Advanced Ethics: Special Concerns
According to Webster’s Dictionary, ethics is defined as “the discipline dealing
with what is good and bad and with moral duty and obligations - ethics are the principles
of conduct governing an individual or group.”
The subject of ethics and ethical behavior is important to every professional
group. The ethical considerations define the way in which a group or profession
conduct themselves.
Ethical considerations can typically be viewed from three different perspectives:
(1) moral/professional judgments; (2) legal considerations; and (3) ethical implications.
Moral/professional judgments refer to the individual counselor’s own value
system. Within the therapeutic relationship, counselors need to ask themselves
“Do I feel comfortable doing ____________?” If a particular situation is morally
uncomfortable for the counselor, but still legal and ethical, then the responsibility
of the counselor is to help the client obtain the desired service in the most
expeditious manner. For example, it is not uncommon to have a client in the
chemical dependency field that has been or is currently involved in dealing drugs
to support their habit. While the counselor may have strong feelings about this
activity, legally and ethically the counselor may not disclose this information to
law enforcement authorities. The counselor is obligated to provide services to
the client (though a referral to another counselor may be appropriate if the
counselor feels they cannot provide adequate service to the client).
Legal considerations relate to whether or not there are laws governing a
specific activity. For example, counselors must determine whether they are
qualified to provide services within their scope of practice. Licensure laws,
currently being developed by many states, specify the types of activities the
chemical dependency professional may perform. In states that do not provide
licensure, certification standards do much of the same thing. Chemical
dependency counselors must not engage in activities beyond the scope of their
training. For example, a counselor may feel that a client would benefit from
marital counseling in their recovery program. While the skill and training of the
counselor may allow him or her to provide basic services to the spouse, including
educational, awareness building services and referral to such programs as AlAnon, marital counseling should be performed by a qualified marriage and family
therapist. It would be illegal as well as unethical for the chemical dependency
counselor to do otherwise.
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Ethical implications refer to the principles set forth by the ethical standards
governing a particular profession. When considering ethical implications, the
counselor should always remember the following:
(1) It is the counselors responsibility to know and understand the ethical
principles that guide them, whether they are state or national guidelines;
(2) It is necessary to consider all of these ethical principles to determine how they
apply to each client the counselor serves;
(3) All variables, including legal responsibilities and medical considerations, must
be reviewed for each case;
(4) Confidentiality is a critical area of concern and this ethical standard is
frequently involved in clinical dilemmas - the primary justification for breaking
confidentiality occurs when a person is a danger to self or others.
(5) Counselors need to be sensitive to the moral and social codes of the
community;
(6) When making decisions involving ethics, counselors should usually be
conservative in their judgment and frequently consult with other treatment
professionals;
(7) Counselors should always have a keen awareness of their areas of
competence and an appreciation of their limitations - regardless of personal
belief, a counselor cannot provide every service that a client needs.
ETHICAL PRINCIPLES
The NAADAC Code of Ethics states that professional alcoholism and drug abuse
counselors “assert that the ethical principles of autonomy, beneficence and justice must
guide their professional conduct.” It is, therefore, important to understand what these
three central principles mean in examining and implementing the Code of Ethics.
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AUTONOMY. This is the principle that supports clients’ independence, freedom
and self-determination. Counselors practice this principle by respecting clients’
values, facilitating clients’ independence and supporting clients’ rights to make
choices about their own life.
BENEFICENCE. This principle relates to the value of doing good. Counselors
apply this principle through their commitment to helping others and by promoting
what is in the best interest of the client.
JUSTICE. This principle relates to fairness and the concept of equal and fair
treatment. Counselors practice this principle when they provide the same quality
of treatment to all clients without discrimination.
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In addition to these three principles, there are others that are inherent in most
ethical codes.
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OBEDIENCE. This principle pertains to the observance of laws and regulations
that govern behavior. Counselors apply this principle by following licensure and
certification regulations, agency policies, and legal mandates.
COMPETENCE. This principle relates to the value that counselors need to be
trained and prepared to provide the services they offer. Counselors practice this
principle when they pursue appropriate credentials, training, experience, and
supervision, and operate within their scope of practice.
FIDELITY. This is the principle that supports honesty and trust. Counselors
promote this principle by being trustworthy with clients and the general public, as
well as, following through with commitments to clients and others.
LOYALTY. This principle pertains to the value of allegiance. Most codes expect
the primary loyalty of the professional to be to the client. Counselors apply this
principle when they advocate for and actively support clients’ needs.
DISCRETION. This is the principle that values the right to privacy. Counselors
promote this by following confidentiality guidelines and privileged communication
laws.
NONMALEFICENCE. This is the principle of doing no harm. Counselors must
avoid any behavior that can cause harm or has the potential to harm a client.
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Self-Inventory
This is for your personal awareness and to begin to focus on some of the areas that will
be discussed in this course. There is no right or wrong answer and in fact, you may
want to answer all of the above or a combination of the answers or create your own.
You might benefit by discussing some of your responses in supervision or with a trusted
colleague. You may also identify other areas of concern in working with these special
issues that you need to discuss with others.
1. If my client stated that he felt I did not understand him because of our different
cultural backgrounds, I would:
a. Ask him for further clarification
b. Seek consultation to improve my knowledge of his culture
c. Refer him to a counselor of his own cultural background
d. Other: ___________________________________________________
2. Ethical multicultural counseling means that:
a. I understand as much as possible about all other cultures
b. I am aware that my worldview may not be the viewpoint of my clients
c. I do not counsel clients from other cultures
d. Other: ___________________________________________________
3. I believe that a client who is court-ordered to treatment:
a. Is usually unmotivated and more difficult to treat than self-referred clients
b. Should not be seen in private practice settings
c. Is more compliant with treatment recommendations than most selfreferred clients
d. Other: ____________________________________________________
4. If a client I was treating was on probation and disclosed to me that she had recently
committed a crime, I would:
a. Contact the probation officer immediately, assuming I had a valid release
form
b. Contact my lawyer and proceed however he/she advised
c. Determine if it was a felony or misdemeanor: report the felony to the
probation officer
d. Other: _____________________________________________________
5. I would have difficulty treating a client who had committed:
a. Sexual battery/rape
b. Kidnapping
c. Drug dealing
d. Other: _____________________________________________________
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6. If my sixteen -year old client revealed that she was pregnant and did not want her
parents to know, I would:
a. Discuss the situation with her and try to determine her reasons for privacy
b. Respect her wishes as long as she agreed to seek medical care
c. Advise her that I need to contact her parents anyway and why
d. Other: _____________________________________________________
7. If my sixteen-year old client revealed that he had just joined a gang and part of the
initiation was to shoplift from a local convenience store, I would:
a. Discuss with him making restitution to the store owner
b. I would advise him that I need to contact his parents for a family discussion
c. I would contact law enforcement authorities
d. Other: ______________________________________________________
8. If my client had AIDS and wanted to discuss physician -assisted suicide, I would:
a. Refer her to a spiritual direction counselor
b. Listen to her views and then try to persuade her not to pursue this
c. Discuss this with her in a neutral, objective manner
d. Other:
_______________________________________________________
9. If my client revealed that he had just been diagnosed as HIV positive but was
refusing medical treatment, I would:
a. Discuss his reasons for refusal and then attempt to educate him and
persuade him to seek treatment
b. Tell him that I could not work with him and refer
c. Respect his decision and not bring it up unless he wanted to discuss it again
d. Other:
_______________________________________________________
10. If I was treating an HIV positive client who refused to notify his/her spouse
regarding his/her status, I would:
a. Discuss my ethical concerns regarding this with a supervisor and probably
refer the client
b. Contact the spouse anyway, citing duty to warn and protection of their
welfare
c. Offer to have a conjoint session to help the client discuss this with the
spouse
d. Other:
_______________________________________________________
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The NAADAC Code of Ethics
Regardless of whether a counselor is credentialed by a state’s licensure law or by a
private associations certification standards, most credentialing bodies have modeled
their ethical guidelines after NAADAC’s Code of Ethics. These ethical principles were
first published in NAADAC’s publication, The Counselor, Vol. 5, September, 1987. You
should already be familiar with these code, but there will be placed here to insure that
you have once again reviewed them. These principles are as follows:
Principle 1: Non-Discrimination
The alcoholism and drug abuse counselor should not discriminate against clients
or professionals based upon race, religion, age, sex, handicap, national ancestry,
sexual orientation, or economic condition.
Principle 2: Responsibility
The alcoholism and drug abuse counselor should espouse objectivity and
integrity, and maintain the highest standards in the services the counselor offers.
a. The alcoholism and drug abuse counselor, as teacher, should recognize the
counselor’s primary obligation to help others acquire knowledge and skill in dealing
with the disease of chemical dependency.
b. The alcoholism and drug abuse counselor, as practitioner, should accept the
professional challenge and responsibility deriving from the counselor’s work
Principle 3: Competence
The alcoholism and drug abuse counselor should recognize that the profession is
founded on national standards of competency that promote the best interests of society,
of the client, of the counselor, and of the profession as a whole. The counselor should
recognize the need for ongoing education as a component of professional competency.
a. The alcoholism and drug abuse counselor should prevent the practice of alcoholism
and drug abuse counseling by unqualified and unauthorized persons.
b. The alcoholism and drug abuse counselor who is aware of unethical conduct or of
unprofessional modes of practice should report such violations to the appropriate
certifying authority.
c. The alcoholism and drug abuse counselor should recognize boundaries and
limitations of counselors’ competencies and not offer services or use techniques
outside of these professional competencies.
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d. The alcoholism and drug abuse counselor should recognize the effect of
professional impairment on professional performance and should be willing to seek
appropriate treatment for oneself or for a colleague. The counselor should support
peer assistance programs in this respect.
Principle 4: Legal Standards and Moral Standards
The alcoholism and drug abuse counselor should uphold the legal and accepted moral
codes which pertain to professional conduct.
a. The alcoholism and drug abuse counselor should not claim either directly or by
implication, professional qualifications/affiliations that the counselor does not
possess.
b. The alcoholism and drug abuse counselor should not use the affiliation with the
National Association of Alcoholism and Drug Abuse Counselors for purposes that
are not consistent with the stated purposes of the Association.
c. The alcoholism and drug abuse counselor should not associate with or permit the
counselor’s name to be used in connection with any services or products in a way
that is incorrect or misleading.
d. The alcoholism and drug abuse counselor associated with the development or
promotion of books or other products offered for commercial sale should be
responsible for ensuring that such books or products are presented in a professional
and factual way.
Principle 5: Public Statements
The alcoholism and drug abuse counselor should respect the limits of present
knowledge in public statements concerning alcoholism and other forms of drug
addiction.
a. The alcoholism and drug abuse counselor who represents the field of alcoholism
counseling to clients, other professionals, or to the general public should report fairly
and accurately the appropriate information
b. The alcoholism and drug abuse counselor should acknowledge and document
materials and techniques used.
c. The alcoholism and drug abuse counselor who conducts training in alcoholism or
drug abuse counseling skills or techniques should indicate to the audience the
requisite training/qualifications required to properly perform these skills and
techniques.
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Principle 6: Publication Credit
The alcoholism and drug abuse counselor should assign credit to all who have
contributed to the published material and for the work upon which the publication is
based.
a. The alcoholism and drug abuse counselor should recognize joint authorship, major
contributions of a professional character, made by several persons to a common
project. The author who has made the principal contribution to a publication should
be identified as a first listed.
b. The alcoholism and drug abuse counselor should acknowledge in footnotes or an
introductory statement minor contributions of a professional character, extensive
clerical or similar assistance, and other minor contributions.
c. The alcoholism and drug abuse counselor should acknowledge, through specific
citations, unpublished, as well as published material, that has directly influenced the
research or writing.
d. The alcoholism and drug abuse counselor who compiles and edits for publication the
contributions of others should list oneself as editor, along with the names of those
others who have contributed.
Principle 7: Client Welfare
The alcoholism and drug abuse counselor should respect the integrity and
protect the welfare of the person or group with whom the counselor is working.
a. The alcoholism and drug abuse counselor should define for self and others the
nature and direction of loyalties and responsibilities and keep all parties concerned
informed of these commitments.
b. The alcoholism and drug abuse counselor, in the presence of professional conflict,
should be concerned primarily with the welfare of the client.
c. The alcoholism and drug abuse counselor should terminate a counseling or
consulting relationship when it is reasonably clear to the counselor that the client is
not benefiting from it.
d. The alcoholism and drug abuse counselor, in referral cases, should assume the
responsibility for the client’s welfare either by termination by mutual agreement
and/or by the client becoming engaged with another professional. In situations when
a client refuses treatment, referral, or recommendations, the alcoholism and drug
abuse counselor should carefully consider the welfare of the client by weighing the
benefits of continued treatment or termination and should act in the best interest of
the client.
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e. The alcoholism and drug abuse counselor who asks a client to reveal personal
information from other professionals or allows information to be divulged should
inform the client of the nature of such transactions. The information released or
obtained with informed consent should be used for expressed purposes only.
f. The alcoholism and drug abuse counselor should not use a client in a demonstration
role in a workshop setting where such participation would potentially harm the client.
g. The alcoholism and drug abuse counselor should ensure the presence of an
appropriate setting for clinical work to protect the client from harm and the counselor
and the profession from censure.
h. The alcoholism and drug abuse counselor should collaborate with other health care
professional(s) in providing a supportive environment for the client who is receiving
prescribed medications.
Principle 8: Confidentiality
The alcoholism and drug abuse counselor should embrace, as a primary
obligation, the duty of protecting the privacy of clients and should not disclose
confidential information acquired, in teaching, practice, or investigation.
a. The alcoholism and drug abuse counselor should inform the client and obtain
agreement in areas likely to affect the client’s participation including the recording of
an interview, the use of interview material for training purposes, and observation of
an interview by another person.
b. The alcoholism and drug abuse counselor should make provisions for the
maintenance of confidentiality and the ultimate disposition of confidential records.
c. The alcoholism and drug abuse counselor should reveal information received in
confidence only when there is clear and imminent danger to the client or to other
persons, and then only to appropriate professional workers or public authorities.
d. The alcoholism and drug abuse counselor should discuss the information obtained in
clinical or consulting relationships only in appropriate settings, and only for
professional purposes clearly concerned with the case. Written and oral reports
should present only data germane to the purpose of the evaluation and every effort
should be made to avoid undue invasion of privacy.
e. The alcoholism and drug abuse counselor should use clinical and other material in
classroom teaching and writing only when the identity of the persons involved is
adequately disguised.
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Principle 9: Relationships
The alcoholism and drug abuse counselor should inform the prospective client of
the important aspects of the potential relationship.
a. The alcoholism and drug abuse counselor should inform the client and obtain the
client’s agreement in areas likely to affect the client’s participation including the
recording of an interview, the use of interview material for training purposes, and/or
observation of an interview by another person.
b. The alcoholism and drug abuse counselor should inform the designated guardian or
responsible person of the circumstances that may influence the relationship, when
the client is a minor or incompetent.
c. The alcoholism and drug abuse counselor should not enter into a professional
relationship with members of one’s own family, intimate friends or close associates,
or others whose welfare might be jeopardized by such a dual relationship.
d. The alcoholism and drug abuse counselor should not engage in any type of sexual
activity with a client.
Principle 10: Interprofessional Relationships
The alcoholism and drug abuse counselor should treat colleagues with respect,
courtesy and fairness, and should afford the same professional courtesy to other
professionals.
a. The alcoholism and drug abuse counselor should not offer professional services to a
client in counseling with another professional except with the knowledge of the other
professional or after the termination of the client’s relationship with the other
professional.
b. The alcoholism and drug abuse counselor should cooperate with duly constituted
professional ethics committees and promptly supply necessary information unless
constrained by the demands of confidentiality.
Principle 11: Remuneration
The alcoholism and drug abuse counselor should establish financial
arrangements in professional practice and in accord with the professional standards that
safeguard the best interests of the client, of the counselor, and of the profession.
a. The alcoholism and drug abuse counselor should consider carefully the ability of the
client to meet the financial cost in establishing rates for professional services.
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b. The alcoholism and drug abuse counselor should not send or receive any
commission or rebate or any other form of remuneration for referral of clients for
professional services. The counselor should not engage in fee splitting.
c. The alcoholism and drug abuse counselor in clinical or counseling practice should
not use one’s relationship with clients to promote personal gain or the profit of an
agency or commercial enterprise of any kind.
d. The alcoholism and drug abuse counselor should not accept a private fee or any
other gift or gratuity for professional work with a person who is entitled to such
services through an institution or agency. The policy of a particular agency may
make explicit provisions for private work with its clients by members of its staff, and
in such instances the client must be fully apprised of all policies affecting the client.
Principle 12: Societal Obligations
The alcoholism and drug abuse counselor should advocate changes in public
policy and legislation to afford opportunity and choice for all persons whose lives are
impaired by the disease of alcoholism and other forms of drug addiction. The counselor
should inform the public through active civic and professional participation in community
affairs of the effects of alcoholism and drug addiction and should act to guarantee that
all persons, especially the needy and disadvantaged, have access to the necessary
resources and services. The alcoholism and drug abuse counselor should adopt a
personal and professional stance that promotes the well-being of all human beings.
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ETHICAL AND PROFESSIONAL ISSUES FOR
COUNSELORS
The ethical principles listed by NAADAC are phrased in general terms. It is
therefore essential for the alcohol and drug abuse counselor to have a more detailed
understanding of the responsibilities and consequences associated with some of these
principles and, in some cases, be familiar with laws that relate to them. In addition,
alcohol and drug abuse counselors must be aware of several professional issues
relevant to alcohol and drug abuse field and the mental health field in general.
Patient Rights
There have been a number of legal cases related to the rights of involuntarily committed
patients. In the case of Wyatt v. Stickney, a U.S. District Court ruled that involuntarily
committed patients are constitutionally entitled to treatment; commitment without such
treatment constitutes indefinite punishment and violates the fundamentals of due
process. Moreover, involuntarily committed patients must be treated in the least
restrictive environment available. In a related issue, some states have passed laws that
give involuntarily committed patients the right to refuse treatments associated with
negative side effects and the right to refuse to take psychoactive drugs.
In some ways, the substance abuser does not enjoy the same legal protections as a
person who has been involuntarily committed. Many users are pressured by the court,
their employers, or even family members to undergo “voluntary” treatment. Although
these patients sign voluntary consent to treatment forms, they often do not have the
opportunity to give truly informed consent. Of course, chemical dependencies are often
characterized by denial and self-delusion. and in these cases it is almost certainly
necessary to use some coercion, especially in the early stages of treatment, to get help
to users who pose a danger to themselves or others. However, substance abuse
professionals need to take it upon themselves to offer as much freedom of choice and
the least restrictive treatment alternatives possible.
A problem often exists in that the decision as to where and how the patient should be
treated is not always undertaken with the patient’s best interests in mind. For instance,
in some situations, the person who forces a patient into a treatment program may be the
person who runs the program. In addition, employee organizations sometimes make
