Ethical Issues in Counseling Practice Ethical decision-making is an evolutionary process that requires you to be continually open and self-critical. Recognizing the potential for countertransference: what are your own needs? Do you have areas of unfinished business? Are there potential personal conflicts that would interfere with helping the client? Do you recognize your own areas of prejudice and vulnerabilities? Counselor impairment often leads to countertransference. The more common characteristics of impairment are: • Fragile self-esteem Difficulty establishing intimacy in one’s personal life • Professional isolation • A need to rescue clients • A need for reassurance about one’s attractiveness or one’s competence • A substance abuse Countertransference can show itself in many ways. The following are most common: 1. Being overprotective with a client. 2. Treating clients in benign, superficial ways. 3. Rejecting a client. 4. Needing constant reinforcement and approval. 5. Seeing yourself in you clients. 6. Developing sexual or romantic feelings toward a client. . Giving advice compulsively. 8. Desiring a social relationship with a client. 9. Delaying termination Whose needs are being met in this relationship—my client’s or my own? Is it unethical to meet our personal needs through our professional work? Don’t we benefit by being nurturing, feeling adequate, displaying competence, being respected and appreciated? Steps in Ethical Decision-Making 1. Identify the potential problem. Is the problem mainly ethical, legal, professional, clinical, or moral? 2.
Identify the potential issues for both you and the client. 3. Review the ethical codes for your profession. Are you own values and ethics consistent with or in conflict with the relevant guidelines? 4. Consider the applicable laws and regulations. 5. Seek consultation from other professionals or from your professional organization. 6. Brainstorm possible courses of action. 7. Evaluate the consequences of possible courses of action. 8. Decide on the best possible course of action. 9. Follow up to evaluate the outcomes
INFORMED CONSENT: clients must be provided with information that they need to made informed choices; their rights and responsibilities must be given to them in paper form and they must sign that they have read and agree with the information. Includes: goals of counseling, the responsibilities of the counselor toward the client, the responsibilities of clients, limitations of and exceptions to confidentiality, legal and ethical parameters of the therapeutic relationship, the qualifications and background of the therapist, the fees involved, the approximate length of the therapeutic process.
See handout for model. CONFIDENTIALITY: information shared in the clinical setting must be kept private, but confidentiality is not an absolute and exceptions must be explained to the client. Confidentiality must be broken when it is clear that the client may do serious harm to either themselves or others. There is a legal requirement to report incidences of child abuse, abuse of the elderly and of dependent adults. Confidentiality must be breached if a client under the age of 16 is a victim of incest, rape, abuse or some other crime; when the client needs hospitalization, when information is made an ssue of court action and when the client requests that records be released. Clients must also be informed if the therapist may be discussing details of the relationship with a supervisor or a colleague. DUAL AND MULTIPLE RELATIONSHIPS: counselors must not assume two or more roles (sexual or non-sexual) simultaneously or sequentially with a client. Examples given include bartering for services, borrowing money from a client, providing therapy to a friend, a relative or employee, accepting an expensive gift from a client, or going into a business venture with a client.
Any multiple relationship that would impair the therapist’s objectivity, competence or effectiveness is not allowed; multiple relationships that do not cause impairment or risk exploitation are not unethical. Can you give some examples? MULTICULTURAL COMPETENCE: theories and practices of counseling must take into consideration the worldviews of all populations that enter into a therapeutic relationship. Example: Euro-American culture emphasizes the importance of individuality and independence as the foundation for maturity. Some cultures value collectivist and communal ethics and consider the group more important than the self.
ASSESSMENT AND DIAGNOSTIC COMPETENCE: diagnostic assessments are based on the DSM-IV-TR (2000); correct diagnosis is central to the counseling process, although there are those who avoid diagnosis based on the notion that it is counterproductive: Yalom believes that “diagnosis limits vision, diminishes a therapist’s ability to relate to a client as a person, and may result in a self-fulfilling prophecy. ” (p. 44) Assessment and Diagnosis Procedures 1. Clinical Interview [pic]Unstructured: flexible; suggestive leads from therapist; clinical judgment may be biased pic]Structured: standardized questions; increased reliability and validity; model from DSM-IV: Structured Clinical Interview (SCID) and Diagnostic Interview Schedule for Children (DISC) 2. Mental Status Exam [pic]Appearance/Behavior [pic]Thought Processes/Perceptions: flow, continuity of thought, rational, speed, delusions, ideas of reference, hallucinations [pic]Mood/Affect: appropriate; flat; blunted; inappropriate; prominent feeling [pic]Intellectual Functioning: vocabulary, insight, abstractions, memory [pic]Sensorium by person, time, place: oriented x 3; awareness of surroundings and reality . Behavioral assessment: tracking by the clinician or the client (self-monitoring) or the client’s family; in the office or in real life (home or school): direct observation; specific context; ABC model: antecedent behaviors(target behavior(consequences; 4. Environmental Assessment: rating the family system, the school, the community setting or a long-term care institution; example: See Family Background Questionnaire 5.
