Ethical Jeopardy: What Do You Really Know ?

1. Ethical Jeopardy: What Do You Really Know? Michele D. Aluoch, PCC River of Life Professional Counseling LLC c. 2013

2. Benefits of Ethical Standards • Gives some specific guidance • Helps professionals keep their colleagues accountable • Gives the public outlines regarding hat should be expected for the welfare of clients

3. Categories: Part One (You Pick)

4. Categories: Part Two (You Pick)

5. Categories: Part Three (You :Pick)

6. Categories: Part Four (You Pick)

7. “Codes of ethics do not come to professions on stone tablets from high mountains. Rather they are always a work in progress. They are developed by committees, examined by professionals and the public they serve, and then lived out by frail humans and adapted to changing contexts.” From: Ponton,R.F. & Duba, J.D. (2009)

8. Limitations of Ethical Codes: • Profession bound (whereas practice is not) • Do not include underlying rationale to help the practitioner make better decisions • Can never be comprehensive b/c so many situations • Challenges enforcing codes • Reactive rather than proactive • Personal versus field ethics • Must be adapted to various cultural and other contexts • Some situations not easily handled by ethical codes

9. Ethics Vs. Legality:(from Thompson, A., 1990) 1) Ethical & Legal 2) Ethical & Illegal 3) Ethical & Alegal 4) Unethical & Legal 5) Unethical & Illegal 6) Unethical & Alegal

10. Ethics: The Issues

11. Ethical Issues: Sex With Clients • No sexual relationship allowed: “including kissing, sexual intercourse and or touching by the client or therapist of the others breasts or genitals”, also “no physical advances or verbal or nonverbal conduct that is sexual in nature.” • Considerations: vulnerability, power differential, and trust issues • “ a therapist who is choosing to engage in a sexual relationship with a current or former patient is effectively choosing to discard his or her career.”

12. Boundary Setting • Know your clients’ beliefs/expectations (clients most/least comfortable with, values and belief systems, theoretical approaches preferred) • Know the standards of your agency (policies and procedures, mission/goals, methods of dealing with things) • Know/keep up with the latest board rules and regulations • Be familiar with the social, multicultural, and interpersonal qualities of who you serve, where you are situated • How will you communicate these? • Verbally • Written policies & procedures • Other

13. Ethical Issues: Receiving Gifts From Clients(Gerig,M.-July 2004) Questions to Consider Regarding Gift Giving • What will accepting (or not accepting) this gift do to the dignity and worth of the other person? • Is there potential for exploitation? • Would this be considered boundary crossing? • Do I have any approach-avoidance conflict within me? • What are the meanings behind accepting this gift?

14. Ethical Issues: Receiving Gifts From Clients(Gerig,M.-July 2004) • Voluntarily given form one person to another • With both natural and symbolic value • Recipient sees it as a gift • A form of communication • Three categories: 1) a “tip” for good service 2) for the client to regain status after something lost 3) as a payment of homage • Voluntarily given form one person to another • With both natural and symbolic value • Recipient sees it as a gift • A form of communication • Three categories: 1) a “tip” for good service 2) for the client to regain status after something lost 3) as a payment of homage

15. Ethical Issues: Confidentiality • Has to do with private information being protected through reasonable expectation that it will not be further disclosed except for the purpose for which it was provided Areas Protected: • Whether or not a person has been a client • The frequency and intervals of appointments • Types of treatment or services received • Reasons for treatment • Specific words, behaviors or observations during treatment • Client diagnosis • Course and prognosis of treatment • Summaries and recommendations

16. Ethical Issues: Confidentiality Disclosure: • Requires informed consent- specifying what consenting to, with discussion to client about advantages and disadvantages and potential limitations of disclosure • Should be in your policies and procedures about confidentiality, possible breaks of confidentiality and how this is should be handled • Should be in writing and signed by all parties

17. Ethical Issues: Confidentiality • Information cannot be disclosed in court proceedings unless both: 1) a subpeona has been issued 2) a court order has disclosure. Then court must find that the need for information outweighs the public policy for confidentiality (42 CFR 2.61-2.65 and 45 CFR 164,512 (e) (1) (ii) • By law confidentiality continues even after the death of the patient, death of the therapist of sale of the practice to others • “When in doubt don’t give it out.”

