Category Archives: ethics

Gain: Ethical boundaries relating to client gifts


[note: I found this document in my Ethics course files. I think I wrote this some time ago...but I don't remember. It is possible that I received a WORD document with this in it from someone else. If so, I apologize for posting without acknowledging the source. Ah, the joys of aging.]

Professional counseling is founded on the assumption of the patient/practitioner relationship. The practitioner/expert provides a needed and appropriate service and the patient pays a reasonable fee—or their insurance company does for them. However, the extremely personal nature of counseling work often creates strong feelings between client and therapist and consequently the client may wish to bring a token gift signifying their thankfulness for a job well done.

Gifts beyond the token category provide therapists with “gain” and likely disrupt the fee/service relationship mentioned in the previous paragraph. While gain may not cause actual harm and may be unavoidable, the wise counselor remains aware of possible sources of gain and their consequences.

Consider the following examples and check whether you think they may be problematic:

  • A Board member of the counseling center offers one of the counselors tickets to a ball game
  • A Client offers his private counselor tickets to a ball game.
  • A student offers her teacher tickets to a ball game

Should the counselor in any of these scenarios accept the tickets? Does the cost of the gift or the wealth of the person giving a gift matter? Would it change your answer if the gift were a week’s stay at a beach house? Does it matter if the student is currently in a class with the teacher or not?

Gifts are a form of gain. Others may come in other forms of benefit for the counselor. If the counselee owns a publishing company, should the counselor accept an offer to have him or her publish his next book? If the counselor has a non-profit ministry, should he or she accept client gifts to that ministry? If a client offers to sit for a testimonial ad for the counselor’s new technique, should the counselor accept?

Gifts, though, represent expressions of thankfulness and thus a policy of rejecting all gifts may bring harm to the counseling relationship.

Wise Counselors explore with their clients any possibilities of gain and their potential consequences. Counselors consider how gains may harm the client or create an indebtedness that in the future clouds clinical judgment. For example, counselors do not accept gifts or fee sharing from treatment facilities in return for referrals. On the other hand, a cup of coffee brought to the session likely is just a cup of coffee, a friendly gesture. Christmas cookies are a small but personal thank you for a job well done. But, don’t assume that small gifts can not produce a quid pro quo (this for that) interaction. So, back to our first line in this paragraph. Take the time to explore the meaning of an offered gift and be willing to talk about it with clients.

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Filed under christian counseling, christian psychology, counseling, counseling skills, ethics

Suicide assessment mistakes


Yesterday’s post was about suicide. Counselors sometimes fail to adequately evaluate suicidal ideation, plan, or intent in their counselees. Some years ago, I ran across a research study looking at the most common mistakes made by 215 masters level counselors when dealing with suicidal clients. I’ve lost the bibliographic data for the article and couldn’t find it easily in Psychlit…

Here are some of the mistakes (in no particular order):

  • Superficial reassurance (“you have so much to live for”
  • Avoidance of strong emotions (not allowing client to express strong despair–usually with first bullet point)
  • Professionalism (cold and distant, possibly seen as uncaring in assessment)
  • Inadequate assessment (failure to explore fully because of nervousness or fear of asking)
  • Failure to identify precipitating causes (most suicides have both current and historical precipitating events. Counselors may identify historic event (e.g., divorce 4 years ago) but miss the current precipitant.)
  • Passivity; failure to be empathic (25% took this stance)
  • Insufficient directness. No contract to not harm, no next steps
  • Overbearing advice. Counselee needs to be involved in the planning for safety
  • Stereotyping response (“She’s just a borderline!”)
  • Defensiveness (usually about whether hospitalization is necessary)

Every counselor worries about how they will perform when addressing the serious problem of suicide risk assessment. We do well to review (a) our natural inclinations when stressed (e.g., do we tighten up, become over-controlling, too professional?), (b) our standard of practice when confronted with despairing or suicidal clients, and (c) our assessment procedures with all clients. While there is no way to prevent the suicides of highly motivated people, we can increase our capacity to respond well to those the Lord sends our way.