contractual arrangements with a single treatment facility, and some employers and
unions have gone into the business of providing treatment for their own employees.
Such arrangements can potentially create conflicts of interest, reduce patient choice,
and lower the quality of care provided.
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In the past two year, the field has seen a significant loss of private care facilities. Many
abuses were uncovered by various states in1992 that suggested some of the larger
national treatment chains were involved in questionable practices. Inappropriate
admissions, failure to provide the least restrictive (and less costly) level of care, paying
counselors for referrals, and inappropriate lengths of stay seemed to be acceptable
practice. As a result, newer, more stringent guidelines have been developed by many
states, and several of the national chains have closed facilities due to declining revenue
and increased litigation costs. While there exists a need to allow clients to choose
among several acceptable treatment facilities, choices are becoming fewer.
Substance abuse professionals should act in line with provisions 7a and 7b of
NAADAC’s Ethical Code, which state respectively that “The alcoholism and drug abuse
counselor should define for self and others the nature and direction of loyalties and
responsibilities and keep all parties concerned informed of these commitments" and
“The alcoholism and drug abuse counselor, in the presence of professional conflict
should be concerned primarily with the welfare of the client.” Thus, in situations where
there is only one source of treatment for in a particular place or for a particular
organization, counselors should strive to ensure that clients are informed as to the
nature of any agreements involved, that treatment is sufficiently individualized, and that
treating facilities are checked intermittently to the quality and timeliness of care. In
addition, there should be no opportunity for the counselor to profit from his/her referral in
any way.
Confidentiality of Alcohol and Drug Abuse Patients
Confidentiality between a counselor and a client is crucial to the success of the
counseling relationship. The client’s beliefs about confidentially will determine the extent
and the nature of the information revealed during the course of care. The importance of
confidentiality is acknowledged by the NAADAC Code of Ethics in the preamble of
Principle 8, which states, “The alcoholism and drug abuse counselor should embrace,
as a primary obligation, the duty of protecting the privacy of clients and should not
disclose confidential information acquired, in teaching, practice, or investigation.” The
basic principle of confidentiality is that no information divulged by patients in the course
of treatment even the fact that a particular person is (or is not) a patient in a treatment
facility may be revealed to an outside source without the written consent of the patient
when he/she is rational and drug-free. Professional handling of information means that it
will never be divulged in a careless, casual, or irresponsible way, discussed in social
conversations, or revealed in casual inquiries.
The privacy of persons receiving alcohol and drug abuse prevention and treatment
services is protected by federal laws. The legal citation for these laws is 42 U.S.C.
290dd-3 and ee-3. The regulations directing the implementation of these statutes were
issued in 1975 and revised in 1987. They are found in the Code of Federal Regulations:
42 C.F.R. Part 2. A complete copy of these regulations can be found in Appendix C.
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Many States also have confidentiality laws that apply to substance abuse treatment.
These may afford individuals even greater privacy than the federal law. However, State
laws may not be less stringent than federal laws. If they are, the federal law (or the
more rigorous one) prevails. Violation of the regulations may result in fines up to $500
for a first offense and up to $5,000 for subsequent offenses.
The federal confidentiality law applies to all programs providing alcohol or drug abuse
diagnosis, treatment, or referral for treatment that are federally assisted. Included are
the following:
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programs receiving any type of federal funding;
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programs receiving tax exemption status through the Internal Revenue Service;
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programs authorized to conduct business by the federal government, such as
those licensed to provide methadone or those certified as Medicare providers;
and
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programs conducted directly by the federal government or State or local
governments that receive federal funds.
The primary intent of the confidentiality law is to prevent disclosure of information "both
written records and verbal information" that would identify a person as a patient
receiving alcohol or drug treatment. This protection is even extended to those who have
applied, but were not admitted to the program for treatment, and to former patients and
deceased patients. Not only are programs prohibited from disclosing information, except
under certain conditions to be discussed later, but they also are not allowed to verify
information that is already known by the person making an inquiry.
According to these regulations, the very fact that a person is a patient in a treatment
facility cannot be revealed, or denied, without the patient’s express written consent.
Thus, in response to inquiries about whether a particular person is a patient in such a
facility, one can only answer “according to Federal law, I can neither confirm nor deny
the presence of any client in our facility.” In addition, these regulations set forth a strict
standard for signed consents to disclose information - consent forms must specify what
information will be disclosed, to whom the disclosure will be made, and set a time limit
for such release of information. Too often, release of information forms used by
facilities are too general, in essence granting a blanket release of what information is
released without regards to time limitations. This is never appropriate.
Patients are entitled to notification of the federal confidentiality laws and regulations.
Programs should provide a written summary of these provisions upon admission. The
written summary should include:
• information about the circumstances in which disclosure can be made without the
patient's consent;
• a statement that violations of the regulations may be reported as a crime;
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• a warning that committing or threatening a crime on the program's premises or
against program staff can result in release of information;
• notification that the program must report suspected child abuse or neglect; and
• reference to the federal law and regulations.
Programs must keep patient records in a secure room, a locked file cabinet or other
similarly protected places. There should be written procedures concerning who has
access to patient records. A single staff member, often the director, should be
designated to handle inquiries and requests for information about patients.
Confidentiality vs. Privilege
“Privilege” is a legal term that refers to an individual’s right not to have confidential
information revealed in court or other legal proceedings. Most states have laws that
establish the “professional-patient privilege.” Thus, while the legal concept of privilege is
similar to the ethical concept of confidentiality, it is much narrower in scope and applies
specifically to situations involving court or other legal proceedings.
Ordinarily, the client is the “holder of the privilege”, which means that a therapist cannot
reveal confidential information in a legal proceeding unless the privilege has been
waived by the client. Privilege is waived when the client has consented to disclosure of
the information, when the client has disclosed a significant part of the information to a
third person, and in certain legally-defined situations, which vary from state to state,
such as when a client sues a counselor. Once the client has waived privilege, the
therapist has no grounds for withholding relevant information if asked to do so in court.
Even though chemical dependency counselors have a confidential relationship with their
clients, most states to not view this as privileged . Thus, when a chemical dependency
counselor is subpoenaed to testify in court or release a patient’s records to the court,
they usually cannot be excused from these obligations under the laws relating to
privilege. In some states, the law regarding privilege does apply to a person whom the
patient reasonably believes to be a licensed professional. Thus, under this stipulation of
law, communication between a patient and a licensed substance abuse counselor may
be privileged in some cases and in some states. It is the responsibility of the counselor
to be aware of state laws regarding privilege.
Exceptions to the General Confidentiality Conditions
Sometimes the good of the client, the protection of the public, and/or the law require or
permit a substance abuse counselor to breach a client’s confidentiality. The fact that
confidentiality is not an absolute requirement is reflected by Principle 8c of the
NAADAC’s Code of Ethics, which states that “The alcoholism and drug abuse counselor
should reveal information received in confidence only when there is clear and imminent
danger to the client or to other persons, and then only to appropriate professional
workers or public authorities.” Such issues as suicide, child abuse, or elderly abuse
would be grounds for breaching confidentiality.
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Although the degree to which one should, if ever, breach confidentiality in the
counseling relationship is a matter of great controversy, there is general agreement on
one point: the client has a right to know the limits that may exist with regard to the
confidentiality of information discussed in treatment. Ideally, a discussion of the limits of
confidentiality should take place during the intake or orientation process in the
counseling relationship. In addition, a facilities staff policy manual should indicate the
limits of confidentiality.
Under certain conditions, programs may disclose information about persons receiving or
applying for substance abuse treatment. These are described in the following sections.
Patient Consent
Patients may sign a consent form allowing for the release of information. However,
consent forms must contain specific information, including the following:
•program name;
• person or individual to receive the information;
• patient's name;
•purpose or need for the disclosure;
• the specific amount and kind of information to be released;
• a statement that the patient may revoke the consent at any time;
• date, event, or condition upon which the consent will expire;
• signature of the patient; and
• date upon which the consent is signed.
Only information that is necessary to accomplish the purpose stated in the form may be
released. Even if a properly-signed consent form is in force, programs are allowed
discretion about disclosing information, unless the form is accompanied by a subpoena
or court order. It is usually necessary for patients to sign separate consent forms for
each type of disclosure and for each person or organization to whom information is to
be released. However, if similar information will be released to the same
person/organization during the period the consent form is valid, signing a form for each
release is not required. This might occur with funding sources requiring verification of
treatment provided over the course of a person's enrollment in a treatment program. On
the other hand, if a different type of information is requested by the same
person/organization, a new consent form would be required.
Patients may revoke their consent at any time, either verbally or in writing. This does not
require the program to retrieve information disclosed when the consent form was valid.
If a patient revokes a consent form permitting disclosure of information to a third- party
payer, the program still may bill the payer for any services provided during the time the
consent form was valid. However, after revocation of consent, the program may not
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release information to third-party payment sources. If services continue to be provided,
the program risks not receiving reimbursement.
The expiration date of consent forms should be at a time that is reasonably necessary
to achieve the purpose for which they are signed. Rather than a specific date, consent
forms may expire when a certain event or condition occurs. For example, if information
is released to a physician the patient will see one time, the consent form may indicate
that it is valid until the patient's appointment with the doctor. On the other hand, a
consent form to provide verification of enrollment in the treatment program for an
employer, who has placed the person on probation pending treatment, may be in effect
until the end of the probationary period.
State laws are relied upon to determine the definition of minors and whether or not the
consent of a parent (or guardian or other person legally responsible for the minor) is
required for them to obtain substance abuse treatment. The regulations concerning
consent for release of information follow State laws: If State law requires parental
consent for treatment, then consent of both the minor patient and the parent (or
guardian) must be obtained to disclose information. However, regardless of the
requirement for parental consent, programs must always obtain the minor's consent for
disclosure. The parent's signature alone is not sufficient.
In States requiring parental approval for the treatment of minors, programs must obtain
the minor's consent before contacting a parent/guardian to obtain his or her permission
for treatment. However, if the program director determines that certain conditions exist,
s/he may contact the parent/ guardian without the minor's consent. In such cases, all of
the following conditions must be present:
• the minor is not capable of making a rational choice because of extreme youth or
mental or physical impairment;
• the situation presents a threat to the life or physical well-being of the youth or
another person; and
• the risk may be reduced by communicating relevant facts to the minor's
parent/guardian.
If these conditions are not present, the program personnel must inform the minor of his
or her right to refuse consent to communicate with a parent/guardian. However, the
program cannot provide services without such communication and parental consent. If
State law does not require parental permission for treatment, programs still may
withhold services from minors who will not authorize a disclosure so the program can
obtain financial reimbursement for treatment, as long as this does not violate a State or
local law.
Similarly, for adult patients who have been adjudicated incompetent, consent for
disclosure may be made by the person's guardian or authorized representative. In
situations in which a person has not been adjudicated incompetent but the program
director determines that his or her present medical condition interferes with the ability to
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understand and take effective action, the director may authorize disclosure without
patient consent only to obtain payment for services from a third-party payment source.
For deceased patients, disclosure may be authorized by the executor or administrator of
his/her estate, spouse, or a family member. Without such consent, programs may make
limited disclosures to comply with State or federal laws concerning collection of vital
statistics or to respond to inquiries into the cause of death.
Any time a program releases information about a patient, it must be accompanied by a
written statement indicating that the information is protected by federal law and the
recipient cannot make further disclosure unless permitted by the regulations.
At times, patients may consent to disclosure of information to employers. Often, this can
be limited to verification of treatment status or a general evaluation of progress. The
program should limit disclosure to only information that is related to the particular
employment situation.
Persons may be required to participate in treatment as a condition of probation or
parole, sentence, dismissal of charges, release from incarceration, or other criminal
justice dispositions. These patients also are entitled to protection of confidentiality, but
some special qualifications apply concerning the duration and revocability of consent. A
sample consent form for release of information for a criminal justice system referral is
shown on the next page.
Whenever a person moves from one phase of the criminal justice system to another, a
substantial change in status occurs. Until such a change occurs, consent forms cannot
be revoked. Criminal justice system consent forms can be irrevocable so that individuals
who agree to treatment in lieu of prosecution or punishment can be monitored.
However, the irrevocability of consent ends with the final disposition of the criminal
proceedings. Information obtained by criminal justice agencies can be used only with
respect to a particular criminal proceeding. It may be advisable for judges or criminal
justice agencies to require that the individual sign the necessary consent forms before
referral to a treatment program. If not, and the program is unable to obtain the
individual's consent for disclosure, it may be prevented from providing information to the
criminal justice agency that referred the patient to the program. Treatment programs are
allowed to apprise criminal justice agencies, without obtaining patient consent, if a
person referred for treatment by such agencies fails to apply for or receive services from
the program.
Because of the potential for abuse of methadone, these programs must take
precautions that patients are not enrolled in multiple programs. Patients can be required
to sign a consent form before they enter treatment to release information to a central
registry. If the registry receives information about the same person in more than one
program, each program may be notified so the problem can be resolved. Such consent
remains in effect as long as the patient is enrolled in the program.
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With a proper consent form, programs may release information to a patient's attorney.
However, the program may use discretion to limit its response. Some programs may be
concerned about potential lawsuits, but if they refuse to disclose information, attorneys
may subpoena the records.
Internal Communications
Information about a patient may be shared among staff within a program only if there is
a legitimate need for them to know it. When there is a need for internal communications,
information that is shared always should be specifically related to the provision of
substance abuse services being delivered.
When a program is part of a larger organization, such as a general hospital, community
mental health center, or school, necessary information may be disclosed to other
departments, such as central billing or medical records. However, any information that
is not necessary to other departments should not be disclosed.
Releasing Information to Other Professionals
Releasing information to professionals outside of a treatment setting can pose a number
of ethical difficulties for counselors. One reality of good clinical care is that in many
situations, clients are referred from one professional or agency to another for testing or
special services, or for follow-up care. Sharing of information among professionals or
agencies is often in the best interest of the client and, indeed, is necessary to bring the
optimum resources to aid the client’s recovery. Many times, information is also shared
in this way with spouses, parents, teachers, and other significant people. This kind of
information sharing should be done only with the client’s full knowledge and informed
consent.
Disclosures Without Identification of Patients
Programs may release information that does not identify an individual as a substance
abuser or verify someone else's identification of a patient. Reports of aggregate data
about a program's participants may be provided. Individual information may be
communicated in a manner that does not disclose that the person has a substance
abuse problem. For example, the program may disclose that a person is a patient in a
larger organization (e.g., general hospital, community mental health center, school)
without acknowledging that s/he has a substance abuse problem. Information may be
disclosed anonymously without identifying either the individual's status as a substance
abuse patient or the name of the program. Finally, an individual's case history may be
reported anonymously, provided information about the patient and the agency are
disguised sufficiently that the person's identity cannot be determined by a reader.
Medical Emergencies
In a situation that poses an immediate threat to the health of the patient or any other
individual, and requires immediate medical intervention, such as a dangerous drug
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overdose or an attempted suicide, necessary information may be disclosed to medical
personnel. Such a disclosure must be documented in the patient's records, including the
name and affiliation of the person receiving the information, the name of the person
making the disclosure, the date and time of the disclosure, and the nature of the
emergency. Programs should ask participants in advance to indicate a person to be
notified in the event of an emergency, and the patient should be asked to sign a consent
form allowing the program to notify the named person if an emergency should arise.
Even without patient consent, information may be disclosed to the federal Food and
Drug Administration if an error has been made in packaging or manufacturing a drug
used in substance abuse treatment and this may endanger the health of patients.
Court Orders
State and federal courts may issue orders authorizing programs to release information
that otherwise would be unlawful. However, certain procedures are required when such
court orders are issued. A subpoena, search warrant or arrest warrant alone is not
sufficient to permit a program to make a disclosure. First, a program and a patient
whose records are sought must be given notice that an application for the court order
has been made. The program and the individual must have an opportunity to make an
oral or written statement to the court about the application. If the purpose of the court
order is to investigate or prosecute a patient, it is only necessary to notify the program.
Before an order is issued, there must be a finding of good cause for the disclosure. If
the public interest and need for disclosure outweigh possible adverse effects to the
individual, the doctor-patient relationship, and the program's services, the order may be
issued. Information that is essential for the purpose of the court order is all that may be
released. Only persons who need the information may receive it. A court order may
require disclosure of confidential communications if one of the following conditions
exists:
• disclosure is necessary to protect against a threat to life or of serious bodily injury;
• disclosure is required to investigate or prosecute an extremely serious crime; or
• disclosure is necessary in a proceeding in which the patient has already provided
evidence about confidential communications.
Before a court order can be issued to release patient information for a criminal
investigation or prosecution, five criteria must be met. These are:
1. the crime is extremely serious (e.g., threatening to cause death or serious injury);
2. the records sought will probably contain information that is significant to the
investigation or prosecution of the crime;
3. there is no other feasible way to acquire the information;
4. the public interest in disclosure outweighs any harm to the patient, doctor-patient
relationship, and the agency's ability to provide services; and
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5. the program has an opportunity to be represented by independent counsel when
law enforcement personnel seek the order.
Ethical responsibilities regarding confidentiality often come into direct conflict with legal
requirements when a counselor or agency is served with a subpoena (a summons to
appear in court or release records to the court). Subpoenas may require a person to
appear to give testimony or to bring documents to a hearing. Although they may be
signed by a judge or other legal officials, subpoenas are not the type of court order
required by the confidentiality regulations. Thus, federal confidentiality laws and
regulations prohibit treatment programs from responding to subpoenas by disclosing
information concerning current or former patients. However, if the person about whom
the information is requested signs a proper consent form authorizing the release, the
program may do so. If a court order is issued after giving the program and patient an
opportunity to be heard, and after making a good cause determination, treatment
programs may respond to subpoenas.
In most cases, any part of a client’s formal file or record can be subpoenaed and placed
in evidence in a court of law. Counselors should be aware that such notes or reports are
