and broken that trust. As a counselor, Keith is meeting basic requirements for trust – as the client continues to see him. But moving forward, he will need to work hard to improve his competencies and seek supervision. That will keep him from breaking the trust placed in him, as he is doing now.

NBCC Policy Regarding Distance Services

The National Board for Certified Counselors, a non-profit professional organization which oversees the assessment products used in part for the state licensing of counselors across the U.S., maintains a Policy Regarding the Provision of Distance Professional Services, applicable for counselors certified by the NBCC (2016). This policy document would apply to Keith’s practice as a Nationally Certified Counselor (NCC) if he is maintaining this professional status.  Because Keith has elected to proceed with the application of distance counseling modalities, the best practices outlined in this document may have useful, ethical implications and uses, regardless of whether or not he has applied for or currently maintains NCC status.

According to the NCC Distance Professional Services policy (2016), Keith should only provide services for which he is adequately qualified. He should adhere to all legal regulations which may apply to the practice of counseling and observe state regulations and laws which apply to the states in which the clients he is counseling reside or claim legal residency (NBCC, 2016). Client privacy must be prioritized and protected by way of using tools encrypted for therapeutic use, as well as warning clients about password “auto-saving” features on application and tools and potential network risks (NBCC, 2016). Records should be backed up safely and retained for a minimum of five years (NBCC, 2016). Clients and services should be assessed for appropriateness of distance counseling tools (NBCC, 2016). Clients should be screened for these services to assess for the potential risks or benefits of distance counseling use, as well as be provided with clear informed consent and engaged in ongoing identity verification practices (NBCC, 2016). Lastly, social media use policies should be provided to clients, and social media platforms should be avoided for the exchange, dissemination, or storage of confidential information (NBCC, 2016).

Many of the responsibilities outlined in this NBCC policy were not met by Keith and reflect issues aforementioned in relation to the ACA Code of Ethics. Though he was not trained in distance counseling, and did not screen his client for use in these tools, he proceeded to engage with his client using an unfamiliar distance counseling modality, and he did not indicate that he was aware of laws surrounding use of this modality. Keith did not indicate that he provided updated informed consent information to his client or warning about potential risks. He did not indicate that he was maintaining records in a consistent way. Lastly, Keith did not indicate that any kind of social media use or communications policy was provided to Tina before or during their exchanges.

Court Cases

When faced with an ethical dilemma, referencing relevant court cases can help counselors in their decision making. One ethical dilemma Keith faces is the decision to provide online counseling to his former client, Tina, who now resides in a rural area in another state. In Abraham vs. Bureau of Professional and Occupational Affairs, Board of Psychology, 2014, a psychologist from Israel was providing online counseling services to residents in Pennsylvania without being licensed in the state (Professional Licensing Report, 2014). Pennsylvania courts ruled that this was in violation of Pennsylvania laws because Abraham had a physical presence in PA via a Pennsylvania phone number and address, therefore requiring the need for him to also have a Pennsylvania license. The board felt that Abraham’s actions were potentially harmful to his clients and that he was in violation of Section 3 of the psychological practice act (Professional Licensing Report, 2014).

Other landmark cases such as Jaffee vs Redmond, 1996, highlight the importance of client confidentiality within the counseling relationship (APA, 2020). Ethical standards remain the same whether a therapist is providing face to face or online counseling sessions. This means that the online counselor may have to take additional precautions in order to ensure that their client’s vulnerable information is protected. Contech, Kaplan, Martz & Wade suggest that counselors take measures such as encryption, segregated storage, and avoidance of internet hotspots to safeguard client information (2011). Without privacy-oriented practices and competencies in place, client safety may be at risk, and harm to clients may occur.

Recommendations for and Evaluations of Professional Actions (Steps 4-7)

Following identification and explanation of Keith and Tina’s dilemma, and the characterization and formal identification of relevant ACA codes applicable to this case, these counselors-in-training have designed a proposal which continues to adhere to Forester-Miller and Davis’ decision making model. Foundational principles were considered, rated, and applied to the selection and design of the proposed recommendations; next, actions were proposed and both unconsidered and selected actions were re-evaluated; lastly, these actions were recommended for implementation with model-aligned meta-implementation steps, considerations, and activities.