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Filed under christian counseling, christian psychology, counseling, counseling science, counseling skills, Depression, Despair, ethics, Psychology, Uncategorized

Professional communications by counselors: What do they reveal?


What we say and how we say it can tell someone quite a bit about our character. We counselors earn our keep with words. And yet, it is our words that may do the most harm to others. As a result, I encourage us to take stock of our words. What do they reveal about us? Oh, and don’t just consider the words you use in a session. How you talk to a colleague, about a colleague, to another professional may reveal your character more than you think. Consider the following communication issues:

1. Client put-downs. In agencies where counselors share clients with other professionals (e.g., psychiatrists, social workers, community workers, etc.), it is common for conversation to descend into put-downs. No doubt these professionals care about their clients. But if they are frustrated with the client, does it result in blaming the client? Making fun of their idiosyncracies? “He’s such a narcissist; She’s so Borderline”. These kind of comments reveal more about the speaker than the one spoken about.

2. Professional Lingo. Every guild has its lingo. Read a psychiatric or psychological evaluation and you will likely come across a number of words that only make sense if you are on the inside. The client probably wouldn’t really know what is being said about them with translation help. What do your progress notes communicate? Who are you writing for? How might our lingo hinder our work. I highly suggest that use the client as a standard to evaluate all our written communications. If the client couldn’t understand or could possibly be harmed by what we write, the think better of it.

3. Professional Territorialness. We communicate with other professionals about our clients. Does our communication reveal any condescending attitudes? Any unnecessary hierarchy? How do you talk about another professional to clients? To other colleagues? Do we withhold data for power reasons? For fear of mis-use by the other. If so, we have serious issues to address. Leaving them unaddressed will only injure the client.

4. Unprepared staffings. Staff communications regarding shared clients often include off-the-cuff comments about clients. These kind of statements can sound as if they are well supported by data. Sadly, we can offer up anecdotes about a client and they are weighted as heavily as objective test data. Can we support our comments and insights with data? Are there other data that might challenge our offered hypotheses?

5. General coarseness. I once had a supervisor who used the “F” word in every sentence (and in every form of speech possible). He relished the power he got from using that word. I’m not opposed to ever using curse words but they usually reveal more about the user than the situation. More recently, I’ve noticed how frequently we use genital imagery to talk about important character traits. “Do you have the stones to do that?” I heard this question asked in prime-time television. Why couldn’t they just talk about the trait of courage? I do think that language has a way of devolving in the heat of battle. Counselors work in the trenches and so it stands to reason that they might slip here some.

6. General grumbling. It is easy to slip into the habit of grumbling. I am tempted to revel (yes revel since I think I enjoy it some) in pointing out the failures of other people. I feel better when I can see their mistakes that I would never commit. We grumble against people, against institutions, against policies; against pretty much anything that irritates us.

Let us be diligent to explore what our communication reveals about our hearts and character and let us resolve, with God’s help, to love others even when they are not watching–and to model that love in our speech.

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Filed under christian counseling, christian psychology, counseling, counseling skills, deception, ethics, Psychology, Uncategorized

Clicking with your counselee


In every first session with a client I tell them that part of their job is evaluate whether I am the right therapist for them. While it is very important that your counselor is well-trained, if you don’t click with your counselor, the work you are trying to do will be much harder. Now, of course it often takes a few sessions to determine whether you can form a trusting, collaborative relationship or not.

I am always thankful when a client is willing to raise the “fit” problem with me. It gives us an opportunity to explore the disconnect, fix it if possible or happily refer to someone else. Too frequently disconnected clients choose to either keep plugging away (but being less and less vulnerable) or just fade away and you never know what went wrong.

But what if the counselor doesn’t connect with the client…and the client doesn’t know it? What should the counselor do?