not completely private. Caution should be taken when entering speculative remarks or
assigning labels to clients. If a counselor wishes to maintain privacy of certain interview
notes or other case materials, he/she should address notes as “memoranda to myself’
and not include them in the formal record. Such memoranda are not generally subjects
to subpoena although a counselor may be ordered in court to testify about their
contents.
Various authorities have attempted to resolve this complex issue. The following
guidelines are offered to chemical dependency counselors if their records are
subpoenaed:
1. Never ignore a subpoena - but this does not mean that you automatically respond
by releasing the information being requested;
2. Contact the lawyer who has issued the subpoena and determine the nature of the
subpoena (e.g., does it require attendance by the therapist and/or production of
records?);
3. After talking the matter over with the attorney, it may become apparent to the
lawyer that the information contained within your records would not be helpful to
the matter - in such cases, you will probably be asked to destroy the subpoena
and you will not have to follow its request;
4. If the subpoena is requesting records protected by the federal confidentiality
guidelines covering chemical dependency information, a subpoena will not be
sufficient to force releasing information - a court order, based upon a hearing, will
have to be issued before the records could be released;
5. Regardless of the nature of the subpoena, therapists should initially assert the
privilege not to reveal confidential information, if this is an available option -
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again, a hearing would need to be held and a court order would allow you to
release such information;
6. Therapists should immediately contact the client or client’s attorney. If the client
wants the therapist to testify or release the requested records, written consent
from the client should be obtained - if the attorney requesting information is not
representing your client, again it may be best to force the court to order the
release of any records - this is for your protection and for the protection of the
client.
Search warrants, similarly, may not be used to allow law enforcement officers to enter
the program's facilities. However, arrest warrants do permit law enforcement personnel
to search for a particular patient who has committed or threatened a crime on the
premises of the program or against program personnel. Unless the arrest warrant is
accompanied by a court order, the program may not cooperate with a search for a
patient who committed a crime elsewhere.
The “Duty to Warn”
The concept of the “duty to warn” stems from the California Supreme Court’s decision in
Tarasoff v. Regents of the University of California. In this case, a psychotherapy client
at U.C. Berkeley told his therapist that he intended to kill his girlfriend, Tanya Tarasoff.
Although Tarasoff was out of the country at the time, the therapist notified the police,
who took no action. The therapist subsequently destroyed his notes and did nothing
further to prevent the crime. When Tanya Tarasoff returned to the States, the client did,
in fact, kill her. Tarasoff’s parents sued on the grounds that the therapist and the
University had not adequately protected their daughter. They won the suit - the court
ruled that a psychotherapist must breach patient confidentiality when he/ she
determines that a patient is a danger to another person.
The “duty to warn” implies that when a therapist’s client is threatening violence to a
specific victim the therapist has a responsibility to warn both the intended victim and the
appropriate police officials of the danger. Although the therapist in the Tarasoff case
notified the police, he did not warn Tarasoff herself; this case, then, extended a
therapist’s responsibility to also include warning the intended victim.
This law only covers situations in which there is a “reasonably identifiable victim or
victims.” Sometimes a therapist may encounter a client who seems generally
dangerous, but a potential victim cannot
be precisely identified. In such cases, there is no clear legal guidance, but a breach of
confidentiality, if necessary to protect the public or the client, is usually considered to be
ethically justifiable. If the client’s dangerousness is due to a mental disorder, involuntary
hospitalization is also an option.
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That the duty to warn exists only when the client him/herself is the violent party - if a
client were to tell his/her therapist that he/she knew someone else who intended to
commit murder, the therapist’s legal obligation under duty to warn laws would not exist.
However, the therapist in such a case should encourage the client to report the threat to
the police or to take other appropriate action.
Although the “duty to warn” laws originated in California, many states now have similar
requirements. Unless your state specifically has passed legislation that limits the liability
of a chemical dependency counselor to warn potential victims of harm, it is your duty to
do so. In addition, it is always appropriate to tell your clients, both verbally and in
writing, that should they make threats of harm to others, you will report that information
to appropriate health care, law enforcement, or individual entities.
If a Client is Dangerous to Self
When a client threatens suicide, a therapist is ethically justified in breaking
confidentiality in order to protect the client - in other words, in such situations, a
counselor is ethically justified in disclosing confidential information if such disclosure is
deemed necessary to prevent the threatened danger.
Although there is no specific procedure outlined in the law, such as exists for child
abuse and elderly abuse reports or threats of violence to identifiable victims, because
the client is “dangerous to self,” substance abuse professionals are generally acting
within acceptable boundaries if they break confidence when a client is at risk for suicide.
Note that this option is generally interpreted to mean the therapist has a RIGHT rather
than a duty to disclose confidential information.
When a client is suicidal, a counselor’s ethical obligation is to do everything within
reason to prevent a suicide, with as little violation of the client’s privacy as possible. In
some cases, it may only be necessary to involve another professional or a family
member. In more extreme cases, a counselor or other member of an agency may need
to notify the police or an emergency psychiatric facility. If a substance abuse counselor
is not qualified or is unable to deal with a suicidal client, he/she should consult with
another professional when a client threatens suicide.
If a Client is Dangerous to Others
Ethical principles permit a breach of confidentiality when a client poses a danger to
others. In situations where a client has threatened violence towards an identifiable
victim, a counselor or agency may be bound by “duty to warn” laws, as previously
noted. If these laws do not apply, counselors are still ethically justified in breaching
confidentiality if such a breach can prevent the threatened danger. If a client is
considered dangerous but a specific victim cannot be identified, a counselor is ethically
justified in choosing to breach confidentiality if such a breach can prevent the
threatened danger. As with threats of suicide, a breach of confidentiality in these cases
is an option rather than a legally-mandated duty.
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In both of these situations, any breach of confidentiality should respect the privacy of
the client to the greatest degree possible. For example, a substance abuse counselor
might contact another professional with more expertise before calling the police. If the
police are brought in, they should only be given information that is necessary to prevent
the threatened danger.
Crimes at the Program or Against Program Staff
A program may report, or seek assistance from law enforcement agencies, when a
patient commits or threatens to commit a crime on the program's premises or against
program personnel. Information that may be disclosed includes the suspect's name,
address, last known whereabouts, and status as a patient in the program.
Information a patient may divulge about crimes or threats to persons away from the
program present special dilemmas. In some States therapists are liable if they fail to
warn someone that a patient has threatened to harm him or her. At the same time, the
federal regulations, which override State laws, prohibit disclosures that identify
substance abuse patients unless they are made pursuant to a court order or without
identifying the patient. Such circumstances require knowledge of the applicable State
and federal laws and a balancing of moral and legal obligations. If possible, the best
solution may be for the program to try to make the warning in a manner that does not
identify the individual as a substance abuser.
Public Presentation of Client Information
Principle 8e of NAADAC’s Code of Ethics requires that counselors obtain prior consent
and/or disguise all identifying data before publicly presenting information gained in a
professional relationship. If, for example, a counselor functioning as both a counselor
and a instructor at a training institute, college or university were to substantiate lecture
material with case examples using actual client information, he/she would need to
carefully disguise all information that might identify individual clients. If possible, a
signed release or consent would also be advisable.
Third Party Payers
Frequently, the costs of treatment are paid by someone other than the client, such as
parents, spouses, employers, and insurance companies. Often such individuals or
organizations feel that they have a right to obtain information about the client or even to
influence the course of treatment. While certain information may be necessary, clearly
their involvement does not provide them with any rights of access to confidential
information. Information should be made available only at the client’s request, or when
the client consents to have it released at the request of another, and when it is in the
client’s best interests. In addition, the counselor should clarify with all involved parties
the conditions surrounding the release of information. This clarification should take
place at the beginning of the counseling relationship.
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This issue becomes somewhat sticky when it comes to insurance companies. Insurance
forms are processed in a variety of ways, involving many persons and agencies. These
forms may be seen by clerks and agents of insurance companies and/or their
intermediaries. They may also be processed through the client’s employer. There is,
therefore, no way to assure confidentiality in the usual sense. A DSM diagnosis usually
must appear on the insurance claim form. This requirement mandates involving the
client in a discussion of the availability of his/her diagnosis to others and of the issue of
confidentiality in general. Practitioners must take every precaution regarding who will
see such information. However, there is no absolute guarantee of confidentiality by
either employers or insurance companies. Again, these issues should be discussed with
clients and the client’s signed consent to release information should be obtained.
Research and Audits
Researchers may obtain patient-identifying information if certain precautions are
applied. The research protocol must ensure that information will be securely stored and
not redisclosed except as allowable under the federal regulations. Confidentiality
safeguards must be approved by an independent body of three or more persons.
Researchers are strictly prohibited from redisclosing patient information. Reports of the
research must not identify a patient, directly or indirectly.
Government agencies, third-party payers and peer review organizations may need to
review program records without patient consent to conduct an audit or evaluation.
Those persons involved in such activities must agree in writing that they will not
rediclose patient identifying information unless it is pursuant to a court order to
investigate or prosecute the program (not a patient). A government agency that is
overseeing a Medicare or Medicaid audit or evaluation also may receive patient
information.
Child Abuse/Elderly Abuse
As indicated, substance abuse professionals are legally obligated to breach
confidentiality when, in a professional capacity, they acquire knowledge or suspicion of
child abuse or neglect or elderly abuse or neglect. Reports are made to the appropriate
state agencies or authorities. Laws related to child abuse and elderly abuse reporting
generally includes penalties for failure to report and provide immunity for the reporter
from criminal and civil liability. Note that when reporting suspected child abuse or elderly
abuse, the professional must report only the information required by law.
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Laws pertaining to the reporting of abuse are somewhat controversial. It has been noted
that determination of abuse or potential for abuse is subjective, that the potential breach
of confidentiality can have detrimental effects on the therapeutic relationship between a
therapist and the abuser or abused individual, and that such laws create the ethical
dilemma of whether or not a therapist must warn clients of the limits of confidentiality
prior to treatment. In addition, some have argued that these laws make abusers
reluctant to seek treatment and therefore fail to result in a long-term reduction in child
abuse and elderly abuse. Regardless, counselors must follow the law and report known
or suspected incidents of child abuse or elderly abuse to appropriate state authorities.
Qualified Service Organization Agreement
A service organization is a person or agency providing services to the program.
Examples include data processing, dosage preparation, laboratory analyses, vocational
counseling, accounting, and other professional services. A qualified service organization
agreement (QSOA) is a written agreement, between two parties only, acknowledging
that the service organization is fully bound by the confidentiality regulations when
dealing with information about patients from the program. It further must promise to
resist efforts to obtain access to information about patients, except as permitted by the
regulations. A sample form for a qualified service organization agreement is provided on
the following page.
Confidentiality and Other Diseases
Doctor-patient privilege is an accepted practice in medical treatment. In most cases,
medical personnel are ethically bound not to divulge information about their patients'
medical conditions. However, confidentiality requirements for most medical situations
are not nearly as stringent as those that apply to substance abuse treatment programs.
For example, generally, physicians are not restricted from acknowledging that an
individual is a patient, as is the case with substance abuse treatment.
For substance abuse treatment programs, there are some special considerations when
patients have specific diseases. The medical emergency exception to confidentiality
does not apply to reporting the results of venereal disease tests to public health officials,
as this does not present an immediate medical danger. Thus, these diseases are not
reportable by substance abuse treatment programs (Legal Action Center, 1991).
There are some special considerations related to HIV disease, which is also a highly
stigmatized illness requiring strict patient confidentiality. All States mandate that cases
of AIDS be reported to public health authorities who subsequently report them to the
federal Centers for Disease Control and Prevention. Some States also require that
positive tests for HIV be reported. Sometimes information is used for tracing and
contacting persons who might have been exposed to HIV by the patient, constituting a
duty to warn. This may pose conflicting legal obligations for programs to report such
information and maintain patient confidentiality. In some cases, anonymous reports can
be made using codes rather than patient names. It also may be possible to get patient
consent to make mandated reports. Some programs enter into qualified service
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organization agreements, and the necessary information is reported by a laboratory or
medical care provider without identifying the individual as a recipient of substance
abuse treatment. In the event that substance abuse treatment records must be released
with patient consent or by a court order, programs may need to take precautions not to
reveal HIV status inadvertently. Such release of information about HIV status to
insurers, employers, and others could have serious ramifications for the infected
individual. Ways to avoid unnecessary release of HIV information include maintaining a
separate medical file which is not released, releasing the file without the HIV-related
information, or having the individual sign a consent form authorizing the release of HIVrelated information (Legal Action Center, 1991).
Client Welfare and Client Relationships
Dealing with Transference and Countertransference
We include a discussion of transference and countertransference because of our
assumption that if these factors are not attended to, the client's progress will be
impeded. Therapists inevitably have to come to grips with these issues regardless of
their therapeutic orientation. Although the terms transference and counter-transference
are derived from psychoanalytic theory, they are universally applicable to counseling
and psychotherapy (Gelso & Carter, 1935). They are used to refer to the client's general
reactions and orientation to the therapist and to the therapist's reactions in response.
Conceptualizing transference and counter-transference broadly, Gelso and Carter
assume that these processes are universal and that they occur, to varying degrees, in
most relationships. The therapeutic relationship intensifies the natural reactions of both
client and therapist. The ways in which practitioners handle both their feelings and their
clients' feelings will have a direct bearing on therapeutic outcomes. Because dealing
with such feelings ineffectively is likely to block successful therapy, this matter has
implications from both an ethical and a clinical perspective.
According to Deffenbacher (1985), a good cognitive-behavioral therapist works to
build rapport, lessen interpersonal anxiety in the relationship, increase trust, and create
a climate that invites open discussion and therapeutic work. Cognitive behavioral
therapists use themselves and the relationship with their client to achieve the aims of
therapy. Yet in many cases this working alliance is insufficient to bring about change. If
a client looks on a therapist as cold and distant and the therapist is unaware of or
ignores this perception, therapeutic outcomes are likely to suffer. Some people in a
client's life may have been cold and critical, which would certainly have an impact on the
client in therapy, regardless of the therapist's orientation. This learning history would
explain the client's sensitivity to the real or imagined coldness of the therapist.
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Transference: The 'Unreal' Relationship in Therapy
Transference refers to the process whereby clients project onto their therapist
past feelings or attitudes they had toward significant people in their lives. Transference
typically has its origin in early childhood, and it constitutes a repetition of past conflicts.
Through this process clients' unfinished business produces a distortion in the way they
perceive and react to the therapist. The feelings that they experience in transference
may include love, hate, anger, ambivalence, or dependency. The essential point is that
these feelings are rooted in past relationships but are now directed toward the therapist.
Gelso and Carter (1985) refer to transference as the "unreal" relationship, because such
projections are in error, even though the therapist's actions may serve to trigger them.
Transference entails a misperception of the therapist, either positive or negative.
Watkins (1983) identifies the following five transference patterns in counseling
and psychotherapy:
1. Counselor as ideal. The client sees the counselor as the perfect person who
does everything right, without flaws. Psychoanalytically, the counselor is given
an idealized image, which may be the way the client viewed his or her parents
at one time. The danger here is that counselors, their egos fed, can come to
believe these projections! Yet not challenging clients to work through these
feelings results in infantilizing them. When clients elevate the therapist, they
put themselves down. They lose themselves by trying to be just like their ideal.
2. Counselor as seer. Clients view the counselor as expert, all-knowing, and allpowerful. They look to the counselor for direction, based on the conviction that
the counselor has all the right answers and that they themselves cannot find
their own answers. Again, a danger is that the counselor may feed on this
projection and give clients advice based on his or her own need to be treated
as an expert. The ethical issue here is that clients are encouraged to remain
dependent.
3. Counselor as nurturer. Some clients look to the counselor for nurturing and
feeding, as a small child would. They play the helpless role, and they feel that
they cannot act for themselves. They may seek touching and hugs from the
therapist. A danger here is that the counselor may get lost in giving sympathy
and feeling sorry for the client. The counselor may become a nurturing parent
and take care of the client. In the process, the client never learns the meaning
of personal responsibility.
4. Counselor as frustrator. The client is defensive, cautious, and guarded and is
constantly testing the counselor. Such clients may want advice or simple solutions and may expect the counselor to deliver according to their desires. They
may be frustrated if they don't receive such prescriptions. Counselors need to
be aware that merely providing easy solutions will not help the client in the
long run, and they should be careful not to get caught in the trap of perceiving
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this client as fragile. Also, it is essential that counselors avoid reacting
defensively to the client, a response that would further entrench the client's
resistance.
5. Counselor as nonentity. In this form of transference the client regards the
counselor as an inanimate figure without needs, desires, wishes, or problems.
These clients use a barrage of words and keep their distance with these outbursts. The counselor is likely to feel overwhelmed and discounted. If
counselors depend on feedback from their clients as the sole means of
validation of their worth as counselors, they may have difficulty in managing
cases in which this phenomenon exists.
The potential effect of transference in these examples shows how essential it is
for counselors to be clearly aware of their own needs, motivations, and personal
reactions. If they are unaware of their own dynamics, they will avoid important
therapeutic issues instead of challenging their clients to understand and resolve
the feelings they are bringing into the present from their past.
Transference is not a catch-all intended to explain every feeling that
clients express toward their therapists. For example, if a client expresses anger
toward you, it may be justified. If you haven't been truly present for the client,
instead responding in a mechanical fashion, your client may be expressing
legitimate disappointment. Similarly, if a client expresses affection toward you,
these feelings may be genuine; simply dismissing them as infantile fantasies can
be a way of putting distance between yourself and your client. Of course, most of
us would probably be less likely to interpret positive feelings as distortions aimed
at us in a symbolic fashion than we would negative feelings. It is possible, then,
for therapists to err in either direction-to be too quick to explain away negative
feelings or too willing to accept whatever clients tell them, particularly when they
are hearing how loving, wise, perceptive, or attractive they are. In order to
understand the real import of clients' expressions of feelings, therapists must
actively work at being open, vulnerable, and honest with themselves. Although
they should be aware of the possibility of transference, they should also be
aware of the danger of discounting the genuine reactions their clients have
toward them.
We will now present a series of brief, open-ended cases in which we ask
you to imagine yourself as the therapist. How do you think you would respond to
each client? What are your own reactions?
Your client, Shirley, seems extremely dependent on you for advice in making
even minor decisions. It is clear that she does not trust herself and that she often
tries to figure out what you might do in her place. She asks you personal
questions about your marriage and your family life. Evidently, she has elevated
you to the position of one who always makes wise choices, and she is trying to
emulate you in every way. At other times she tells you that her decisions typically
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turn out to be poor ones. Consequently, when faced with a decision she
vacillates and becomes filled with self-doubt. Although she says she realizes that
you cannot give her "the" answers, she keeps asking you what you think about
her decisions.