18. Practical Privacy Considerations • Respecting those in waiting room from hearing sessions or session or client related information • Telephone calls in reception area should not be overheard by clients • Messages regarding client information should not be given in ways that violate privacy • Training support staff regarding confidentiality (e.g. sign a pledge)

19. Ethical Issues: Privileged Communication • Privilege: a legal term, legal protection against breaking confidentiality in legal proceedings • The client holds the privilege • Must have clearly been in context in which specified “not be disclosed” ahead of time • Would cause injury if shared

20. Ethical Issues: Privileged Communication • Exceptions: judicial discretion, nature of the violation (e.g. harm to others- abuse, homicide, likelihood to commit future crimes) 3 Automatic Waivers of Privilege • 1. If requires immediate hospitalization • 2. If court ordered • 3. If specifying info. on the emotional condition of the patient is part of the client’s defense in a court case

21. Ethical Issues: Informed Consent • Extent and nature of services • Pros and cons (counseling in general, electronic counseling, phone counseling, techniques used, setting) • Limitations • In clear, understandable, non-technical language • Specified provider name • Therapist’s responsibility to make sure the client understands (e.g. if cannot read, blind, etc.)

22. Ethical Issues: Informed Consent • Defines role of counselor (versus mediator, court guardian, expert witness) • Expectations of both therapist and client behaviors • Risks/benefits of therapy • Qualifications of the therapist • Financial considerations and responsibilities

23. Ethical Issues: Informed Consent • Time per session • Confidentiality and its limitations • Releases of info.- when required, specifications (provider, what information, to whom, 1 or 2 way, time frame, nature of release and intended use) • Signature of individual or someone authorized to sign on their behalf

24. Ethical Issues: Diagnosis • Unethical- therapist as moral agent, client no longer autonomous person coming for help • Ethical- based on observation of concrete, observable or clients self reported behaviors compared to “norms” and researched and studies standards • with respect to client perspectives and worldview • with full information and informed consent • under a specific “contract” outlining terms of the clinical relationship

25. Ethical Issues: Education • Do not promote a degree from a school not accredited by the US Dept. of Education • “No person may claim, either orally or in writing, to possess an academic degree… or title associated with said degree, unless the person has in fact, been awarded said degree from an institution that is accredited by a regional or professional accrediting agency recognized by the United States Department of Education at the Commission on Recognition of Postsecondary Accredidation.”

26. Reasons for Discipline by the Board: • Violation of Board rules • Falsification of information regarding licensure & registration • Accepting a commission or rebate for referring persons to the board • Conviction of a felony in Ohio • Impaired ability to practice (drugs/alcohol, physical or mental conditions) • Misdemeanors in any state in the course of practice under licensure • Practice outside your scope of practice • Practice without supervision

27. Possible Reactions to Ethical Complaints: • Discussing the complaint • Sanctioning the member • Recommending resignation • Recommending the member be dropped • Recommending remedial action (ongoing supervision, personal therapy, additional CEUS)

28. Ethical Issues: Licensure • Citizenship, residency- OH will consider those from other states and even out of US after review of packet • Education- Accredited educational institution, specifically counseling, 90 quarter hours min. (including 30 quarter hours in certain areas) • Exam- pass standard set by board on national counseling exam • Experience- supervised, pre-approved • Not the same in every state

29. Ethical Issues: Record Keeping • Diagnostic assessment • Psycho-social history • Specific, concrete behavioral symptoms • Tx plan- service goals and outcomes (justifiable, research based standard of practice) • Measurable clinical outcomes • Direct quotes from clients (in quotation marks) • Monitor progress, re-evaluate goals periodically

30. Ethical Issues: Record Keeping NOT • Opinions • Assumptions based on behaviors • Questions and investigations • Second hand judgments of clients or others in the client’s life • Diagnosis of people who are non-clients

31. Responding to Records Requests • What does the client want? • Anything potentially harmful? • What parts should or should not be revealed? • Is discussion beforehand advisable?

32. Ethical Issues: Family Counseling • Be clear who the client is • (individual, couple, family) • Refer when potential conflicts

33. Disclosure of Records to Family Members:(ORC 5122.31 (a) (7) ) • Limited circumstances • The family member is involved directly in planning, providing, and monitoring services to the client • Client notifications and informed consent without objection • Only information with intention of supporting client’s mental health

34. Disclosure of Records to Family Members:(ORC 5122.31 (a) (7) ) • Under 18 years old- patients have right to disclosure of records except SA whereby only child can give consent • Emancipated child under 18 - full control of all records and parent- none

35. Ethical Issues: Client Dependency: • Issues such as when to introduce topics, how long to talk about topics, and when to keep a client on a topic he or she may feel uncomfortable about • Ask client regarding his or her comfort level • Client as equal partner in therapeutic process • Avoid high ambiguity situations- promoted dependency (ex: high usage of sessions, more time with the therapist) • Use balance in giving homework assignments • Avoid judgments like, “you are doing much better now.” (Instead, stick to concrete behavioral outcomes)