Psychophysiological assessment: measurement of one or more of the physiological processes that reflect autonomic nervous system activity: heart rate, skin conductance, muscle activity, brain electric activity, pulse and body temperature. 6. Neuroimaging: Noninvasive technologies for imaging the brain: CAT, MRI, PET, SPECT are most familiar methods 7. Psychological Testing [pic]Self-report inventories (see Beck Depression Inventory; Child Bipolar Assessment) [pic]“Draw a person” [pic] Psychological Inventories: MMPI-2 and NEO-PI-R; PAI [pic]Projective Tests: Rorschach, TAT pic]Intelligence Tests: Stanford-Binet; WAIS-III; WISC-III; WPPSI [pic]Neurological assessment: Bender-Gestalt, Trail Making Test, Weschler Memory; Halstead-Reitan; Luria-Nebraska 8. THE MINNESOTA MULTIPHASIC PERSONALITY INVENTORY (MMPI-2) • 567 true/false statements related to self (behaviors, thoughts, feelings) • provides ten clinical scales and three validity scales • Hypochondriasis • Depression • Hysteria (psychosomatic symptoms) • Psychopathic deviance • Masculinity-femininity • Paranoia Psychasthenia (obsessions, fears, guilt) • Schizophrenia • Hypomania (emotional excitement) • Social introversion • Lie scale (L) • False Positive scale (K) • False Negative scale (F) Diagnosis of Pathology –with a medical model (related to ICD-10) –by description rather than explanation –by category: either you do or you do not meet the symptom criteria (DSM and ICD use this approach) –by dimension: where do you fall along a continuum of mild, moderate, severe. –by time: chronic, acute, continuous, episodic Why diagnose? pic]a common language among professionals [pic] indication of etiology (cause) of a disorder [pic] narrows down treatment modalities [pic]allows for scientific research on syndromes [pic] enables third party payment The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV-TR) (2000): the diagnostic bible: the most widely used diagnostic systems in the United States; approved by the APA. This is a multiaxial classification system, which means that there are five axes (principle structures or dimensions) on which to diagnose: [pic]Axis I: Clinical Syndromes.
The traditional clinical labels are included on this axis. These clinical disorders are the subject of any psychopathology course; i. e. , mood disorders, anxiety disorders, eating disorders, gender-related disorders, personality disorders [pic]Axis II: Personality Disorders/Mental Retardation. There are ten personality disorders included on Axis II. These disorders are generally observed in childhood or adolescence and may persist in stability over time. Insurance will not cover treatment for personality disorders. These most often are secondary to an Axis I diagnosis.
Mental Retardation is included on Axis II, perhaps because of its chronicity [pic]Axis III: General Medical Conditions. All medical problems that may relate to psychological problems are listed here [pic]Axis IV: Psychosocial and Environmental Problems. Listed here are any sources of difficulty during the past year, or anticipated events that would be stressful. [pic]Axis V: Global Assessment of Functioning (GAF). The present level of adaptive functioning in three areas: personal relationships, occupational functioning and use of leisure time.
Scale from 1 (suicidal, homicidal) to 100 (superior functioning). Weaknesses and criticisms of the DSM-IV-TR (“a strange mix of social values, political compromise, scientific evidence and material for insurance claim forms”) 1. the subjectivity of the diagnostician 2. heavy reliance on the medical model (assuming symptoms of underlying pathologies) 3. weak empirical data for some categories of disorders (personality disorders) 4. disorders are not mutually exclusive and may overlap into another 5. oes not include etiology or treatment recommendations (descriptive, not explanatory) 6. stigmatization of labeling an individual with a disorder 7. effect on individual’s sense of esteem or competence 8. may produce a self-fulfilling prophecy 9. subject to psychological or social influences; may be biased against women; are feminine personality characteristics perceived as pathological, i. e. personality disorders such as histrionic and dependent 10. .insensitive to culture-bound disorders
To review the Code of Ethics for the following professional organizations, check out the website for: 1. American Counseling Association (ACA) http://www. counseling. org/resources/ethics. htm#ce 2. American Psychological Association (APA) http://www. apa. org/ethics/code2002. html 3. National Association of Social Workers (NASW) http://www. naswdc. org/pubs/code/default. asp 4. American Association for Marriage and Family Therapy (AAMFT) http://www. aamft. org/resources/LRMPlan/index_nm. asp