Counseling Ethics

Nature & Limits of Confidentiality…

Confidential: Ethical & Legal Issues

“B.1.b. Respect for Privacy Counselors respect the privacy of prospective and current clients. Counselors request private information from clients only when it is beneficial to the counseling process…B.1.c. Respect for Confidentiality Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification. B.1.d. Explanation of Limitations At initiation and throughout the counseling process, counselors inform clients of the limitations of confidentiality and seek to identify situations in which confidentiality must be breached.” (ACA, 2014 p. 6-7)

During the informed consent process, clients should be explained how privileged communication and documentation will be utilized, and what measures are taken to protect their privacy.  Corey, et al, (2011) note that confidential is both an essential right for clients and necessary for effective therapy (p. 210).  Additionally, “as a general rule, psychotherapists are prohibited from disclusing confidential communication to any third part unless mandated by law to do so” (Corey, et al, 2011, p. 211).  However, certain legal limitations exist regarding a therapist’s ability to protect a client’s information.  They must be warned of this in advance…

Defining Key Terms…

  1. Privileged Communication: “A legal concept that generally bars the disclsure of confidential communication in a legal proceeding…All states have enacted into law some form of psychtherapist-client privilege…when a client-therapist relationship is covered as privileged communication by statue, clinicians may not disclose confidential information” (Corey, et al, 2013).
    1. If the client waves this privilege, the therapist is obligted to “disclose information that is necessary and sufficient when the client requests it” (Corey, et al, 2011, p. 213).
    2. “Generally Speaking,…[this] does not apply to group counseling, couples counseling, family therapy, child and adolescent therapy.” (Corey, et al, 2011, p 214)
  2. “Privacy: as a matter of law refers to the constitutional right of individuals to be left alone and to control their personal information…Practitioners should exercise caution with regard to the privacy of their clients” (Corey, et al, 2011, p. 2015).

Steps to Protect Client Privacy…

  1. “PREPARATION: Before you explain the limits to confidentiality, it is important for you to understand these limtits yourself.  Review the relevant legal and ethical standards and contemplate/define your own moral principles.
  2. BE UP FRONT:  Tell the client the limits imposed to you  legally.  Obtain the client’s consent and have them sign relevant documentation indicating they understand these limts.
  3. OBTAIN INFORMED CONSENT BEFORE DISCLOSURE:  (should not require explanation.  However, sometimes for reasons listed below this is not always possible).
  4. RESPOND ETHICALLY TO LEGAL REQUESTS FOR DISCLOSURE:  if there is a pending legal demand for disclosure, notify the client and limit information so the extent that is legally allowed.
  5. AVOID ‘UNAVOIDABLE’ BREACHES:  monitor your recordkeeping, electronic communication, and note-taking practices to avoid unintentional breach…
  6. TALK ABOUT CONFIDENTIALITY:  Disuss with clients and fellow counselors… “(Corey, et al, 2011 p. 213)

Exceptions to Confidentiality

B.2.a. Serious and Foreseeable Harm and Legal Requirements The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception. Additional considerations apply when addressing end-of-life issues….B.2.c. Contagious, LifeThreatening Diseases When clients disclose that they have a disease commonly known to be both communicable and life threatening, counselors may be justified in disclosing information to identifiable third parties, if the parties are known to be at serious and foreseeable risk of contracting the disease. Prior to making a disclosure, counselors assess the intent of clients to inform the third parties about their disease or to engage in any behaviors that may be harmful to an identifiable third party. Counselors adhere to relevant state laws concerning disclosure about disease status. B.2.d. Court-Ordered Disclosure When ordered by a court to release confidential or privileged information without a client’s permission, counselors seek to obtain written, informed consent from the client or take steps to prohibit the disclosure or have it limited as narrowly as possible because of potential harm to the client or counseling relationship.” (ACA Code of Ethics, 2014, p. 7).

FIRSTLY: Explain to the client the Four Key Exceptions to Confidentiality….

