Ethical Issues in Clinical Practice

1. Ethical Issues in Clinical Practice UMHCA Fall Conference October 18, 2019 Janine Wanlass, Ph.D. Westminster College jwanlass@westminstercollege.edu

2. Session Learning Objectives • Participants will: • Describe two characteristics of an ethical stance to providing treatment; • Drawing from research, list three common ethical problems resulting in licensing sanctions; • Identify two factors that predispose counselors to ethical missteps & mistakes; • Describe two common boundary challenges in counseling practice; • Discuss application of a decision-making model for ethical dilemmas.

3. Developing & Maintaining an Ethical Stance

4. Defining an Ethical Attitude Incorporates codes of ethics Draws from theories of moral development (Allphin, 2005) Involves “questioning decisions, being respectful of the views of others, and doing no harm” (Allphin, 2005, p. 458) Includes “facing unsolvable dilemmas, uncertainty, suffering, and shame” (Allphin, 2008, p. 458)

5. Developing & Maintaining an Ethical Capacity 1 • Engaging in continuous self-reflection & self-examination • Pursuing own treatment when indicated • Seeking regular consultation • Questioning whose needs are being met in any client-therapist interaction (Allphin, 2005) • Recognizing countertransference pulls • Caretaking • Adopting a thoughtful, independent stance, while valuing input from others (Allphin, 2005)

6. Developing & Maintaining an Ethical Capacity 2 • Taking responsibility for mistakes & making reparations • Being considerate of others (clients & colleagues) within our professional & global communities • Implementing self-care • Identifying personal vulnerabilities • Addressing our narcissistic needs • Living with connection, meaning & integrity

7. Setting a Context

8. Everyday Ethical Dilemmas 1 My client is in crisis. Should I extend the treatment hour? Should I accept a referral of a new client from an existing client? My client is asking about my own substance abuse history. When is self-disclosure appropriate? Do I inform my adolescent client’s parents about their cutting?

9. Everyday Ethical Dilemmas 2 Can I provide recommendations to the court about visitation arrangements for my distressed child client? Can I offer clinical supervision to my graduate student who is also my advisee? Can I provide therapy over the internet to my client who is on vacation in Hawaii & called in “crisis” requesting a session?

10. Research Findings

11. Neukrug, Milliken, & Walden (2001) • Data from 35 licensing boards • Survey identified 10 common types of ethical complaints & an “other” category • Highest percentages of infractions were: • 24% for nonsexual dual relationships, • 17% for incompetence in counseling, • 8% for misrepresentation of credentials, • 7% for sexual relationship with client.

12. Phelen(2007) • Professional Organizations membership expulsion over 10 years • Ranking: • American Psychological Association (126, .084%) • American Associaiton of Marriage & Family Therapists (17, .071%) • National Association of Social Workers (21, .015%) • American Counseling Association (4, .007%) • American Mental Health Counseling Association does not adjudicate complaints • 50% or more were for dual relationships, most often sexual

13. Boland-Prom, Johnson, & Gunaganti(2015) • Ethical complaints for social workers resulting in disciplinary actions by licensing boards • Highest percentage of infractions were: • Dual relationships 22.32% (nonsexual 12.73%; sexual 9.59%) • Failure to comply with continuing education requirements 19.68% • Record keeping issues 5.25%

14. Wilkinson, Smith, & Wimberly(2019) • Data from 49 states & Washington, D.C. • 24 descriptive codes for ethical violations • Highest percentage of infractions were: • Failure to complete continuing education requirements 16.8% • Nonsexual dual relationships 12.5% • Sexual relationships with clients 9.0% • Misrepresentation of credentials 6.7% • Legal arrest 6.6%

15. Informal Investigation Review of Utah DOPL discliplinary newsletters from July 2017 – June 2018 Infractions by clinical social workers, counselors, marriage & family therapists, & psychologists resulting in disciplinary action 35 individuals, 28 with complete data

16. Utah Findings

17. Risk Factors for Ethical Mistakes

18. Beginning Treatment: Considering Referrals (Shapiro & Ginzbers, 2003) • Current & former clients • Attend to the meaning of a referral as a gift • Consider impact on both referring client & new client (overlapping worlds) • Contact outside office • Anticipate when too much overlap between personal & professional relationship • Nature of referral source • Making exceptions for “special” people

19. Ending Treatment: Termination • Greater levels of self-disclosure • Blurring or shifting nature of the relationship • Trouble dealing with loss & saying goodbye • Unanticipated termination by therapist • Same day dismissals • No professional will

20. Use of Technology & Social Media • Blind trust in security protections on internet • Assume anything posted is accessible to clients • Internet searches • Google yourself but not your clients • Invitations to social media platforms • Facebook friend vs. Linked in • Technological advances • Client recording sessions without permission • Lack of familiarity with new ethical guidelines & recommendations • Use of non-HIPAA compliant platform & specialized informed consent • Verification of identity • Starting treatment in person