Selection of Priority Foundational Principle: Nonmaleficence

These counselors-in-training individually ranked the six foundational principles by two domain variables, perceived case relevance and perceived case impact. Following individual ranking, assessed values were applied collaboratively to determine the rank-order in which these variables would be applied to this case’s evaluation. These counselors-in-training determined that non-maleficence would be prioritized in this case’s evaluation as the most critical value, sharing in agreement that reducing or eliminating potential harm to Tina, through counseling, was necessary groundwork in order to pursue therapeutic beneficent work, increase and acknowledge autonomy, act or continue to act in just ways, pursue honest interactions, and thereby develop good faith promises that could be and should be kept.

In observance of the value of nonmaleficence, these counselors-in-training concurred that Keith’s lack of competencies related to online and distance counseling, the tools selected for distance counseling, social media use within the counseling relationship, legal issues surrounding distance counseling, and rural populations needs and interests were a significant risk of harm to the counseling relationship and Tina’s wellness. Adequate resources were not provided to Tina, including a well-informed opportunity for referral to a competent community or distance counselor. Lastly, Keith’s engagement with Tina through use of social media may be potentially harmful to both their counseling relationship and her wellbeing. If these several issues are not addressed and resolved, Keith risks engaging with his client in a way that is not only unethical, but potentially detrimental to her.

Recommended Courses of Action

These counselors-in-training recommend that Keith immediately seek professional consultation and acquire professional development on the matters of online and distance counseling tools and best practices, counseling populations recently relocated to rural communities, and use of social media in the counseling relationship. Keith should contact the licensing boards in both the state where he resides and the state in which Tina resides to determine if he is legally and ethically eligible to provide counseling through this modality to his client. Should it be determined that he is able to continue treating Tina through distance counseling means, he should develop new informed consent documentation which outlines the potential benefits and risks of providing counseling this way and clearly outlines professional boundaries that must be observed related to their counseling relationship, social media, and personal phone use. Keith should not continue to provide any online or distance counseling until he has determined, through formal supervision, that he is competent to provide this type of counseling in a way that does not risk harm to Tina or the counseling relationship he has established with Tina. Furthermore, he should be advised to create a new online website presence with documentation related to his licensing information and create a separate social media presence, should he wish to engage with any clients on these platforms, for professional use only. During his next exchange with Tina, he should be prepared to provide her with well-researched professional referral opportunities who can provide counseling to her until he has developed competencies that will enable him to provide nonmaleficent and beneficent professional counseling support, explaining that he will not be able to provide further counseling to her in a time-sensitive manner, pending development of competency.

Further Evaluation of Unselected Courses of Action

These counselors-in-training determined that continuing to provide online, distance counseling to Tina may risk harming or continuing to harm her and their therapeutic relationship. Additional risks include a lack of perceived competency or helpfulness leading to early termination, doubt in the counseling profession on behalf of the client, and unnecessary generalized frustrations with personal wellness positive behaviors and technology use. Continued use of social media use, without clearly outlined boundaries provided through informed consent, could create an uncomfortable or problematic dual relationship or continue to encourage one should it be determined that one has already been created accidentally. Research should be applied towards the pursuit of suggesting referral, as these counselors-in-training determined that there may be counselors who can specifically benefit Tina by way of competency related to moves to a rural community, and not selecting a competent counselor may result in harm to Tina.

Lastly, without selection of the appropriate tools and the inclusion of intentional supervision, Keith risks harming not only Tina, but also other current or future clients through the modalities and tools he has begun using without seeking appropriate consultation and supervision.