1. Use supervision or consultation to explore the disconnect. Maybe the disconnect will reveal something useful about the counselee. Maybe it will reveal some pride or prejudice in the counselor. Maybe it will reveal some naiveté or lack of competency or empathy or conflict over goals. Or, maybe it will reveal some cultural differentness that is really hard to overcome.

2. Assess whether or not (again using supervision) whether progress is being made. Is the counselee growing in insight? Gaining control? Showing more fruits of the Spirit? Seeing a decrease in anxiety or depression? The counselor may need to reassess their goals for the client.

3. Consider attempting more “here and now” to explore what is going on in the relationship between counselor and counselee. HOWEVER, do not do this to tell them how you are feeling NOR to be condescending. This action is designed to help both of you to be more present and decrease disconnection.

4. If all else fails, refer. This would be appropriate if (a) you believe you are not competent to help them or impaired in some way (and you should communicate your lack–in a limited way–to the client when discussing referral), or (b) you believe the problem is that counseling is harmful (and again you should discuss why you think this way and what the options might look like for them. Remember to avoid abandoning them. Referrals are specific, take time, and are for their best interest, not yours.

The bottom line is that the onus is on the counselor to work through the disconnect and to do all that he or she can to fix the problem or to tolerate it if the client is making good progress. This is what it means to “love one another.” We fail to do so if we either ignore the problem or use the disconnect to get rid of counselees that do not feed our egos.

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Filed under christian counseling, christian psychology, counseling, counseling skills, ethics, personality, Psychology, Uncategorized

Should you Google your clients?


Dr. Zur has a new blog post on this topic that raises question (no answers at this point). Should you Google your clients? Dr. Zur wants to consider the ethics of this. There are two ways to try to explore this topic from an ethical point of view.

  1. What do the ethics codes say? Codes say nothing directly about this. Indirectly, we are to work to protect their dignity and human freedom. We are to act beneficently. We are to seek consent before we provide treatment or access private and protected information. We are not to give out their information without consent. Questions to ask: oes googling a client risk revealing their identity to others? It might if you use a shared computer. Would Googling access private and protected information? It shouldn’t. However, many people blog and post private information that might shock them if others in their various circles found out. Many do not consider this when posting comments or personal information.
  2. Beyond the codes, is it good practice to search for information about your clients? Or put another way, how might searching for information about your clients cause harm? Might it change the relationship? Change your opinion of them? Make you less interested in helping them? What if the information you find isn’t accurate? Might it cause you to use that information in a coercive manner? Might it be used to practice a form of voyeurism (which is a form of using clients for our own pleasure)? These kinds of questions raise moral and theoretical issues as much as ethical ones.

Dr. Zur lists a number of vignettes that might well cause you to answer yes to our initial question. Googling might reveal safety issues, legal issues, even life issues that would be helpful to know. So, our answer will never be that it is unethical.

I would leave you with this question. How will you feel if your clients know you have googled them? Will you be embarrassed? If so, you ought not to do it. Similarly, if a client comes in knowing lots of things about you that they gleaned from the Internet (work history, family, etc.), do you feel stalked? Maybe we should consider the “Do unto others…” command here.

One last pragmatic point. It is sometimes possible today to find out who is Googling you. Keep that in mind as you think about this issue.

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Filed under counseling, counseling and the law, counseling skills, ethics, Psychology, Uncategorized

Seeing clients outside the office


Much of what we do in counseling or therapy is enculturated. Confidentiality, the 50 minute session, avoiding dual relationships…these things developed out of the culture of psychoanalysis. Now, that is not a criticism. I personally agree that good therapy requires privacy and the assurance of confidentiality. Who would talk about the deepest matters of the heart if they thought it would be broadcast to the world? And it isn’t as if this is a modern invention. Pastors have been practicing this since the early church.