How would you deal with Shirley? What would you say to her?
What direction would you take in trying to understand her dependence and
lack of self-trust?
How would you respond to her questions about your private life?
If many of your clients expressed the same thoughts as Shirley, what
elements in your counseling style might you need to examine?
Marisa says she feels let down by you. She complains that you are not available
and asks if you really care about her. She also says she feels that she is "just
one of your caseload." She tells you that she would like to be more special to
you.



How would you deal with Marisa's expectations?
How would you explain your position?
How would you explore whatever might be behind her stated feelings instead
of defending your position?
Would you be inclined to tell her how she affected you?
Carl seems to treat you as an authority figure. He once said that you were always
judging him and that he was reluctant to say very much because you would
consider everything he said to be foolish. Although he has not confronted you
directly since then, you sense many digs and other signs of hostility. On the
surface, however, Carl seems to be trying very hard to please you by telling you
what he thinks you want to hear. He seems convinced that you will react
negatively and aggressively if he tells you what he really thinks.



How would you respond to Carl?
How might you deal with his indirect expressions of hostility?
How might you encourage him to express his feelings and work through
them?
Countertransference: Ethical and Clinical Implications
So far we have focused on the transference feelings of clients toward their
counselors, but counselors also have emotional reactions to their clients, some of which
may involve their own projections. It is not possible to deal fully here with all the
possible nuances of transference and countertransference. Instead, we focus on the
improper handling of these reactions in the therapeutic relationship, a situation that
directly pertains to ethical practice.
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Countertransference can be considered, in the broad sense, as any projections
by a therapist that can potentially get in the way of helping a client. For instance,
counselor anxiety, the need to be perfect, or the need to solve a client's problems might
all be manifestations of countertransference. It is essential that therapists deal with
these reactions in some form of supervision or consultation so that "their problem" does
not become the client's problem. It may be helpful to consider the countertransference
material being stirred up as a way of interpreting subtle messages from the client. The
client might actually want a "cold therapist," for instance, because of a fear that more
difficult material would surface if the therapist were warmer. If a therapist becomes
frustrated with a client, it could be that this client, because of anxiety, wants progress to
stop.
It is clear, then, that countertransference can be either a constructive or a
destructive element in the therapeutic relationship. From a constructive perspective, a
therapist's countertransference can illuminate some significant dynamics of a client. A
client may actually be provoking reactions in a therapist by the ways in which he or she
makes the therapist into a key figure from the past. The therapist who recognizes these
patterns can eventually help the client change old and dysfunctional themes.
Destructive countertransference occurs when a counselor's own needs or unresolved
personal conflicts become entangled in the therapeutic relationship, obstructing or
destroying a sense of objectivity. In this way, countertransference becomes an ethical
issue.
Regardless of how self-aware and insightful counselors are, the demands of
practicing therapy are great. The emotionally intense relationships that therapists
develop with their clients can be expected to tap into their own unresolved conflicts.
Because countertransference may be a form of identification with the client, the
counselor can easily get lost in the client's world and thus be of little therapeutic value.
When counselors become so concerned with meeting their own needs that they use the
client for this purpose, their behavior becomes unethical.
Thus, ethical practice requires that counselors remain alert to their emotional
reactions to their clients, that they attempt to understand such reactions, and that they
do not meet their own needs at the expense of their clients' needs. Questions
counselors might ask of themselves are "What am I feeling when I'm with this person?
What am I experiencing? What do I want to say and do? What am I aware of not saying
to the client? Do I find myself hoping the client will fail to show up? Do I find myself
wanting the client to stay longer?" If counter-transference is recognized by counselors,
they can seek supervision as one way of sorting out their feelings.
In writing about the dynamics of countertransference, Gelso and Carter (1985)
comment:
In fact, we think that facing, and indeed inspecting, countertransference-based
feelings is one of the most difficult tasks of the therapist. It requires considerable
courage and a willingness to deal with one's own painful feelings for the sake of
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the therapeutic work. There are no easy answers to the question of how to
accomplish this, but at the same time doing so is a crucial aspect of effective
therapy [pp. 182-183].
Countertransference can show itself in many ways. All of the examples in the
following list present an ethical issue, because the therapist's effective work is
obstructed by countertransference reactions:
1. Being overprotective with clients can reflect a therapist's deep fears. A counselor's unresolved conflicts can lead him or her to steer clients away from those
areas that open up the therapist's painful material. Such counselors may treat
some clients as fragile and infantile, softening their remarks. They thus protect
these clients from experiencing pain and anxiety and may thwart them in their
struggle. Because the clients are not challenged to deal with their conflicts, they
are likely to avoid them.