Essentially it is the counselor’s responsibility to help the client understand that confidentiality is not absolute and there are circumsantes in which client’s must reveal confidential information.  These four key reasons are as follows:

  1. There may be occasions in which I therapist is “subpoena’ed” to testify in court.

  2. If the client expresses an intention to harm his/her self and has a plan in place, I am ethically required ot protect their well-being.

  3. If it is revealed that somebody is abusing the client, I need to inform police.

  4. If the client has a plan to harm somebody else, I must warn that person.

SECONDLY: Also explain that sharing info is essential in order to  provide “competent services” (Corey, et al, 2011, p. 221).

  1. In order to reimbursement disclosure of information may be required.
  2. Clerical assistance may occasional need to handle confidential information.
  3. Occasionally the counselor consults with her supervisor regarding this specific case.
  4. When other mental health professionals request information and client gives consent.
  5. It is also essential to communicate with other individuals involved in the treatment team.
  6. When the client requests information.
  7. Occasionally legally mandated exceptions arise: (i.e civil claim, or complaint filed.

Finally, a quick review of the “Duty to Warn/Protect”

As a result of a series of court rulings, mental health professionals have two seemingly contradictory concerns to contend with.  On the one hand, they must protect the privacy of their clients.  On the other hand, it is essential to protect the safety of the client and/or others if this information is revealed in therapy.  In other words, you have public safety on one hand, and personal privacy on the other.

DUTY TO WARN: (requires disclosure)

“Applies to those circumstances where case law or statue requires the mental health professional to make a reasonable effort to contact the identified victim of a client’s serious threats of harm, or to notify law enforcement of the threat” (Corey, et al, 2011, p. 231).

DUTY TO PROTECT: (provides ways to protect privacy)

“Applies to situations where the metnal health professional has a legal obligation to protect an identified third part who is being threatened; in these cases the professional generally has other options in addition to warning the person of harm”

Failing to warn can result in liability for civil damages

  1. Was there a failure to diagnose and predict dangerousness?
  2. Did the therapist fail to warn a victim of the client’s violent behavior?
  3. Was there a failure to commit?
  4. Was there a premature discharge?

“Client’s must do the following:  (1) identify those clients who are likely to do harm to 3rd parties, (2) protect third parties from those clients… (3) treat those clients who are dangerous.” (Corey, et al, 2011 p. 230).     

  1. Take steps to protect public and minimize liability (Corey, et al, 2011, p. 230).
  2. take careful histories and document thoroughly with those clients who are high-risk.
  3. Continually re-evaluate the potential for high risk behavior & modify TP PRN.
  4. Advise clients of their confidentiality limits.  Examine your informed consent document are terms of forfeiture of confidentiality clear as it pertains to the threat of violence to self and/or others.
  5. Regularly seek consultation (supervisor / attorney).  Know your code of ethics.
  6. Record Steps taken to protect others if necessary…
  7. In cases where client expresses desire to harm someone else, assess for suicidal ideation.
  8. Be familiar of treatment options and resources for managing high-risk clients.

Relevant Cases…

  1. Tarasoff Case – “In August 1969 PRosenjit Poddar was a voluntary outpatient at the student health service at the University of California, Berkeley and was in counseling…Poddar had confided to Moor his intention to kill an unnamed woman…Shortly after [the victim’s] return from Brazil, Poddar killed her…The California Supreme Court ruled in favor of the parents in 1976, holding that a failure to warn an intended victim was professional irresponsible….[the therapist has a} duty to exercise resonable care to protect the foreseeable victim of the serious danger of violence against him or her.” (Corey, et al, 2011, p. 232)…
  2. The Bradley Case: “A second case illustrates the duty not to negligently release a dangerous client…the patient, Wessner, had been voluntarily admitted to a facility for psychiatric care…was upset over his wife’s extramarital affair…He had repeatedly threatened to kill her…He was given an unrestricted weekend pass…met his wife and her lover in the home and shot and killed them…Georgia Supreme Court ruled that a physician had a duty to take reasonable care to prevent a potentially dangerous client from inflicting harm” (Coery, et al, 2011 p. 234).
  3. The Jablonski Case:  “The intended victim’s knowledge of a threat does not relieve therapists of the duty to protect…Melinda Jablonski filed suit for the worngful death of her mother…who was murdered by Philip Jablonski…[who] hjad agreed to a psychiatric examination at a hospital…The physicians determined that there was no emergency and thus no basis for involuntary commitment” (Corey, et al, 2011, p. 234).