One of those culture founded practices is seeing patients only in the office setting. Supposedly, this would maintain the “frame” of the counseling hour so as to avoid unnecessary outward intrusions. Further, it maintains one picture of the therapist. Having coffee with your therapist at the local diner would completely change that frame–and reduce confidentiality when your neighbor comes up and says, “Oh, I saw you go into the diner with Dr. Monroe. How do you know him?”

But there are some reasons why a counselor might intentionally see a client outside the office. Here are some reasons I have:

  1. Observation of a child in a school or home setting as part of an assessment
  2. Visiting a client in the hospital (either as a courtesy call or as part of a treatment continuity plan)
  3. Joint meeting with other providers (therapists, pastors, care team) at another location
  4. Part of a treatment plan (e.g., to practice walking over a bridge, get on an elevator, etc.

I have been asked to have coffee by current clients. I have been invited to house-warming parties. I have been asked to attend other celebrations. I’m more inclined to attend celebrations for kids or if the relationship is quite limited (wedding of a pre-marital client seen for 6 sessions only). I have taken clients outside my office for one reason or another (a brief walk, thrown a ball with a kid, etc.).

Whatever you choose to do. Be sure to evaluate the effect it will have on your relationship with the client. What potential pit-falls exist? Talk to them about it. Afterwards, continue to see if such actions introduce any relationship confusion. Be wary of informality. You don’t have to be stiff but informality breeds complacency and soon you are doing things you never dreamed of doing. Also be especially wary if the client has any history of abuse or boundary violations. Take care to protect those boundaries for their sake.

While psychological ethics are built on “Do no harm,” we know that the bible also supports this. Watch out for your weaker brother or sister!

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Filed under christian counseling, christian psychology, counseling, counseling and the law, counseling science, counseling skills, ethics

Counseling Ethics and Electronic media


Once before I wrote a bit on this topic. Just how much should we use electronic media to work with clients? While most counseling takes place face to face, counselors speak with their clients using the phone, e-mail, texts, live chat, video conferencing, even through “second life” formats using avatars.

In the latest edition of the Pennsylvania Psychologist, I saw another little article reminding us counselors how to manage these electronic methods. Rachael Baturin suggests the following tips:

  1. Always clarify what kind electronic connectivity you will have and the nature of those interactions. For example, use of email to receive documents and make scheduling changes but wary of too long or too informal style emails. If you look like a friend (sharing personal stuff back to the client), it blurs boundaries
  2. Anticipate and respond to abuses of your policy (e.g., frequent texting, demanding emails)
  3. Avoiding the use of e-mails and texts for emergency contacts from clients. Use the phone or answering service for that
  4. Establish a general turnaround policy (how long you will likely take to respond to emails)
  5. Inform clients about privacy issues. Such as, use of work email to contact them, possibility of a shared email.
  6. Maintain a copy of every email or electronic contact. Or summarize them in the next case note.
  7. Use the standard text at end of email msgs to remind them of confidentiality and the possibility of errors in sending.
  8. Remember, tone of voice is missing in emails. Be sure to be extra careful about this

A couple of additional matters not mentioned:

Be clear on whether you bill for time on emails BEFORE you start emailing back and forth. Recognize that SKYPE or other kinds of video conferencing to other countries may not be as private as you might think. Other countries may do more to monitor NGOs and others serving abroad. If you get emailed journals, ask the person to use an agreed upon password for their Word documents. That way, if the email goes awry, no-one else can view the contents but you and your client.

Bottom line? Don’t be lulled into unprofessional activities on-line. Assume everything you send (chat, texts, email) may be printed out or shared with someone else. How would what you are saying or doing look to a court of law determining whether you acted in the best interests of your client and whether or not you held yourself to a high standard of care?

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Infidelity: personality or opportunity?