Are you aware of reacting to certain types of people in overprotective
ways? If so, what might this behavior reveal about you?
Do you find that you are able to allow others to experience their pain, or
do you have a tendency to want to take their pain away quickly?
2. Treating clients in benign ways may stem from a counselor's fears of their anger.
To guard against this anger, the counselor creates a bland counseling atmosphere. This tactic results in exchanges that are superficial. Watkins (1985)
mentions the danger of losing therapeutic distance, with the result that the
client/counselor interchange degenerates into either a friendly conversation or a
general "rap session.


Do you ever find yourself saying things to guard against another's anger?
What might you say or do if you became aware that your exchanges with
a client were primarily superficial?
3. Rejection of clients may be based on perceiving them as needy and dependent.
Yet instead of moving toward them to protect them, the counselor moves away
from such clients. The counselor remains cool and aloof, keeps distant and
unknown, and does not let clients get too close (Watkins, 1985).


Are there certain types of people whom you find yourself wanting to move
away from?
What can you learn about yourself by looking at those people whom you
are likely to reject?
4. The need for constant reinforcement and approval can be a reflection of
countertransference. Just as clients may develop an excessive need to please
their therapist in order to feel liked and valued, therapists may have an inordinate
need to be reassured of their effectiveness. Many beginning practitioners expect
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instant results with their clients. When they do not see immediate positive results,
they become discouraged and anxious. If a client is not getting better, they fear
that the client will not like them. They engage in self-doubt and wonder about their
therapeutic effectiveness.


Do you need to have the approval of your clients? How willing are you to
confront them even at the risk of being disliked?
What is your style of confronting a client? Do you tend to confront certain
kinds of clients more than others? What does this behavior tell you about
yourself as a therapist?
5. Therapists' seeing themselves in their clients is another form of countertransference. This is not to say that feeling close to a client and identifying with that
person's struggle is necessarily an instance of countertransference. However, one
of the problems that many beginning therapists have is identifying with clients'
problems to the point that they lose their objectivity. They become so lost in a
client's world that they are unable to distinguish their own feelings. Or they may
tend to see in their clients traits that they dislike in themselves. Sometimes the
particularly "difficult" client can function as a mirror for the counselor. There are
many "difficult" clients, a few of whom exhibit behaviors such as extreme
resistance, silence, lack of motivation, and annoying mannerisms. The very
behaviors in these clients that counselors react to most strongly are often the very
traits that they dislike in themselves. Thus, an overly demanding client who never
seems satisfied with what his or her therapist is doing can be a reminder of the
therapist's own demanding nature.