Evaluation of Recommended Courses of Action

These counselors-in-training determined that, in subscribing to the ACA Code of Ethics, this strategy provides for fair treatment across Keith’s possible client population, i.e., that it meets the test of justice. Were Tina not to contact Tina on social media, Keith may not have agreed to continue interacting with her that way, and Keith did not indicate that he had established online relationships with any other clients. Furthermore, Keith can explain to Tina that he cannot make exceptions for her related to online counseling, social media use, or the provision of services for which he has not developed competencies as it is not fair to each of the clients with whom he has a counseling relationship. These counselors-in-training determined, furthermore, that this recommendation meets the test of publicity, as public knowledge that a counselor sought professional development and consultation, declined to proceed in a potentially problematic dual relationship, and referred a client for whom he felt he was not competent to provide nonmaleficent care would not be harmful to a counselor’s reputation or professional identity. Lastly, because this rationale was designed by way of the ACA Code of Ethics, relevant laws and legal cases, and policy published NBCC, these counselors-in-training are confident that this rationale could be recommended to a professional peer interested in pursuing distance counseling as a new counseling practice modality, thereby passing the test of universality.

Implementation of Recommended Courses of Action

Should there have been any further progress related to this case made, these consequential recommendations would require reassessment by Keith. Furthermore, following the implementation of these recommendations, Keith should reassess this plan at each step of the proposed implementation to determine that he is continuing to provide professional service that is nonmaleficent, as well as in alignment with the other ACA principles. These steps should be completed in concert with a competent supervisor or supervisory team who has expertise in the domains of action in which Keith is pursuing changes. Any subsequent changes to these recommendations should be made under supervision. Following complete implementation of these recommendations, Keith and his supervisor or supervisory team should re-assess the success of these recommendations, document success and failures, and pursue any necessary further actions potentially prescribed by the ACA principles and Code of Ethics.

Conclusion

In the provided case study, technological tools and counseling modalities were introduced into Keith and Tina’s counseling relationship. Keith proceeded in providing counseling through this new manner without seeking supervision, developing competencies, determining applicable laws, providing updated informed consent, or assessing objective risks and benefits of doing so. Furthermore, Keith and Tina’s counseling relationship began to move into other technical realms, including social media platforms, risking the creation of a potentially harmful dual relationship.

This team of counselors-in-training evaluated this case with guidance from the American Counseling Association’s Code of Ethics, relevant legal cases, and the National Board of Certified Counselors Policy Regarding the Provision of Distance Professional Services, through the framework of the Forester-Miller and Davis’ decision making model. This team collaboratively prioritized nonmaleficence as the chief foundational principle though which to determine recommendations, based on possible professional outcomes. Recommendations and steps for careful re-evaluation and implementation that included the pursuit of supervision, development of professional competencies, provision of updated informed consent, careful selection of tools, and temporary referral or termination were provided so that Keith may be empowered to provide services which, among the profession’s other values, contribute to “enhancing human development throughout the life span,” and “honoring diversity…,” which uphold the counseling profession’s commitment to “practicing in a competent and ethical manner” and ultimately “safeguarding the integrity of the counselor-client-relationship” (ACA, 2014).

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Spotlight on: The ACA Graduate Student Ethics Awards for Doctoral Degree Students winner

This award recognizes exceptional, demonstrable understanding of the ACA Code of Ethics, the foundation of ethical professional counseling practice.

Winners: Connie Elkins, Jay Tift and John Bender of Lindsey Wilson College

Essay:

Abstract

The ethical dilemmas within the scenario include integration of technology and electronic record storage, confidentiality, informed consent, supervision practices, remediation, and gatekeeping. The authors’ response includes: identifying these dilemmas with guidance from the ACA Code of Ethics; recommending courses of action; and utilizing Cottone’s (2001) Social Constructivism Model of Ethical Decision Making. A constructivist approach to supervision and as an ethical decision-making model are helpful for resolution of the dilemmas between Rita, Sam, and Dr. Menendez.

 

2020 ACA Ethics Competition: Doctoral Prompt

The ethical scenario as presented contains a number of issues of concern. Of particular relevance are those issues surrounding the importance of written informed consent with all clients regarding confidentiality and privacy of their information, the ethical use of technology as it relates to storage and transmission of client information, and appropriate gatekeeping and remediation practices in the case of skills deficits for counselors-in-training.