HIPAA For Mental Health Professionals…

“The Health Insurance Portability and Accountability Act of 1966 (HIPAA) was passed by congress to promote standardization and efficiency in the health are industry and to give patients more rights and control over their health information…and are required to sign the appropriate forms authorizing the health care provider to provide information to other health care providers” (Corey, et al, 2011, p. 228).  The purpose of this rule is to provide a federally based uniformity to how health care facilities and workers are required to protet client’s confidentiality.  There are four main categories of requirements:

Privacy Requirements

“Practitioners take reasonable precautions in safeguarding patient information. Licensed health care providers are expected to ahve workign knowledge of and guard patients’ rights to privacy in disclosure of information, health care operation, limiting the disclosure of protected information, payment matters, protected health information, psychotherapy notes, and a patient’s medical record and treatment activities” (Corey, et al, 2011, p. 229).

Electronic Transactions

“HIPAA aims at creating one national form of communication or “language” so that health care proiders can communicate with one another electronically in this common language.” (Corey, et al, 2011, p. 229).

Security Requirements

“Minimum requirements are outlined in HIPAA that are designed to safeguard confidential information and prevent unauthorized access to health information of patients.” (Corey, et al, 2011, p. 229).

National Identifier Requirements

“It is essential that covered entities be able to communicate with one another efficiently.  Health care providers and health plans are required to have national identification numbers that identify them when they are conducting standard transactions” (Corey, et al, 2011, p. 229).

Confidentiality & Privacy in the School Setting.

Corey, et al, (2011) state that maintaining confidentiality in a school setting is especially problematic.  While “obliged to respect the privacy of minor clients and maintain confidentiality [this can] conflict with laws regarding parental rights.” (Corey, et al, 2011, p. 217)  In other words, the counselor must weight the parent’s rights to be a guiding force in their child’s lives against their client’s desire and right for privacy.  One way of handling this, is for the counselor to ask for permission of information release before and let them know about the limts to privacy.  “The basic standard of care for school counselors is clear, courts have uniformly held that school personnel have a duty to protect students from foresseable harm.” (Corey, et al, 2011, p. 236).

Considerations for Suicidal Clients

The guidelines and rules discussed here also apply to suicidal clients.  The issue here is knowing when to take the client’s serious.  “Therapists have a legal duty to make assessments from an informed position and carry out their professional obligations in a manner comparable to what other reasonable professionals would do” (Corey, et al 2011, p. 241).

Protecting Children, Elderly & Dependent Adults…

“Privileged communication doesn’t apply in case of child abuse and neglect, nor does it apply in cases of elder and dependent adult abuse…Such matters constitute a situation of reportable abuse…The professional is required to report the situation under penality of fines and imprisonment.  IF adults reveal in a therapy session that they are abusing or have abused their children, the matter must be reported….the goal of reporting is to protect a child or older person who is being abused….National Child Abuse PRevention Treatment Act (PL 93-247).  

References

ACA Code of Ethics as a resource for an academic work: American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, Amended June 1, 2010 and January 1, 2017). Retrieved from http://www.apa.org/ethics/code/index.aspx
Corey, G, Corey M.S. & Callanan P. (2011). Issues and ethics in the helping professions. 8th Ed.  Belmont CA: Brooks/Cole.

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Informed Consent….

Defining Informed Consent

The American Counseling Association states that clients have the freedom to choose whether they will enter to and/or remain in counseling (ACA, 2014, p. 4).  Therapists are responsible for protecting this client right by providing them with the adequate information to make an informed decision.   The APA (2017) adds the following:

 “(a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of con- dentiality and provide su cient opportunity for the client/ patient to ask questions and receive answers. (See also Stan- dards 4.02, Discussing the Limits of Con dentiality, and 6.04, Fees and Financial Arrangements.)” (Section 10.1)

Essentially, the right of informed consent allows the client to make an independent and knowledgable decision regarding the services we provide.  The first step in protecting this rights for the client includes the review of essential bits of information the client might need in order to make an informed decision (Corey, et al, 2011).  The second step is to have the client read through and sign the informed consent documentation (Corey, et al, 2011).  The important point here, is that the client gives their consent with an understanding of the facts provided.