36. Ethical Issues: Client Dependency: • Solutions to DependencyPromoting Autonomy • Avoid doing what clients can do for themselves • Let the clients be active in their treatment (e.g. cognitive-behavioral treatment of noting thought and behavior patterns) • Adjusting frequency of sessions • Termination plan and closure sessions

37. Ethical Issues: Termination • Pros/cons discussed with client • How to apply techniques on an ongoing basis and generalization • Options of referrals • When a therapist leaves the practice

38. Ethical Issues: Multiple Relationships • Definition- relationships which have the potential to dilute or diminish the therapeutic relationship, reciprocal relationships, bartering relationships • Not in general a good idea • All alternatives discussed • Must be outlined and documented as to how/why beneficial • Should not have room for exploitation • *NOTE: New 2008 Ohio codes on this*

39. Ethical Issues: Duty to Warn • Therapist to use professional knowledge, client judgment • Burden to prevent harm • Consideration of alternatives: tx programs, decrease access to weapons, referral to MD’s for meds, voluntary or involuntary hospitalization, warnings to intended victims, notifying authorities

40. Ethical Issues: Duty to Warn • Clinicians- protected against liability when a clear, credible, explicit threat of imminent and serious harm or identifiable potential threat (if client attempts to hospitalize, tx plan supported by reasonable standard of care of other professionals, likelihood of that threat- serious, and warning to intended victims and law enforcement w/ specific reference to the nature of the threat)

41. Ethical Issues: Competency • Provide reliable evidence of competence- education, specialized training, licensure • Practice only within competency areas • Based on standards of care- reasonable practice • Protection from harm • Only accept referrals in competency areas • Use proven, appropriate techniques

42. Ethical Issues: Advertising Your Practice • Must be accurate statements of qualifications, affiliations, functions (NOTE: if limited time or space does not mean everything has to be included but that that which is included is true) • Must give general information so consumer can make an informed decisions o whether or not to use the service • NO- statements that are predictive • NO-statements that play on client fears to get a person to come in

43. Ethical Issues: Advertising Your Practice • “professional, scientifically acceptable, and factually accurate informative manner.” • Should not use extra-ordinary methods, sensationalism or exaggeration • Research participants: tell pros/cons • Do NOT promise, “this will guarantee ____ result.” • You can say something about techniques used, outcomes, or populations served but make sure you can substantiate or document it. • Dangers- testimonials and radio shows

44. Ethical Issues: Advertising Your Practice • Focus on your specialties on your disclosure statement • Follow up with EAPs, lawyers, ministers, guidance counselors, physicians • Provide clinical information to clients on issues of concern which apply to their counseling • Speak to community groups, churches, businesses, organizations, etc. • Avoid personality descriptions • Avoid clinical jargon • Know trends in your field

45. Ethical Issues: Multicultural Contexts EASTERN Relationship Authoritarianism Extended Family Focus Maturity Emphasized Interdependence Compliance Conformity WESTERN • Individuality • Democratic • Nuclear Family Focus • Youth Emphasized • Independence • Assertiveness • Non-conformity

46. Ethical Issues: Multicultural Contexts WESTERN Competition Conflict Freedom Individual needs Responsibility within individual Express Feelings EASTERN Cooperation Harmony Security Collective goals Responsibility within society Control Feelings

47. Ethical Issues: Multicultural Contexts WESTERN Uniqueness of each person Self actualization Future focus Innovation Morality-internal, individual “Change is very good” EASTERN Uniformity of each person Collective actualization Traditionalism Conservativism Morality-relational “Support is very good”

48. Ethical Issues: Multicultural Contexts • Dealing With Cultural Differences • Counselor and Client Perspectives: Do you share same cultural perspective or not? Is this important or central to the counseling? • What do you wish to do about differences of approach? • Defining Value systems/Cultural Context- “teach me”

49. Ethical Guidelines for Multicultural Counseling(D.W. Sue & D. Sue, 1990) • Therapist awareness of own beliefs, values, feelings and biases • Ability to accept, value, and integrate client culture • Not threatened with referrals or consultations when appropriate • Judge client reactions of treatment approaches within cultural context rather than personally • Therapist learns /allows self to be educated on that culture • (Same guidelines apply to all “special populations”)

50. Ethical Issues: Supervision • *NOTE: New 2008 Ohio codes on this* General Board Rules Re. Supervisors • Supervisor/supervisee relationship must be board approved in advance • Roles and scope of practice are specifically delineated • Start and end dates are delineated • Supervisor/supervisee only have supervision in areas of specified competence • “Not a family member or relative” • Requires documentation of supervisor/supervisee interactions • Reports co-signed by the supervisor • No more than 6 supervisees per clinical supervisor