Informed Consent, Confidentiality, and Technology

Informed consent is a central tenet of ethical practice in counseling. Clients have the right to be fully informed about all aspects of their treatment, including the storage and transmission methods of their files, whether written, audio, or video (​American Counseling Association, 2014). Counselors must not only inform clients verbally, but through the review of a written ​informed consent document that is both understandable and transparent. This is especially important with the use of technology due to its ever evolving nature and potentials for breaches in confidentiality (McAdams & Wyatt, 2010).

Utilization of email is nearly ubiquitous in modern communication, however, in clinical practice it requires caution. The risk of breaches in confidentiality should be addressed prior to use (Atherton, Sawmynaden, Sheikh, Majeed, & Car, 2012). The federal Health Insurance​   Portability and Accountability Act of 1996 (HIPAA) allows for email between counselor and client as well as between a supervisor and supervisee with the client’s informed consent (Rousmaniere, Renfro-Michel, & Huggins, 2016).​ This presupposes utilization of HIPAA compliant technology with full encryption and secure storage. Using email for data transmission poses potential confidentiality risks​ in cases of  unencrypted systems, accidental misaddressing​ (as in the case of this scenario), email within handheld devices which are not password secured, and in standard documentation by email or internet providers (Lustgarten & Elhai, 2018).​ Counselors must be thoughtful and cautious in using email to relay private health information.

Gatekeeping and Remediation

Insuring the practice of counseling in a competent and ethical manner and protecting the integrity of the counselor-client relationship are core values of the profession (American Counseling Association, 2014).​ In the attempt to protect these core values, processes for gatekeeping and remediation are required during counselor training. Trained supervisors are expected to provide on-going evaluation of counselor performance with active remediation activities. If counselors-in-training (CITs) are unable to demonstrate that they can provide competent, professional services, it is the responsibility of their supervisor to develop remediation strategies or to recommend dismissal from training programs. Remediation and gatekeeping are not lone processes; supervisors consult with other professionals and standing policies prior to determining actions toward CITs (American Counseling Association, 2014).

Remediation in training is not considered punitive but supportive as the supervisor and supervisee develop a working alliance (Lampropoulos, 2002). Effective supervision of CITs includes developmental and culturally sensitive approaches with support, guidance, and self-awareness (Handelsman, Gottlieb, & Knapp, 2005; Lampropoulos, 200​ 2;​ Pompeo & Levitt, 2014). The use of a consistent model for supervision is a way to validate remediation strategies,​  with most supervision models paralleling those of counseling models (Destler, 2017; Lampropoulos, 2002). Destler (2017) states that the process of supervision, and the relationship between counselor and supervisor, are similar in structure to the concurrent relationship between client and counselor. However,​ “this triadic configuration does not take a fourth entity into​  account: the relationship between the supervisor and the supervisor’s supervisor” (p. 274). The supervisor’s supervisor is an integral part of the remediation and gatekeeping process, and most often the one responsible for final decisions of gatekeeping.

Identification of the Dilemma

An initial ethical dilemma in this scenario is inadequate informed consent which should be reviewed and signed by the CITs’ clients regarding the videotaping of sessions and use of these sessions in the supervision process. Another dilemma includes difficulty in the supervisory relationship between Rita and her doctoral student supervisor, Sam. Rita is not receptive to Sam’s feedback regarding her clinical skills and therefore chooses to download a video file of a client session, which includes written feedback from Sam, and to share it via email with the rest of her practicum class. Sharing the video with classmates without client consent is a breach of confidentiality.

Other breaches of confidentiality occur as Rita’s classmates share the video, again via email, with their doctoral supervisors. Ultimately, the video is accidentally shared with the faculty supervisor, Dr. Menendez, when he is looped into the email chain regarding the file. It is not directly problematic that Dr. Menendez received this file, as he is responsible for both the CITs and the doctoral student supervisors, but it demonstrates the risk of email in the potential for accidental sharing. It is problematic that Dr. Menendez learns of the sharing and conflicts accidentally instead of through reports from Sam and the other doctoral student supervisors.