The Informed Consent Process…

Corey, et al, (2011), state that the informed consent is an educational process which is usefl as a collaborate therpeutic relationship-buildiing process.  Examples of common questions asked include the following:

  1. “What are the goals of the therapeutic endeavor” (Corey, et al, 2011 p. 151).
  2. “What services will the counselor provide?” (Corey, et al, 2011 p. 151).
  3. How much will it cost? (Corey, et al, 2011).
  4. What are the risks? (Corey, et al, 2011).
  5. What are limitations to confidentiality? (Corey, et al, 2011).
  6. What are your qualifications? (Corey, et al, 2011).

What does the client need to know?

 According to the ACA Code ef ethics (2014) and my old course textbook, (Corey, et al, 2011). What follows is a list of information that should be included in the informed consent document.

THE THERAPEUTIC PROCESS:   It is important to help the client understand the nature of the therapy process.  There will be frank discussions and as the client’s level of awareness increases, old anxieties and traumas may resurface.  Also make a point to explain the nature of any procedures & therapy goals

BACKGROUND OF THE THERAPIST:  What kind of training, credentials, licenses does the therapist have?  What types of clients, specialized skills, and/or theoretical orientation is utilized by the therapist?

COSTS INVOLVED:  make the client aware of the costs involved, how payments are received, and methods of payment allowed

LENGTH OF THERAPY / TERMINATION:  In addition informing the clien of the length of therapy, they should be informed that htey have a right ot terminate services at any time

CONSULTATION W/ COLLEAGUES:  Make sure the client understands that it may be necessary to consult with your therapist regarding their case from time to time.

INTERRUPTIONS IN THERAPY:  Who can the client contact in case of emergency?  Who can they see in the event that you need to take time off?

BENEFITS/ RISKS – As stated above, clients shoul dunderstand what the therapy process involves.  “Clients need to know that no promices can be made about specific outcomes, which means that ethical practitioners avoid promising a cure…” (Corey, et al, 2011, p. 169)

ALTERNATIVES TO TRADITIONAL THERAPY:  What alternatives are there to therapy?  Help the client learn aobut various community resources and support systems available to the client (Corey, et al, 2011).

RIGHT TO ACCESS FILES:  “Clients records are kept for the benefit of clients…A profssional writes abot a client in descriptive and nonjudgmental ways.  A clinician who operates in a professional manner should not have to worry if his or her notes were to become public information or be read by a client” (Corey, et al, 2011, p. 170).

RIGHTS PERTAINING TO DIAGNOSTIC CLASSIFCATION:  Therapists frequently need to give clients a diagnostic classifications for insurance purposes.  “Some clients are not informed that they will be so classified…or that the classifications…will be given to insurance companies…Clients also do not have control over who can receive this information…Ethical Practice includes informing clients that a diagnosis can become a permanent part of their life” (Corey, et al, 2011 p. 171). 

LIMITS TO CONFIDENTIALITY Must also be discussed with the client.  I will go into greater detail about the limits of confidential in a later post. 

References

ACA Code of Ethics as a resource for an academic work: American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, Amended June 1, 2010 and January 1, 2017). Retrieved from http://www.apa.org/ethics/code/index.aspx
Corey, G, Corey M.S. & Callanan P. (2011). Issues and ethics in the helping professions. 8th Ed.  Belmont CA: Brooks/Cole.

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Boundary Setting

 

Abstract

This brief paper discusses the importance of a therapeutic relationships and issues of maintaining professional boundaries including types of boundaries, guidelines for maintenance, and common errors of judgment.