21. Engaging in Multiple Roles • Allowed with caution vs. forbidden • Seeing multiple family members • Therapist vs. evaluator • Identifying potential areas of conflict • Teacher, advisor, supervisor • Child work & parent work • Considering counselor motivation for decisions

22. Risks for Boundary Violations: Types of Clients History of boundary issues, often related to trauma Diagnosis of personality disorder Pull for rescue, caretaking, or special status Present as higher functioning, sometimes with issues similar to counselor

23. Risk for Boundary Violations: Counselor Vulnerabilites 1 Typically new clinicians & very experienced clinicians Need to be liked, which interferes with limit-setting Practicing in isolation & without regular consultation Ignoring or minimizing evidence of discomfort Over-identification with client

24. Risk for Boundary Violations: Counselor Vulnerabilities 2 • Wish to be helpful • Placing ethical risk in the “other” • Feeling frustrated with the treatment and/or strong countertransference pulls • Practicing in a rural community • Personal or relationship crisis • Untreated mental health issues • Substance abuse • Depression

25. Helpful Tips to Minimize Risk • Contemplate “worst case scenario” before deciding • Anticipate “unintended consequences” • Explore intentions for taking risk & all possible other alternatives • Attend continuing education seminars on ethics • Regularly review ethical codes & standards • Get regular consultation • Seek personal therapy & engage in self-care • Attend to that nagging feeling that something is wrong

26. Assessing Personal Risk

27. Identifying Areas of Personal Vulnerability 1 • Complete a structured risk assessment • Corey, Corey, & Callahan (2015) • “Regarding the issue of counseling friends, I think that: • A. It is seldom wise to accept a friend as a client. • B. It should be done rarely, and only if it’s clear that the friendship will not interfere with the counseling relationship. • C. Friendship and therapy should not be mixed. • D. It should be done only if it seems appropriate to both parties.”

28. Identifying Areas of Personal Vulnerability 2 • Consider potentially difficult areas • Fees • Diversity • End of life decisions • Boundaries • Competence • Touch • Referrals • Religion • Gifts • Social justice • Value conflicts • Record keeping

29. Identifying Areas of Personal Vulnerability 3 • Ask for feedback from trusted others • Make this a subject for discussion & candid feedback • Draw on insights from personal therapy • Based on personal history, where are you vulnerable? How do you get pulled in? • Attend to situations where you feel uncomfortable or make atypical judgments & evaluate further

30. Identifying Areas of Personal Vulnerability 4 Consult when you want to stay quiet Conduct continuous self-evaluation Stay current on changes to ethics codes & rules that govern practice

31. Applying an Ethical Decision-making Model

32. Walden’s Decision-making Model (2015) Identify the problem or dilemma Identify the potential issues involved Review the relevant ethics codes Consider applicable laws & regulations Obtain consultation Consider possible & probable courses of action Outline the consequences of various decisions Choose what seems the best course of action Evaluate the outcome of your actions

33. Ethical Dilemmas

34. Choose Your Own Dilemma Discuss with the person next to you Apply a decision-making model, including relevant ethical codes Consider all possibilities & decide on the best alternatives

35. References Allphin, C. (2005). An ethical attitude in the analytic relationship. Journal of Analytical Psychology, 50(4), 451-468. Boland-Prom, K., Johnson, J., & Gunaganti, G. (2015). Sanctioning patterns of social work licensing boards, 2000-2009. Joiurnal of Human Behavior in the Social Environment, 25, 126-136. Corey, G., Corey, M., & Callahan. (2015). Issues & Ethics in the Helping Professions. Pacific Grove, CA: Brooks/Cole. Kaslow, F.W., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research & Practice, 42(2), 105-112. Neukrug, E., Milliken, T., & Walden, S. (2001). Ethical complaints made against credentialed counselors: An updated survey of state licensing boards. Counselor Education & Supervision, 41, 57-70. Phelan, J. E. (2007). Membership expulsions for ethical violations from major counseling, psychology, and social work organizations in the United States: A 10 year analysis. Psychological Reports, 101, 145-152. Pope, K.S., & Spiegel, P.K. (2008). A practical approach to boundaries in psychotherapy: Making decisions, bypassing blunders, & mending fences. Journal of Clinical Psychology, 64 (5), 638-652. Shapiro, E.L., & Ginzberg, R. (2003). To accept or not to accept: Referrals and the maintenance of boundaries. Professional Psychology: Research and Practice, 34 (3), 258-263. Warren, J., Alhs, C., Asfaw, A.H, Nunez, J., Weatherford, J., & Zakana, N.S. (2014). Ethics issues and training needs of mental health practitioners in a rural setting. Journal of Social Work Values and Ethics, 11(2), 61-75. Wilkinson, T., Smith, D., & Wimberly, R. (2019). Trends in ethical complaints leading to professional counseling licensing board disciplinary actions. Journal of Counseling & Development, 97, 98-104.