A final concern is the lack of communication between Rita, Sam, and Dr. Menendez. Dr. Menendez is ultimately responsible for client services and CIT performance and should be providing guidance to Sam as Sam strives to deliver effective feedback to Rita. Sam should be continually consulting Dr. Menendez with any supervision, remediation, or gatekeeping concerns for his CITs. This demonstrates issues related to effective gatekeeping and remediation, both for Rita and for Sam.

The views of Rita and Sam are at the heart of this dilemma. Sam has become concerned about Rita’s practical application of counseling skills and is struggling to provide feedback in a way that is helpful. Rita has become increasingly frustrated with her perceived unfair feedback and is not receptive to Sam’s supervision. This mutual frustration may have created an impasse between Rita and Sam, and further consideration must be given of the viability of the relationship.

Social Constructivism Model – Cottone

The Social Constructivism Model for ethical decision making is a social interpretation of the decision-making process, taking into account how decisions occur and how values are weighed by the individuals involved (Cottone, 2001). Within this approach there is a recognition of competitive truths in which ethical dilemmas are normalized, initial consensus is established, and resolution is negotiated through interactive reflection with other professionals​ or through​ arbitration.  Professionals avoid linkages of vulnerability and cultivate linkages of professional responsibility, emphasizing growth and change as opposed to failure (Cottone, 2001).

Within the constructivist approach decision-makers engage in interactive reflection. This is not an internal process of the mind but a continued reappraisal of actions in consultation with other counseling professionals (Cottone, 2001). Decision-makers consult colleagues to insure that the dilemma is fully understood and defined through obtaining complete information.

Interactive reflection is utilized throughout the processes of assessing relationships between conflicting parties, consulting expert opinion, negotiating, consensualizing, and arbitration- all defining features in the social constructivist ethical decision process. Social constructivist processes do not require linear progression and may occur simultaneously while seeking solutions to ethical dilemmas.

A social constructivist approach to supervision and ethical decision-making can be helpful in resolving ​ the dilemmas between Rita, Sam, and Dr. Menendez. Rita’s lack of progress,​  lack of trust in Sam’s input, and her defensiveness and frustration are seen as symptoms of anxiety and problematic relationships (Guiffrida, 2015; ​ McKibben, Borders, & Wahesh, 2019).​ These dilemmas can be resolved through a social constructivist process since her response “probably derives as much from the relationship to the accuser or enquirer as it does from the nature of the alleged misconduct” (Cottone, 2001, p.42). Remediation of Rita’s lack of progress and breach of client confidentiality is an ethical responsibility for both Sam and Dr. Menendez and will be emphasized throughout the discussion of the scenario, however, the most important relationship is between Rita and her client, and all efforts of support and remediation are to ethically establish and maintain their​ ​ therapeutic relationship.

Obtain Information from Those Involved

As part of the Social Constructivism Model, the views of all parties involved must be taken into account. This includes both explicit and implicit views. Rita is given the opportunity to express her perspective and to account for her actions, explaining her decisions to reject Sam’s input and to share counseling sessions. She is encouraged to evaluate her actions in light of professional ethics and have her opinions heard by Dr. Menendez. This process can have remedial value as she is allowed to assess her actions in a supportive atmosphere.

It is also necessary to obtain information from Sam, his fellow doctoral students, and Dr. Menendez. Dr. Menendez expressed concern regarding both the actions of his CITs and of Sam and the other doctoral students who were aware that this information was being circulated. Sam is given the opportunity to explain his actions, which also may provide remedial value as he assesses these actions in light of his professional ethics. The doctoral students can communicate their perspectives and assessment of the dilemmas, using this as a learning opportunity. Through information gathering, it is hopeful that Dr. Menendez will realize the inadequacies of the current informed consent document.

Assess the Nature of Relationships

An evaluation of the relationships between Rita and Sam, Sam and Dr. Menendez, and Rita and Dr. Menendez is beneficial to remediate Rita’s skills and to repair ethical breaches created in this scenario. The supervisory relationship is foundational to supervisee growth and development, and skillful nurturing and application of these relationships creates the environment for an optimal outcome (Cottone, 2001; Guiffrida, 2015; McKibben et al., 2019). McKibben et al. (2019) found that the stronger a supervisee perceived the relationship to their supervisor, the more likely critical feedback was viewed as valid. Receptiveness to, and encouragement of feedback between Rita, Sam, and Dr. Menendez will greatly improve the chances of optimal resolution in this scenario.