Professional Issues Reflection Paper: Boundaries

As a student therapist who is working on completing her internship hours, I have become profoundly aware of the importance of boundary setting in the context of a therapeutic relationship. Buhari (2013) describes therapeutic relationships as based on the following characteristics: (1) a power-imbalance; (2) trust; (3) empathy; (4) respect; (5) emotional intimacy, and (6) a therapeutic alliance. The driving goal of therapeutic relationships is to address the client’s needs first and foremost. As the therapeutic relationship becomes solidified, therapist get to know their clients intimacy and learning to maintain professional boundaries is critical (Buhari 2013). In an audiotaped interview segment, Carl Rogers makes a statement on the concept of empathy.  The following quote from a YouTube provides an overview of the audio recording of Carl Rogers discussing the concept of empathy. This video highlights one critical aspect of the therapeutic relationship and the importance of boundary setting (Rutsch, 2015).

“When I can let myself enter softly and delicately into the vulnerable inner world of the other person…lay aside my views and values and prejudices…check the accuracy of my acceptance of him or her…then I can be a companion to that person, pointing at the felt meaning of what is being experienced (Rutsch, 2015).

The Zone of Helpfulness

The goal of therapy is to facilitate communication of the client’s thoughts, feelings, and beliefs in order to examine them critically, uncover unhealthy belief systems, maladaptive coping tools and self-destructive behaviors (Herlihy & Corey, 2015). One resource for this paper discusses the concept “Zone of Helpfulness” (Buhari, 2013, p. 162) when discussing the issue of boundary setting. This Zone of Helpfulness” (Buhari, 2013, p. 162), rests within a continuum of involvement between two opposing extremes with enmeshment on extreme and aloofness on the other. It is critical for new therapists to develop a conceptual understanding of where this “Zone of Helpfulness” (Buhari, 2013, p. 162), rests in their daily practice. The following concepts have been a useful guide for me lately.

Types of Boundaries & Boundary Violations

Definition of Professional Boundaries

Buhari (2013) defines a boundary as a “dynamic line which if crossed will constitute unprofessional or unethical behavior. In other words, professional boundaries are useful in defining the “Zone of Helpfulness” (Buhari, 2013, p. 162), in a therapeutic relationship. They are important as mutually understood standards of conduct defining the limits of a relationship between therapist and client.

Types of Boundaries

Buhari (2013) also discusses types of boundaries that are useful in defining a critical aspect of the therapeutic relationship. For example, physical boundaries define rules of acceptable physical interaction (i.e. shaking hands, or hugging) (Buhari, 2013). They tend to be socially-defined concepts that define how much of the physical space around us is concerned personal. In this respect, physical boundaries define how closely people tend to stand when engaging in casual conversation.

Buhari (2013) also describes abstract boundaries as pertaining to attitudes regarding what behaviors considered rude, abrasive, or disrespectful. This element of boundary setting in a therapeutic relationship sheds light on the importance of multicultural sensitivity. For example, in my mother’s culture it is considered important to respect your elders. This would mean, calling an older client “Mr. So-and-So” until they gave you permission to use their first name.

Inner boundaries are highly relevant to Carl Roger’s definition of empathy provided earlier, (Rutsch, 2015). Being aware for issues of counter-transference issues is critical when setting inner boundaries. It also requires self-awareness, for example I work in the nursing field and tend to people’s needs all day. Doing this in an inpatient therapeutic setting is not always therapeutic or helpful to my clients in the long run. Finally, Buhari, (2013), describes interpersonal boundaries as occurring between the client and therapist relationship: (i.e emotional, verbal, and behavioral).

Boundary Guidelines

ACA Code of Ethics

The ACA Code of Ethics states the following regarding professional boundaries. Firstly, prohibits romantic and/or sexual relationships between therapist and client (American Counseling Association, 2014). Secondly, it cautions therapists to consider previous relationships with an individual before accepting them as a client (American Counseling Association, 2014). Thirdly, the ACA Code of Ethics warns therapists to careful consider actions that might bypass conventional parameters such as going to a client’s wedding (American Counseling Association, 2014). Finally, the ACA Code of Ethics stresses the importance of carefully documenting all actions taken to extend the boundaries in the therapeutic relationship (American Counseling Association, 2014).