On the way to work today I heard a radio personality muse about the rampant sexual infidelity among politicians and sports figures. They talked about how people (i.e., men as the stereotype goes)  in power have much more opportunity for sexual acting out because they have more women offering themselves to them. Probably true…

But, is it that they have more opportunity (and thus more chance to give in to temptation) or is it because they have a personality that sets themselves up for infidelity? And would  you have a different answer if we were talking about bribe taking or other financial temptations instead of sexual indiscretion?

I think they are the same AND I think every has opportunity (some more than others). What matters is one’s perceptions of self and others. While personality plays a part of our self awareness, the drive to win, be the best, to get the prize, listening only to one’s fans, the sense that you are better than others also is formed from self-talk. Thus, opportunity makes it possible but failure to be self-critical is the key feature that makes opportunity become reality.

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Filed under Cognitive biases, ethics, personality, Psychology, Sex

Technoethics?


At September’s AACC conference I attended a presentation entitled, “Technoethics” by Jana Vanderslice, a psychologist from Texas. She got me thinking about the use of e-mail and other Internet-based technologies with counselees. Here are some of the issues:

1. E-mail. Do you have a policy about your use of e-mail with counselees? Do you inform them about the limits or possible problems that might be encountered? Problems such as security and confidentiality, whether or not you will read them “in time”, what becomes of them (printed out and kept in a file?), whether or not you provide brief counseling through e-mail and possible charges, etc. Dr. Vanderslice suggests having a start to the email that says, “Confidential! This is not meant to take the place of in person consultation…”

2. If you do e-mail counseling, do you (a) know who you are emailing? What data do you collect from the person you provide email counseling to? And (b), do you think about how your email may sound if it is printed off and/or forwarded to others. You should assume that your electronic communications may be passed on. Further, if you have regular e-mail contact, how will you deal with the nature of always being at the beck and call of clientele?

3. Your Social networking accts. Do you use twitter? Do you have a Facebook or MySpace account or the like? Do you “friend” your clients? Do you have anything personal on the web you’d rather your clients didn’t see? This becomes a form of self-disclosure. There may be things revealed about yourself on-line that you would never reveal to a client. Remember, if the client is in the same Facebook network, they can likely see more of you than you might realize.

4. Google searches. Similarly, it might be worth your while to search yourself and see what is out there. Did you know that there are “rate my counselor” type sites out there? Many of these exist to help you find healthcare providers in your area, but include ratings by current or former clients. Do you know what others are saying about you?

5. IT and other providers. Who has access to your accounts and computer? Does your IT dept (if you are in a larger organization) know to honor HIPAA regulations? If you use a vendor (e.g., Geek Squad), they need to sign an agreement to maintain the privacy of the clientele data on your email or database. Can you encrypt email and/or WORD documents?

Can you think of other technoethics issues?

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Filed under Communication, confidentiality, counseling, counseling skills, ethics, Psychology, teaching counseling

The APA on identity therapy and conversion therapy


[Let me wade into something that tends to fire up lots of feelings and lead to controversy. And let me ask all to be civil. Civility seems to be the first thing that disappears when we discuss matters near and dear to our hearts. But let us be different and listen to each other rather than talk at or past each other. As James tells us, let us be quick to listen and slow to speak.]

In recent days media outlets have picked up the story of the American Psychological Association’s release of a report and declaration of their official stance on reparative or conversion therapies for individuals seeking to change their sexual orientation. You can read their press release and find their 100 page research review here. Being a member of the organization, knowing a few of the players in the research side of things, and knowing how easy it is to get caught up in debate and miss some of the finer points, I thought I might make a few comments that may not make it to the public eye.