Rita’s frustration and resistance to Sam’s interventions are symptoms of her anxiety and lack of trust in Sam’s guidance. Strategies include an honest evaluation of their relationship along with activities to establish mutual trust and acceptance. As the supervisor, Sam can encourage and normalize Rita’s feelings of anxiety and frustration in the growth process. He can also share some of his personal experiences as a CIT to create mutual empathy. Empowering Rita to create agendas for their supervision sessions and to critique his ability in providing helpful feedback can increase her sense of autonomy and comfort in the relationship as well as giving Sam insight into his supervision approach. Rita’s mistakes can be seen not as failures but as part of the learning process, particularly when Rita recognizes and corrects them while counseling or during supervision. As their relationship develops Sam can teach Rita to critically reflect on her thoughts, feelings, and behaviors in counseling sessions. Rita’s increased self-awareness and decreased fear of failure will help her to apply effective strategies while working with her clients.

The relationship between Sam and Dr. Menendez also needs to be addressed as part of Sam’s remediation. Dr. Menendez is Sam’s supervisor, and ethical breaches and lack of progress with Sam and his supervisees are problematic. The fact that Sam did not notify Dr. Menendez of the electronics breach and issues with Rita indicates that Sam is not entirely forthcoming in their supervisory relationship. Sam is likely experiencing anxiety as supervisor of CITs. Dr. Menendez must work to create a sense of safety for Sam to engage in reflection of his thoughts, feelings, and behaviors within his supervisory responsibilities. Sam and Dr. Menendez can then cooperatively strategize remediation plans for Rita’s performance. Sam’s development as a supervisor will be supported through reflective interaction with Dr. Mendez.

Another relationship that needs to be assessed is that of Rita and Dr. Menendez. Dr. Menendez should insure that Rita and the other CITs feel secure enough to express concerns they are having in the counseling and supervision process. He needs to be accessible and supportive, normalizing anxiety and mistakes as part of the developmental process, while also providing clarity on the institution’s dual commitment to protecting clients and helping CITs grow. Strategies might include sharing his experiences as a counselor as well as discussing realistic expectations of students from a developmental perspective. From this stance, he and Rita can cooperatively assess their relationship and create a plan to strengthen and maintain it.

Consult Valued Colleagues and Expert Opinion

It is vital that a supervisor-in-training be in regular consultation regarding all supervisees with their supervision supervisor. This is especially true if they have a supervisee who is demonstrating skills deficits or rejecting supervisor feedback. In this case, Rita’s defensiveness and her difficulty in translating academic learning into clinical practice needs to be a regular discussion point for Sam and Dr. Mendez. Sam also has the opportunity to consult with his doctoral classmates in their supervision class. Doing so may provide him with different perspectives and strategies for supporting Rita. Group consultation is helpful for any counselor in order to prevent becoming myopic or rigid in the approach to a client or a supervisee.

Dr. Menendez can benefit from consultation with his valued colleagues, particularly if this becomes an issue of gatekeeping. Colleagues can advise or help with revision of the informed consent document and help insure that appropriate procedures are followed if Rita is not successful in remediation efforts. While colleagues within his department are the most direct source of consultation, it may also be of use to reach out to colleagues in other institutions and in professional organizations to get an idea of how others are handling similar situations both proactively and as they come up.

The basis of expert opinion is the ACA Code of Ethics. As counseling professionals, all individuals within the scenario should consult these standards to guide the ethical decision process. Among the values listed in the preamble of the 2014 ACA Code of Ethics, two are particularly relevant to this scenario. The first is that counselors must work to “safeguard the integrity of the counselor-client relationship” (American Counseling Association, 2014, p. 3).​ It is important to consider the potential impact that sharing the video might have on the relationship between Rita and her client if this information was shared without clear consent from the client.