Defining the Parameters

When meeting clients for the first time it is essential to be clear right from the outset the parameters that define the therapeutic relationship (Buhari, 2013). This should include discussing the nature of the therapeutic and purposes of therapy. Relevant issues such as: (1) limits to confidentiality, (2) method of payment, (3) office policies, (4) setting, (5) duration and (6) frequency of services, should also be discussed. Issues to consider carefully involve an examination of the therapeutic benefits of self-disclosure and the possibility of dual relationships.

Ethical Decision Making tips

Pope, et al, (2008) suggest knowing ethical codes while also considering boundary setting issues in terms of their alternative therapeutic outcomes. For example, while ethical codes state that gift giving between client and therapist are inappropriate, there are some rare instances in which it may be culturally insensitive reject a gift. In this respect, ethical decision-making should first entail a careful examination of all relevant aspects of a situation. Pope, et al, (2008), stresses the importance of self-awareness in the decision making process so we can clearly define the feelings and thoughts that underlying these ethical decision. Finally, having colleagues to discuss these issues can be a useful reality check. An article titled “To Cross or Not to Cross” (Zur, 2004) cautions against being overly rigid with boundaries since it can decrease therapeutic effectiveness and can at times cause harm to the client (p. 30). A common misconception exists regarding boundary called the “slippery slope argument [in which] crossing of boundaries inevitably lead to a violation” (Zur, 2004, p. 30). Ultimately decision making based on three critical factors: client welfare, ethical standards, and therapeutic effectiveness (Herlihy & Corey, 2015 & Zur, 2004).

Errors in Judgment.

Boundary violations include deliberate actions that are clearly inappropriate crossing the line of decency (Buhari, 2013; Zur, 2004). They include misuses of influence and power of the client for the therapist’s own benefit (Buhari, 2013; Zur, 2004). While the process of boundary setting might at first appear straightforward, the ethical decision-making requires us to consider factors that often contradict one another. They must be made cautiously, with a clear understanding of all relevant aspects of a situation. To illustrate this point, Pope, et al, (2008), provides a list of common errors in judgment regarding the issue of boundary setting. When reading through this list there are a few that stand out to me as quite insightful. Firstly, Pope, et al, (2008) state that the felt meaning regarding an act that crosses boundaries can vary between client and therapist. This is especially true if the client and therapist have different cultural backgrounds. Secondly, Pope, et al, (2008) note that these decisions should be taken on a case-by-case basis. In other words, what might be a therapeutic boundary crossing in one instance can be considered harmful in another, (i.e. receiving a small gift).

How to Correct Errors in Judgment

The ACA Code of ethics cautions therapists to carefully consider and document all events involving a crossing of boundaries (American Counseling Association, 2014). In the event that the outcome of this decision isn’t what we had hoped, Pope, et al, (2008), provides some useful guidelines. Firstly, Pope, et al, (2008) state it is important to carefully monitor the situation, and remain “open and non-defensive” (p. 648). This can allow you to fully understand the client’s perspective. Discussing the situation with your supervisor and colleagues. Finally, Pope, et al, (2008) states it is important to show professional responsibility by claiming ownership of our mistakes and apologizing if necessary.

References

American Counseling Association (2014). ACA Code of Ethics, Alexandria, VA: Author.
Buhari, B. (2013). Therapeutic relationships and boundaries. IFE Psychologica, 21(3-S), 162-168.
Herlihy, B., & Corey, G. (2015). Boundary issues in counseling: Multiple roles and responsibilities. Alexandria, VA: American Counseling Association.
Pope, K. S., & Keith Spiegel, P. (2008). A practical approach to boundaries in psychotherapy: making decisions, bypassing blunders and mending fences. Journal of Clinical Psychology, 64(5), 638-652. doi:10.1002.jclp.2047.
Rutsch W. [Screen Name]. (2015, January, 30). Carl Rogers Empathy & Presence. [Video File] Retrieved from: https://youtu.be/B0Xv6Tb2k0E
Zur, O (2004). To Cross or Not to Cross: Do boundaries in therapy protect or harm. Psychotherapy Bulletin, 39(3), 27-32.

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