1. Researchers are beginning to distinguish between sexual identity and orientation. This is a good thing. I dare say that the public lags far behind on this matter. Separating these two different aspects of sexuality allows for individuals to consider and interpret their sexual feelings in accord with their beliefs and NOT as how either the minority or majority of the world tells them to define themselves. This is akin to biracial people determining how they want to self-identify rather than be forced to say they are black or white.  Consider the following quote by one of the players (whom  I don’t know),

The distinction between orientation and identity (or attraction and identity as we often describe it here) is key, in my view, in order for us to understand the experience of those who say they have changed while at the same time experiencing same-sex attraction….I hope we can agree that sexual attraction patterns may be one thing while meaning making aspects may lead two people with the same attraction pattern to identity in disparate ways. (emphasis mine; from http://www.crosswalk.com/blogs/EWThrockmorton/11607271/)

If I understand the relationship between identity and orientation, it would seem that one forms identity from a variety of “data” which leads to an orientation. This is true outside of sexual identity. A number of factors come together for a person to see themself in a particular way (this may include biology, family, life experiences, key “flashbulb” moments, etc) and in cementing that particular identity they develop an orientation towards the world. SO, this may explain why trying to change orientation has little positive effect. Until the person reviews, explores, and reconsiders their identity (something that happens in nearly every counselee I’ve ever worked with) and begins to practice another way of seeing self, not much is going to change in attraction and orientation. Further, what may change is one’s sense of importance (and therefore meaning) of various parts of themself. When my clients explore their identity, it is rare they come to understand that they were completely mis-perceiving their feelings or experiences. Rather, they begin to see those experiences and feelings from a different vantage point.  

2. Change. What constitutes change is still up in the air. Ask a depressed person if they have changed even if they are only 50% less depressed and they will say likely say yes. Ask someone else and they may say “no,  I’m still depressed.” In the realm of sexual orientation, however, many see orientation as all/nothing. All same sex or all opposite sex orientation. Many will tell you this is just not their particular experience. So, IF someone wanted to change their direction of sexual attraction, what standard would they use to determine if change had taken place? Would 50% change be good? Who would decide this?

There is another analogous scenario in psychology. Should psychologists provide weight loss treatment? Given that an extremely large portion of those who lose weight gain it back and more, many have felt it unethical for a psychologist to offer weight loss therapies when they know that success is extremely low. So, how long do you need to keep the weight off to make a treatment worthwhile? How much do you need to lose? Who decides?

My gut feel is that the APA is not accurate in saying that there isn’t evidence that individuals can change. There is some evidence. Not complete change, but let us not deny what is there. Neither are they accurate about their reporting of harm. Harm reports are difficult to objectify. The best research will show you that some are harmed and some are not. Instead of assuming harm, let us evaluate more closely how some are harmed and how some are helped. Just as one might do with the weight loss scenario.  

3.  APA makes an attempt to make room for the work of helping one to find congruence between faith commitments and sexual feelings. This is also a good thing. Now, just how a psychologist does this matters greatly. Does he or she evangelize here? By that I mean (a) encourage a client to choose a different faith or change it to fit one’s sexual feelings, or (b) encourage a client to deny feelings and deny the suffering one might have by choosing not to act on a desire? My personal opininon is that option c (stay neutral) does not exist and is not possible. So, where does that leave us? Informing clients of our personal positions and yet not attempting to force individuals into our view of the situation. In other words, truthful but humble without being demanding.   

This is a divisive topic. Do individuals seeking to change their sexual orientation have the right to try to do so with the help of psychologists? Is change possible? Desirable? Damaging? And of course in trying to answer these questions you have a number of players on each side–each reading the “evidence” the way they would like to see it. You have those who have personal experiences in one direction or another. You have those with political or philosophical agendas. And, on top of that, you have media players interested in creating controversy where they can. I observed this last one myself where a local talk show host did his level best to create differences between two parties that weren’t disagreeing with each other as much he wanted them to.

So, what do you make of the difference between identity and orientation? Is it meaningful? How do we speak of change? Can we admit that it happens for some and not for others no matter our personal opinion whether change is good or not? And finally, can we avoid the “what if…” tendency in our conversations so that we deal with what is happening and not what we fear might happen?

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Filed under APA, Christianity, counseling science, ethics, homosexuality, Psychology, sexual identity, sexuality, Uncategorized