Also, counselors strive to “practice in a competent and ethical manner” (American Counseling Association, 2014, p. 3).​ Rita’s struggles with clinical competence and the ethical issues regarding informed consent, confidentiality, technology, and remediation all must be taken into account.

The principle of autonomy grants the client power over the sharing of their information regarding their treatment. It is also important for supervisors to honor the autonomy of supervisees, giving them the opportunity to voice their concerns with any feedback. Concerning the principle of Fidelity, it is vital to honor commitments to clients regarding maintaining privacy and confidentiality (American Counseling Association, 2014).​

Below we list the most centrally relevant points from the Code related to this scenario. While there are many points throughout the 2014 ACA code that can be applied, we have attempted to be parsimonious in our list.

  • 2.a Informed Consent – While the clients are verbally informed about the use​ of video there is no written informed consent with regard to either video recording or the potential uses of the video. Rita’s desire to share a video with her classmates should be discussed with the client as part of the ongoing informed consent process.
  • 2.b Types of Information – Clients must have a clear understanding of the way​ technology will be used in the course of their treatment with both supervisors and consultation groups.
  • 1.c Respect for Confidentiality – Rita seems to be sharing her client’s videoed​ session with her classmates, and indirectly with their supervisors, without having obtained the client’s consent. She should consider client confidentiality as primary over her own needs for support.
  • 3.b Interdisciplinary Teams – The client must be informed not only that a full​ video session is being shared with Rita’s classmates, but also the reason for the sharing.
  • 3.e Transmitting Confidential Information – In using email to transfer the​ video file to classmates, Rita has not assured the confidentiality of the information being transmitted. This is demonstrated in the fact that Dr. Mendez is accidentally looped into the email.
  • 6.d Permission to Observe – Rita needs to seek permission from her client to​ allow her class to observe videos of their sessions.
  • 7 Case Consultation – In sharing an entire video complete with her​ supervisor’s written feedback, Rita is not making every effort to protect her client’s identity nor has she explained to the client the purpose of her consultation with her classmates utilizing this full video in order to receive their consent for the disclosure.
  • 2.c Online Supervision – The doctoral supervisors who were emailed the video​ of Rita’s session with her client, in choosing to remain silent, have not made efforts to protect the confidentiality of the information from potential breaches inherent in the use of email to transfer electronic files.
  • 6.b Gatekeeping and Remediation – It is Sam’s job to give feedback of Rita’s​ clinical performance. Further, he should refer her to remediation or potential gatekeeping processes. This should be done as an ongoing process and should include consultation and supervision of his own as he navigates his approach.
  • 9.b Evaluation of Students – It is Dr. Mendez’s responsibility to adequately​ evaluate the CITs clinical competencies. In this case, Rita’s difficulty in translating academic knowledge into clinical skills indicates a need for an educative remediation process. With Sam and the other doctoral student supervisors not notifying Dr. Mendez about the issue, he is unable to do this adequately.
  • 2.b Confidentiality Maintained by the Counselor – Rita has failed to​ maintain a confidential relationship by sending the video to her whole class, who then forwarded it on to their various doctoral student supervisors.
  • 2.d Security – Email as a medium for transmitting digital client files is​ inadequate to ensure confidentiality of those files. This is demonstrated in the fact that Dr. Mendez is accidentally looped into the email.
  • 5.a Records – Rita’s client need full knowledge of how their recorded sessions​ files are stored- for both current and future safety.

Negotiate

From a social constructivist perspective negotiating is the process of discussing and debating an issue. Disagreement over an ethically sensitive issue is framed as a “conflict of coessentialities” (Cottone, 2001, p. 41). The first step of negotiation between Sam and Rita is to communicate their differing perspectives of Rita’s progress and Rita’s release of her counseling sessions to the group. As Rita is respectfully given the opportunity to verbalize the intentions behind her behaviors she can begin to evaluate the appropriateness of her actions. Sam and Dr Mendez negotiate their perspectives from a position of experience and protectiveness of both the client and the CITs. If the negotiation is successful all parties will learn from this process and adjust their future behaviors.

Consensualize and Interactive Reflection

Unique to the Social Constructivism Model is the interactive nature of both discussing individual viewpoints and reaching a unanimous plan of action (​Cottone, 2001).​ As part of this process, a solution that best fits all needs and objectives is chosen in place of any one individual viewpoint. The decisions made are ideally inline with norms fitting the social group or organization that governs all individual members involved, in this case the counseling profession. In the event that consenualization is not possible, each member is then encouraged to continue to reflect on their position. Unlike individualistic decision-making models, social constructivism relies on interactive reflection, and if need be, further reflection. In this way, views are not uniquely individual or social, but rather take into account both the view of self and the group (Cottone, 2001).​

In the context of this dilemma, Rita must not only take into account her frustrations regarding her lack of progress and lack of effective feedback and her desire to improve, but she must also consider the impact of her actions on her clients, Sam as her supervisor, Dr Menendez as her instructor, the counseling center, her fellow CITs, and the university. Sam must take into account his frustration with Rita, her lack of progress, and the violation of her client’s confidentiality while also reflecting on his supervision style and remediation strategy, his failure to properly inform Dr Menendez about Rita’s actions, and how he and his fellow doctoral students share responsibility and information about their supervisees. Dr Menendez, along with addressing both Rita and Sam’s behaviors, must address his doctoral supervision course as a whole, and the documentation of the counseling center, which lacks clear documentation regarding the recording and sharing of sessions.

The ideal solution is that Sam provides Rita with supportive and constructive feedback. Rita then applies Sam’s feedback and recommendations. Dr Menendez should address and more concretely operationalizes the process by which Sam and his fellow supervision students convey information. He also needs to revise the confidentiality policies of the counseling clinic. In the event that these steps were not universally accepted, additional interactive reflection continues until consensus is reached.

Arbitrate

In a case where consensualization does not work, the final step of Cottone’s model is that of Arbitration. This is when a third party is selected consensually by those involved as an acceptable authority in the matter at hand (Cottone, 2001). In this case the immediate and​ obvious arbitrator between Rita and Sam, as well as in the case of Rita’s classmates who argue for their use of email to transmit the file to a growing number of people, is Dr. Mendez. As the instructor of record for the practicum course and the faculty supervisor of the doctoral student supervisors, ultimate responsibility for both the actions and clinical competencies of the students falls to him.

In the unlikely event that Dr. Mendez is unable to arbitrate a successful conclusion, further potential arbitrators would be found in the program director and department chair of the counseling program. As per best practices, the department should have clearly defined remediation and gatekeeping processes which are well articulated to students beginning before matriculation and continuing throughout the program, and which would provide the structure for this process (Glance, Fanning, Schoepke, Soto, & Williams, 2012). If remediation efforts are unsuccessful and Rita’s dismissal from the program is the required action, it is likely that the University’s legal department would also be involved to make sure that any final decisions are within appropriate legal bounds. Arbitration is utilized only if negotiating and consensualizing are unsuccessful and can result in a less than desirable conclusion, particularly for Rita. (Cottone, 2001).​

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

COVID-19 update and resources

March 16, 2020

The American Counseling Association is working to keep its members and the public informed as the new coronavirus, COVID-19, becomes an increasing reality and issue of concern across the United States. Updates will be posted at the ACA website, counseling.org.

 

Relevant resources and information:

  • If you are overwhelmed or in crisis, the Disaster Distress Helpline offers 24-7 support. Call 1-800-985-5990 or text TalkWithUs to 66746 to connect with a trained crisis counselor.

 

Related reading, from the Counseling Today archives:

Living with anxiety”

The mental health effects of sheltering-in-place

Lending a helping hand in disaster’s wake

The Counseling Connoisseur: Compassion and self-care during flu season

Stumbling blocks to counselor self-care

“Grieving everyday losses”

“The (misguided) pursuit of happiness”

Virtual school counseling brings unique rewards and challenges

“Apps4Counseling: What’s in your digital toolbox?

Learning to love (or at least leverage) technology

Technology Tutor: Ethical and legal considerations of counseling tech

Technology Tutor: Are you prepared for the unexpected?

Making it safe to talk about suicidal ideation

Addressing intimate partner violence with clients