Have you ever found yourself so much in sympathy with others that you
could no longer be of help to them? What would you do if you felt this way
about a client?
From an awareness of your own dynamics, list some personal traits of
clients that would be most likely to elicit over-identification on your part.
6. One of the common manifestations of countertransference is the development of
sexual or romantic feelings between clients and therapists. Therapists can exploit
the vulnerable position of their clients, whether consciously or unconsciously.
Seductive behavior on the part of a client can easily lead to the adoption of a
seductive style by the therapist, particularly if the therapist is unaware of his or her
own dynamics and motivations. On the other hand, it's natural for therapists to be
more attracted to some clients than to others, and these sexual feelings do not
necessarily mean that they cannot counsel these clients effectively. More
important than the mere existence of such feelings is the manner in which
therapists deal with them. Feelings of attraction can be recognized and even
acknowledged frankly without becoming the focus of the therapeutic relationship.
The possibility that therapists' sexual feelings and needs might interfere with their
work is one important reason why therapists should experience their own therapy
when starting to practice and should consult another professional when they
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encounter difficulty because of their feelings toward certain clients. Besides being
unethical and counter-therapeutic, it is also illegal in many states to sexually act
out with clients.


What do you think you would do if you experienced intense sexual feelings
toward a client?
How would you know if your sexual attraction to a client was countertransference or not?
7. Countertransference can also take the form of compulsively giving advice. A
tendency to advise can easily be encouraged by clients who are prone to seek
immediate answers to ease their suffering. The opportunity to give advice places
therapists in a superior, all-knowing position-one that some of them can easily
come to enjoy-and they may delude themselves into thinking that they do have
answers for their clients. They may also find it difficult to be patient with their
clients' struggles toward autonomous decision making. Such counselors may
engage in excessive self-disclosure, especially by telling their clients how they
have solved a particular problem for themselves. In doing so, the focus of therapy
tends to shift from the client's struggle to the needs of the counselor. Even if a
client has asked for advice, there is every reason to question whose needs are
being served when a therapist falls into advice giving.


Do you ever find yourself giving advice? What do you think you gain from
it? In what ways might the advice you give to clients represent advice that
you could give yourself?
Are there any times when advice is warranted? If so, when?
8. A desire to develop social relationships with clients may stem from countertransference, especially if it is acted on while therapy is taking place. Clients
occasionally let their therapist know that they would like to develop a closer relationship than is possible in the limiting environment of the office. They may, for
instance, express a desire to get to know their therapist as "a regular person."
Even experienced therapists must sometimes struggle with the question of
whether to blend a social relationship with a therapeutic one. When this question
arises, therapists should assess whose needs would be met through such a
friendship and decide whether effective therapy can coexist with a social relationship. Mixing personal and professional relationships often ends up in souring
the relationship. At this point, some questions that you might ask yourself in this
context are:



If I establish social relationships with certain clients, will I be as inclined to
confront them in therapy as I would be otherwise?
Will my own needs for preserving these friendships interfere with my
therapeutic activities and defeat the purpose of therapy?
Am I sensitive to being called a "cold professional," even though I may
strive to be real and straightforward in the therapeutic situation?
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
Why am I inclined to form friendships with clients? Does this practice
serve my own or my clients' best interests?
Clarifying the Nature of Professional Relationships
Principle 7a of NAADAC’s Code of Ethics requires counselors to take responsibility for
clarifying all relationships when other parties have an interest in the client-counselor
relationship. This requirement can apply in a variety of situations, including the provision
of services to employees through EAP’s, the treatment of one member of a family at the
request of another member, or the treatment of a client whose therapy is being paid for
by someone else. In each situation, the counselor has an obligation to clarify the nature
of the relationships between all parties concerned. For example, if an organization
referred an ineffective employee to a counselor for evaluation, the counselor has an
obligation to inform the employee of the nature of the evaluation and the possible
implications it may have for his continued employment. Conversely, if a counselor is
treating an adult client whose treatment is being paid for by a family member, the client,
as an adult, has a full right to a confidential relationship with the counselor. The fact that
another family member is paying for treatment does not affect the confidential nature of
the client-counselor relationship.
Terminating Counseling Relationships
Principle 7c stipulates that counselors must terminate clinical or counseling
relationships when clients are not benefiting from them. The two issues related to this
requirement include the treatment of particularly difficult clients and the failure of
counselors to terminate a nonbeneficial therapeutic relationship. Counselors have a
responsibility to recognize their professional and personal limitations. They must know
when not to accept clients they are not prepared to treat and when to refer clients
elsewhere. In cases where counselors are confronted with patients they are unable to
treat, it is essential that they minimize the risk and discomfort to clients. In these
situations, referrals should always be made appropriately and quickly.
Ethical problems also arise when the client is encouraged or allowed to remain in
treatment beyond the point of benefiting from it. Counselors should be aware of issues
such as dependency on the part of a client or personal bias on their part in making
decisions for appropriate termination. When legitimate doubts arise regarding the
client’s therapeutic needs, they should be discussed with the client and often, the client
should be referred elsewhere for consultation. When a client does not show
improvement or seems to be getting worse, the counselor should seek consultation
and/or an appropriate means to terminate therapy and arrange for referral.
Sexual Intimacies with Clients
The statement “the alcoholism and drug abuse counselor should not engage in any type
of sexual activity with a client” (Principle 9d) implicitly recognizes that any behavior of
this nature represents taking advantage of a position of power.
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Clearly, any sexual relationship with a client is unethical. There are no ethically valid
exceptions to this Principle. Yet this area continues to be one of the highest areas of
ethical violations. A combination of a professional and sexual relationship with a client
represents a “dual relationship,” which violates both professional and ethical
obligations. Such relationships are likely to have adverse consequences on the client. A
survey of mental health professionals conducted by a task force of the California State
Psychological Association found adverse effects stemming from these types of sexual
relationships for over one-third of the clients involved. Sexual relationships with clients
increase a counselor’s vulnerability to malpractice suits as well as criminal charges.
Many states have laws that explicitly prohibit sexual relationships between
psychotherapists and clients.
Another related aspect of client exploitation is sexual harassment. Unwanted attention,
remarks, gestures, “off-color” jokes, or unwanted touching can all be interpreted as
sexual harassment. Conduct by a professional that may be interpreted as sexual
harassment is unethical and unprofessional, and it serves to bring both the counselor
and the profession into disrepute.
A particularly problematic issue is whether or not it is ethical for a counselor to become
sexually involved with a former client. While such a relationship is not clearly prohibited
by either legal or ethical provisions, sexual intimacies between therapists and
“terminated” clients seem questionable for several reasons - for example, it is difficult to
determine when a “terminated” client is actually terminated (former clients may relapse
and return for counseling), and it may be impossible for the counselor-client relationship
to be transformed into a personal relationship where each person has an equal voice in
determining the direction the relationship takes.
Other Dual Relationships
Providing therapy to friends, relatives, students, and colleagues represents another type
of dual relationship cautioned against in Principle 9c. Sometimes, the performance of
multiple functions in an organization can pose problems with regard to this prohibition.
Clearly, a counselor can retain his/her objectivity if he/she is an administrator as well as
a counselor. However, if a counselor has been hired to train and supervise interns and
to provide counseling to the organization’s staff and their families, then dual
relationships will exist that can compromise the effectiveness of treatment.
Socializing with clients presents another ethical dilemma. If the opportunity to enter into
a social relationship with a client exists, a counselor should reject this opportunity. This
serves to protect the counselor’s objectivity in the therapeutic relationship as well as to
reduce potential harm to the client. Counselors need to be aware of the dynamics of
transference and counter transference, and strive to avoid fostering a dependent
relationship that, while flattering to the counselor, could stunt the patient’s growth and
recovery.
Social relationships with clients may be somewhat difficult to avoid if the counselor is a
recovering addict and participates in the same 12-step or similar group as his/her
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clients. If this is the case, the counselor should use common sense and try to keep
social contact to a minimum and under no circumstance should a counselor act as a
sponsor for a client.
Competence and Responsibility
The Beginning Counselor
The issue of competence is a difficult one for the beginning counselor. A lack of
experience with a wide variety of treatment issues is unavoidable in the early stages of
professional development. Beginning counselors must be aware of and sensitive to this
issue and determine when consultation and clinical supervision will allow them to
adequately treat clients versus when co-therapy or referral is required.
Limitations of Therapeutic Techniques
Principle 3c of NAADAC’s Code of Ethics states that “The alcoholism and drug abuse
counselor should recognize boundaries and limitations of the counselors competencies
and not offer services or use techniques outside of these professional competencies.”
This issue is of growing concern for the profession. Various controversial therapies,
treating such issues as repressed memory and post traumatic stress syndrome, have
gathered a great deal of attention. Many professionals, without adequate training or
supervision, are attempting to perform such treatment, causing great harm to their
clients. In addition, many counselors, in an attempt to increase caseloads, are
providing care in areas outside their scope of practice. With the expansion of
“addiction” definitions, including such areas as gambling, sexual behaviors, and eating,
many chemical dependency counselors are attempting to use techniques from their
knowledge of alcohol and drugs in these areas as well. It is important that chemical
dependency counselors recognize their limitations and not attempt to perform services
for which they have no training or clinical experience.
Continuing Education
Addiction counseling is a rapidly changing and highly complex profession. Thus,
substance abuse counselors must take it upon themselves to keep up with new
developments in the field by, for example, reading professional journals and new books
regularly, attending conventions and workshops, and taking
additional courses. This requirement is found in Principle 3 of NAADAC’s Code of
Ethics, which in part states that “The counselor should recognize the need for ongoing
education as a component of professional competency.”
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Licensure laws or certification standards require counselors to complete a certain
amount of continuing education coursework in order to remain licensed and/or certified.
Unfortunately, many counselors delay their education until absolutely necessary. Even
though most relicensure or recertification standards require a minimum number of
educational hours be taken, remember that the word is minimum. If more hours are
needed to stay current of new information and techniques, it is the responsibility of the
counselor to upgrade their skills and knowledge on an ongoing basis.
Working With Unfamiliar Populations
Limitations to professional competence can at times include an unfamiliarity
with the population one is treating or researching (e.g.. a cultural minority, a
member of a particular religious group). Counselors are obligated to obtain the
necessary guidance and/or additional training required to assure competent
treatment or research related to such populations. If a counselor feels
uncomfortable, for whatever reason, working with a member of a particular
group, the counselor should seek consultation or make an appropriate referral.
Coursework in cultural awareness or on special populations should be a must
for all counseling professionals.
Because of the importance and difficulty that many counselors experience in this area,
we’ll take a look at four cases that help illustrate some of the problems and issues with
this topic area.
Case One: Cultural Diversity
“The clash of worldviews, values and lifestyles is inescapable for therapists not only in
their personal lives, but their professional ones as well. It will be impossible for any of
us not to encounter client groups who differ from us in terms of race, culture, and
ethnicity. Increasingly, therapists will come into contact with culturally different clients
who may not share their worldview of what constitutes normality-abnormality; who
define helping in a manner that contrasts sharply with our codes of ethics and standards
of practice; and who require culture-specific strategies and approaches….” (Sue and
Sue, 1999,p. 10)
Discussion questions:



In response to the above quote, list the different characteristics of clients you are
currently seeing in your practice.
What is one of the ethical dilemmas you identify?
If you are not currently practicing, what type of client do you think you might have
difficulty in treating?
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Case Scenario
Sharon is providing group counseling in her agency for parents whose children have
learning problems. Her co-therapist is Joe. She is African American and Joe is
Caucasian. The group clients are from various cultures. The group has been meeting
for several weeks without any participation from Kwan.
Tonight, Joe and Sharon both get frustrated as their attempts fail to get Kwan, a Korean
client who is a single parent, to talk in the group. Afterwards, Sharon suggests to Joe
that she should meet one on one with Kwan. She believes further assessment is
needed as to his appropriateness for the group and wonders if there could be a
language problem. Joe argues that she would be reinforcing his lack of participation and
forming an unhealthy bond that could hurt the group process.
He says they need to address her concerns with Kwan in the group next week.
What are your reactions to this scenario?
What are the ethical concerns?
Case Scenario Discussion
Joe is responding in a traditional group counseling model that works for many
populations but may not be the best approach for Kwan. The underlying belief is that
people benefit from being in a group together to discuss problems they have in
common. Although Sharon is trying to meet Kwan’s needs, she is blaming the client for
not being “appropriate” rather than looking at the treatment approach as culturally
insensitive.
Without knowing much about Kwan, we have to generalize about what may be
occurring. If he is first generation Korean, it may be a language problem as Sharon
suggested. Ideally this would have been identified in his initial assessment but whoever
did that may not have been trained to ask about that or Kwan may have brought an
English-speaking family member with him. The assessment may have been primarily
written and Kwan can read and write English but has limited verbal skills. Sharon’s idea
of further assessment is a good first step.
Another possibility is that Kwan may hold a belief that his family problems should not be
discussed with strangers. Even though the group has met for a few weeks and the
counselors believe trust has been established, that may not be enough time for a client
from another culture to develop enough trust to participate in this group. If this is the
problem then Joe’s idea to discuss Kwan’s lack of participation in the group would not
be the best intervention.
If he is the only Korean client in the group, he may feel isolated and different and not be
speaking for that reason. He may hold beliefs about parenting that are different from
others in the group and not want to speak because of this. Or he may view the
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counselors as authority figures and believe it is disrespectful to speak to them as others
in the group do.
Kwan may also have been traumatized. Many clients who immigrate to America have
been through difficult experiences either in their own country or in the process of their
travels. In addition, he may have experienced discrimination or abuse by a Caucasian
or African-American and is afraid of the counselors.
The ethical concerns are access to treatment (justice), client welfare (beneficence) and
competence. Is Kwan going to get what he needs as a parent and will his family benefit
from his treatment experience? Are Sharon and Joe trained to address the needs of a
Korean client?
One plan would be to proceed with an individual meeting and if Sharon or Joe is not
adequately trained to do this, to seek consultation or supervision. In this meeting the
goal would be to identify what are the issues preventing Kwan from participating in the
group. If after the assessment it appears Kwan’s needs cannot be met at this agency,
Sharon or Joe should check into resources in the Korean community that could benefit
this family and make a referral.
Sharon and Joe also have ethical obligations to the group. Having a group member
leave is often a dilemma in that group members may ask questions but the individual’s
confidentiality needs to be maintained. Part of this process would be to ask Kwan to
give the counselors permission to advise the group of his status or to ask him if he
would like to attend another group meeting or write a letter to let them know of his
decision.
Case Two: Criminal Justice
“Several studies indicate that clients who enter treatment because they are forced to do
so by the criminal justice system make as much progress as those who enter treatment
voluntarily. However, some researchers are opposed to coerced treatment on
philosophical or constitutional grounds, and there are clinicians who believe there is little
benefit to forced treatment.” (CSAT, TIP 17, p. 10)
Discussion questions:



In response to this quote, what is your position on forced treatment?
What are the ethical principles that support forced treatment?
What are the ethical principles that are violated by forced treatment?
Case Scenario
Li is in private practice as a licensed psychologist. George is court-ordered to her to
participate in an eight-week anger management program. He was found guilty of
assault of a neighbor and has previous domestic violence charges. When Li meets with
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him to do an assessment, he discloses information regarding extensive childhood
sexual abuse. He describes symptoms of anxiety and depression. Li determines that he
is not appropriate for the program at this time and recommends to him that he
participate in individual counseling with her along with a psychiatric evaluation for
medication. George states he does not have a problem and refuses to sign a release
for Li to send her report to the court. He states that he does not want this personal
information discussed in court. When George returns to court in sixty days, there is no
report from Li and he is sentenced to jail time.
What are your reactions to this scenario?
What are the ethical concerns?
Case Scenario Discussion
The assumption in this case is that Li has a contract with court systems to provide an
anger management program for mandated clients. Part of this contract includes
assessing clients prior to admitting them to the program.
The ethical concerns in this scenario are autonomy, beneficence and confidentiality.
Li is supporting George’s autonomy by accepting his right to say he does not want to
participate in individual therapy with her and that he does not want information disclosed
to the court. However, in upholding this ethical principle when working within a criminal
justice system, client welfare is often compromised. The results of George’s
autonomous decision are probably not in his best interest. This is a client she has
assessed as in need of therapy and psychiatric care that he will now probably not
receive due to incarceration.
One possibility is that Li knows there are services at the jail where he will be and that is
why she did not intervene. In most jails, these services are not available or are
inadequate. The ethical obligation with George is to make sure he understands the
consequences of his choice and to try to problem-solve with him.
Another consequence of supporting his decision is that he could have harmed someone
within the 60 days prior to his return to court. Ethical obligations to society are also a
concern when working with criminal justice systems. This relates to the section in this
module on therapeutic jurisprudence that indicates the mental health practitioner offers
options that uphold the normative values of the legal system. Hopefully Li had
something in her contract that addressed this or received legal consultation.
Another concern regarding beneficence is that George was referred for the anger
management program and then told that he would be doing something different by Li.
George’s resistance could have been a reaction to this and further clinical exploration
might have provided a different outcome. Li may have had an expectation that
mandated clients will do whatever she recommends and this could have impacted how
she responded to George’s resistance.
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The section of the psychologist code of ethics referenced in this module speaks to the
need to resolve these conflicts in a responsible manner. (7.05) It could be argued that Li
did so by respecting George’s decision. It would have been unethical to place him in
the anger group just to keep him out of jail so that was not a responsible approach to
resolving the conflict. What other options did she have?
If George had an attorney, one option is to ask if he would be willing to sign a release so
that Li could speak with him/her and discuss what is in the client’s best interest. The
attorney may also be able to get George’s permission to discuss the situation with the
judge. At the very least, the attorney would be aware that this client is not receiving
services for 60 days. If George did not want to sign a release, Li could suggest he
contact his attorney to discuss the situation before making a final decision.
Another option is that in the contract with the courts, Li asks that a release of
information be signed at the time of the referral. This would give her permission to
release just the assessment findings and would prevent this kind of bind. She could
then have submitted her report immediately. The court would have the information that
this client was not involved in treatment and could take action sooner than the 60 days.
Ethical concerns with this option are: a client is being asked to sign away confidentiality
rights with a provider they have not met yet; the client might feel coerced to do so since
this takes place within the legal setting.
Another option would be to ask George to take a few days to think about this and
schedule another appointment as a continuation of the assessment. Ask if there is
someone he could talk it over with like a minister, family member or trusted friend. This
continues to support his autonomy but allows for Li to stay involved. She would also
have time get some consultation as to ideas for how to respond. If Li’s schedule does
not allow for this or George refuses to return, she could suggest he telephone someone
while he is in her office and discuss it.
Li should document all of the options discussed with George and his reactions. A follow
up letter to him outlining what occurred in his session would also be good practice.
Case Three: Adolescents
“For clients under the age of 18, the law in all states stipulates that they are not adults
and, therefore, are not competent to make fully informed voluntary decisions.
Consequently, whether or not non-emancipated minor clients are developmentally
capable of making informed decisions, their privacy rights legally belong to the parents
or guardians. Herein lies the most pressing issue in counseling minors …” (Huey, 1990,
p. 241)
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Discussion Questions:


In response to the above quote, do you agree or disagree that this is the most
pressing issue in counseling minors? Why?
What are the ethical principles in conflict with privacy rights law?
Case Scenario
Rosa, a licensed professional counselor, is providing group and individual counseling
for adolescent females in an outpatient community-based program. Laura, a 16 year
old, is one of her clients who has been in group and individual counseling for several
months. She was referred by the school guidance counselor due to behavior problems
and falling grades. Laura’s parents have refused to meet with Rosa but sent written
permission for Laura to participate in treatment at the agency. In an individual session,
Laura tells Rosa that she thinks she is pregnant. The father of the baby is a 20 year-old
man that she has been dating. He is a friend of her older brother and her parents do not
know about their relationship. Laura claims that she and the boyfriend are planning to
get an apartment and get married as soon as he can get some money saved.
When Rosa says she needs to contact her parents, Laura becomes extremely upset
and says she will never come back to the agency if that happens. Rosa agrees that she
won’t talk to her parents without her permission on the condition that Laura makes an
appointment immediately with her family doctor and gives Rosa permission to talk with
the doctor. Laura agrees.
What are your reactions to this scenario?
What are the ethical concerns?
Case Scenario Discussion
Rosa’s decision involves several ethical principles: beneficence, autonomy, discretion
and competence. The dilemma she faces involves deciding if the welfare of the client is
best served by contacting the parents or by keeping her engaged in the therapeutic
relationship since the two seem mutually exclusive at this point.
She has made the decision that she thinks is in the best welfare of her client: to
preserve the therapeutic relationship. To do this she has contracted with her regarding
medical care in order to attend to Laura’s medical needs as well as the baby’s health.
This approach supplants the parental authority but it prevents the client from leaving
treatment prematurely. In addition, Laura may not be pregnant so it prevents a potential
family crisis situation.
On the other hand, this is a medical issue and Rosa is presumably not competent to
address medical concerns and Laura is a minor. If Laura is pregnant and has a
miscarriage or other complications, ethical and legal consequences could occur. One
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way to address this is to make sure Laura makes the call from her office to obtain an
appointment immediately. Gaining Laura’s permission to speak with the doctor, Rosa
can then consult with him/her about the issue of involving the parents. The doctor is not
under the same confidentiality requirements and could make his/her own decision
regarding the family. This removes Rosa from the role of contacting them and diffuses
Laura’s threat to terminate treatment.
If the doctor responds that Laura is pregnant and reports that the parents have not
responded to his/her phone calls, then Rosa is back in the dilemma. One option is to
again discuss this with Laura. Adolescents often do not think through all the
consequences of their decisions. Has she realized that her parents are going to see that
she is pregnant in a few months? How will they react then? This type of clinical
intervention may help resolve the ethical/legal conflicts. If Laura still refuses to give
Rosa permission to talk with them then Rosa would need to consult with an agency
supervisor and an attorney.
Another point of view is that adolescents often threaten to do things in the heat of the
moment and do not follow through. Rather than making the contract she did, Rosa could
discuss with Laura the reasons, legally and ethically, for involving at least one of her
parents. Laura may be receptive to involving one parent rather than both. Or Rosa can
help Laura discuss all of her options, including the decision to leave treatment, and
request that she present this in the next group counseling session. This supports
Laura’s autonomy and utilizes clinical interventions first. Laura also will hopefully get
some needed support from her peers regarding this situation. Depending on Rosa’s
clinical approach, Laura could utilize the group to role-play discussing this with her
parents, preparing for all of their possible reactions.
Whatever course of action is taken, Rosa needs to carefully document her decision and
why. Client welfare issues are typically a good defense but this would need to be welldocumented. For example, reasons why Rosa believed Laura’s threats to leave
treatment were authentic and why leaving treatment would be harmful at this time.
Case IV: HIV/AIDS Clients
“Taking the most ethical course of action becomes even more complex when HIV/AIDS
is thrown into the mix of concerns that the client may present. HIV/AIDS has its own
unique ethical issues. Because HIV can be transmitted through sexual activity and by
sharing drug equipment, it evokes significant personal feelings and judgments in the
general public, as well as in health and social service providers”. (Center for Substance
Abuse Treatment, Treatment Improvement Protocol 37, 2000. p. 173).
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Discussion questions:


What unique ethical issues have you encountered in working with clients with
HIV/AIDS?
If you have not worked with these clients, what areas of concern can you identify
with regard to autonomy, justice and confidentiality?
Case Scenario
Menakshi is a licensed mental health counselor providing individual counseling for
Robert a 26 year old client. His presenting problem was that he was feeling depressed
and having trouble sleeping. He has been married five years and they have a one-year
old child. After meeting for a few sessions, he reveals to Menakshi that he is bi-sexual
and has been having an affair with a male partner. They have both been recently tested
and he has discovered he is HIV+ as is his partner. He states his wife does not know
about this affair. Robert thinks his depression was triggered by the diagnosis.
When Menakshi expresses concern for the welfare of Robert’s wife, he states they have
been practicing safe sex but lately his wife has been talking about having another child.
Menakshi suggests that Robert needs to discuss his behavior and diagnosis with his
wife. Robert becomes upset and refuses. He states that he is afraid that his wife would
leave him and take his son away if she knows about the affair and that this would
increase his depression. Menakshi advises Robert about her ethical responsibilities to
his wife and possible unborn child and that he has until their next appointment to tell his
wife on his own or she will need to act.
Robert does not appear for the next scheduled appointment. Menakshi writes a letter to
Robert with a copy to his wife listing her concerns regarding his behavior.
What are your reactions to this scenario?
What are the ethical concerns?
Case Scenario Discussion
Menakshi is clearly taking the position that the welfare of others with regard to HIV
positive information takes precedence over the individual desires of her client.
The ethical concerns in this scenario are autonomy, client welfare (beneficence) and
confidentiality.
Robert did not state that he planned to do his wife any harm. In fact, he indicated that
he is practicing safely with her. Although Menakshi may have reason to doubt him, she
does not have any evidence to support her legally in using Tarasoff as a reason to notify
the wife. If she is a member of the American Counseling Association, she does have
their Code of Ethics to support her decision. (See B.1 d) However, it could be argued
that Menakshi did not put enough effort in determining if Robert was going to notify his
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wife on his own per the guidelines in the code. Because he did not return to the session,
she did not have a chance to find out what he did before sending the letter. One option
would have been to contact him first to discuss his reasons for not returning. This would
have supported his autonomy and perhaps have prevented Menakshi from violating his
confidentiality. However her action did support the autonomy of the wife in that it could
be argued she could not practice self-determination without the information her husband
was withholding from her. If she became infected, it could also infect her child if she
became pregnant. However, those are two ifs that may not stand up in court.
Menakshi is not a medical person and she only has Robert’s word that he has this
diagnosis. Another option would have been to ask for a release to obtain his medical
records or speak with his doctor. Clients are often confused about medical information.
It could also be that the doctor has already informed the wife and Menakshi could
document that information and not have to take any other action. As it is, she contacted
the wife about a medical diagnosis without documenting that this information is correct.
In terms of Robert’s welfare, there is the concern about his depression. This was what
the initial treatment contract was about and should have been Menakshi’s focus as his
counselor. Further sessions may have helped him overcome his fears and decrease his
depression to the point that he would have been willing to discuss his HIV status with
his wife or at least seek couples’ counseling. By taking the action she did, Menakshi
possibly compromised the therapeutic relationship to the point that now Robert has no
help for any of his problems. He did demonstrate trust in revealing to her his affair and
bi-sexuality.
In addition, he stated that he believed his wife would leave him if she was given this
information. Again, Menakshi has no way of knowing if this is true but since Robert
probably knows his wife and the counselor doesn’t, this information should be taken into
consideration. Further assessment of the marital situation and offering to meet with
Robert and his wife could have provided more data to help Menakshi make a decision
that was more beneficial to this client.
Menakshi may have felt strongly about upholding the ethical principles that she did
regarding the wife’s welfare and that of an unborn child and that this was more
important than keeping a client engaged in treatment. She also gave Robert informed
consent that this was what she was going to do. However, if her action was based on
her value system that was in conflict with his behavior, for example, an affair when
married or bi-sexual behaviors, then her action would need to be re-evaluated in terms
of ethical practice. Another option would have been for her to report his status to the
public health authorities without identifying herself and then they could contact the wife.
Again, advising Robert that this was what she planned to do would have supported his
autonomy. Another option would have been to discuss all of these suggestions with the
client and the pros and cons of each, including possible referral if Menakshi felt her
values were in conflict with treating this client. Then together they could have developed
a plan.
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Personal Problems and Professional Effectiveness
Counselors must “recognize the effect of professional impairment on professional
performance and should be willing to seek appropriate treatment for oneself or a
colleague.” When personal problems impair professional performance, it is critical that
professionals take the appropriate steps to ensure that clients and colleagues are
protected and that the impaired counselor receives the rehabilitation he or she needs.
Chemical dependency, mental illness or emotional problems on the part of a counselor
do not justify ethical misconduct - there are many counselors with emotional problems
who seek treatment without committing an ethical violation.
A special concern for substance abuse counselors is the possibility of relapse, since
many counselors are themselves recovering addicts. This issue is discussed below, in
the section titled “The Recovering Addict as Counselor.”
Interprofessional Relationships
Conflict Situations
Principle 10a discusses the counselor’s duty to other professionals when situations
arise that may cause conflict. This concern arises in cases where treatment is sought
from a counselor but the client is already in similar therapy with another mental health
professional. Although the client has the right to chose a professional he/she is
comfortable with, this Principle stipulates that the alcohol and drug abuse counselor
should not offer services “except with the knowledge of the other professional or after
the termination of the client’s relationship with the other professional.” It is advisable in
these situations to encourage the client to discuss his/her dissatisfaction directly with
the other therapist. If the client will not agree to this course of action, the therapist
should seek authorization from the client to contact the other professional and discuss
the problem. The counselor should not offer services if the client is unwilling to take
steps to terminate the other relationship or to allow the two therapists to work
cooperatively.
Alcoholics Anonymous
AA is an organization which has much to offer to recovering alcoholics and asks in
return only that its customs and traditions be respected and followed. Thus, in referring
a patient to AA, a counselor should consider the patient’s needs in the context of AA’s
overall well-being.
One highly-valued AA tradition is anonymity - AA members are forbidden to identify
themselves as such through the media, and are forbidden to identify others as members
at all. This tradition is intended to reassure newcomers who might fear for their
reputations, protect the fellowship from adverse publicity if a member relapses, and
prevent individuals from appointing themselves as spokespersons. All addiction
professionals should strive to protect this tradition.
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In addition, counselors should think carefully about whom they refer to AA. For example,
a large number of referrals, especially all at once, could be damaging to a chapter that
has very few members. Another problem exists when programs require AA participation
as a part of the treatment program. This can mean that many angry and hostile
individuals descend on an AA group which can also be damaging. Many times, such
referral occurs without clients having the benefit of learning about the customs and
traditions of AA. Counselors should be familiar with the nature and the ways of their
local chapter, insure that clients are informed as to the customs and traditions of AA,
and act with understanding and respect at all times.
Health Insurance/Third Party Payments
Systems of Health Care Coverage and Reimbursement
Health care costs, especially mental health care costs, have been rising dramatically in
recent years. Health care coverage and reimbursement that enable consumers to use
health care services take a variety of forms in addition to traditional coverage by private
companies thorough clients’ employers. Many states have recently mandated that
coverage for substance abuse problems be included in insurance policies, and that
reimbursement occur at a level that is reasonable and comparable to traditional health
care coverage.
The substance abuse counselor, especially if he/she works in a treatment facility, may
play a variety of roles that would require him/her to be familiar with systems of thirdparty payment - especially Medicaid. Such roles include helping clients and their
families make care-related decisions by interpreting information for them, making
necessary social and environmental changes to ensure that the patient continues to
receive the services he/she needs, and case management which would require the
counselor have the ability of following utilization requirements for reimbursement.
While many options currently exist and continue to emerge with the trend towards a
national health care system, three of the most common systems of health care
coverage and reimbursement - Medicaid, Medicare, and Health Maintenance
Organizations (HMOs), are discussed below.
a. Medicaid: Medicaid is a federal and state government funded, means-tested
program that provides payment for medical and hospital services to people who
cannot afford them. In most areas, Medicaid is managed through local public
assistance offices. Persons receiving SSI may be helped with applications for
Medicaid at their local Social Security offices.
The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) allowed states to
charge persons receiving Medicaid benefits small co-payments for some required
and optional services. Exceptions to this include emergency services, family
planning and pregnancy-related services, services to categorically needy minors,
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and services to the categorically needy in skilled nursing or intermediate care
facilities or enrolled in HMOs.
b. Medicare: Medicare, a part of Social Security, is a federal entitlement program
that guarantees benefits to persons over age 64 and to persons with long-tern
disabilities. It consists of two parts: Part A is hospital insurance that covers
hospital care, skilled nursing facilities, home health agencies, and hospices. Part
A is financed through Social Security payroll taxes. Part B is voluntary
supplemental insurance obtained partly through premium payments and partly
through government financing. It covers outpatient and inpatient physician
services, hospital outpatient and laboratory services, durable medical equipment,
treatment for end-stage renal disease, and medical supplies.
c. HMOs: The Health Maintenance Organization Act of 1973 is an alternative to the
traditional fee-for-service delivery system. HMOs deliver wide-ranging health
services to their enrolled members for a fixed, prepaid fee, covering a particular
time period. Most HMO members are healthy middle-class working people and
their families. HMOs include basic and supplementary services such as
physician, outpatient and inpatient. mental health, emergency, family planning,
immunization, physical exams, etc.
With HMOs, staff, records, and facilities are more centralized. The following
advantages of HMOs have also been noted: (1) they reduce the cost of health
care by relying less on hospitalization; (2) they rely more on ambulatory and
preventative services by offering increased access to primary care: (3) because
of higher quality, continuity of care is improved and less unneeded surgery is
performed; and (4) they make productive use of auxiliary health professionals.
Issues in the Use of Third Party Payment
It is only recently that third-party payers have begun, on a widespread basis, to
reimburse patients for treatment for substance use disorders. In the past, insurance
fraud occurred in the form of using a medical diagnosis to provide care for the
chemically dependent client, for example, a physicians might list the diagnosis of a
patient being treated for substance abuse as “cirrhosis of the liver,” or something
similar, on insurance forms. Today, however, the potential for insurance fraud exists in
fitting the diagnosis of a client to fit the type of coverage. For example, a client may
have coverage for alcohol related problems, but not for a drug such as cocaine. It
would be tempting to create an alcoholism diagnosis, even thought the client doesn’t
use alcohol, and cite it as primary, thus allowing treatment for the cocaine problem.
Another example might be that many insurance companies will not reimburse family
members of a chemically dependent individual for family therapy, unless the family
members have received a psychiatric diagnosis. Thus, an addiction professional, with
the patient’s best interests in mind, may at times be tempted to assign an unwarranted
diagnosis.
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In line with Principle 12 of NAADAC’s ethical principles, substance abuse counselors
should act as advocates for any efforts which strive to institute changes in public policy
and legislation that benefit their clientele. At the same time, addiction professionals
must remember that all forms of insurance fraud - which includes misleading an
insurance company in any way - are not only illegal but also unethical.
The Recovering Addict as a Counselor
One of the unique aspects of the chemical dependency field is the fact that a significant
number of alcohol and drug abuse counselors are themselves recovering addicts. As
counselors, such individuals offer the advantage of serving as role models for their
clients. These counselors can offer hope to their clients that a life free from substance
use is not only possible but can be rich and fulfilling as well.
The use of recovering addicts as counselors, however, raises the question of how long
the would-be counselor should maintain sobriety before he or she Is hired. The AA
Guidelines For AA Members Employed in the Alcoholism Field (New York; 1987)
suggest that members remain abstinent for three to five years before working in the
field. Bissell and Royce (Ethics for Addiction Professionals) recommend at least two to
three years of continuous sobriety as the standard. However, according to Bissell and
Royce, the field is plagued with individuals who present themselves as qualified
counselors after only a few weeks of abstinence. Agencies are often eager to hire such
individuals, since their salary demands are often low and their level of enthusiasm and
dedication is high. However, hiring such individuals poses risks such as relapse to the
counselor and a low quality of service to clients.
Regardless of how long a recovering addict has maintained sobriety before beginning
work as a counselor, the risk of relapse is always present. The relapse of a counselor
raises many difficult issues for an agency, such as what should happen to a counselor,
and what patients should be told. Bissell and Royce recommend that this problem be
discussed before it happens, so that employees know what to expect and management
knows what to do if a relapse occurs. The agency’s policy regarding relapse should be
made known to new staff when they are hired. Although the relapse of a counselor will
always have profound effects on an institution, thoughtful advance policy planning helps
keep the distress to a minimum.
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Guidelines for the Counselor
While it would be nice and easy if all ethical concerns and considerations were
able to be listed in terms of absolute guidelines, reality is that this is impossible. Every
situation brings with it special issues and needs that must be addressed as it relates to
that issue, not how it should be in the real world. Counselors would be best served if
they all understood and followed the dictum “Primum non nocere” (Latin for “do no
harm”).
In an effort to provide some better guidelines for ethical practice, below are a set
of guidelines for ethical practice adapted from the work of Gerald Corey in his book
“Theory and Practice of Counseling and Psychotherapy, 4th edition, 1991. They are
followed by some guidelines for ethical decision making.
Guidelines for Ethical Practice
1. Counselors must at all times be aware of what their own needs are, what they are
getting from the work they perform, and how their needs and behaviors influence
their clients. It is essential and critical that the therapist’s own needs not be met at
the expense of the client’s well-being.
2. Counselors must have the training and experience necessary for the assessments
they make and the therapeutic interventions they attempt. New skills and
applications must be studied and perfected in educational settings, then under
proper supervision prior to using such skills with a client.
3. Counselors must always be aware of the boundaries of their professional
competence and either seek qualified supervision or refer clients to other
practitioners when they recognize that they have reached their limit. They are
required to be familiar with community resources so that they can make appropriate
referrals when necessary.
4. Although practitioners know the ethical standards of their professional organizations,
they must exercise their own judgment in applying these principles to each particular
case they work with. The counselor needs to realize that many problems which
occur may not have clear-cut answers or solutions, and they accept the
responsibility of finding appropriate answers.
5. It is important for counselors to have some theoretical framework of behavioral
change to guide them in their practice.
6. Counselors must update their knowledge and skills through various forms of
continuing education. Such updating should occur in an ongoing and timely fashion
to insure that the best possible care is always offered to the client.
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7. Counselors must avoid any relationships with clients that are clearly a threat to the
therapeutic relationship. If any potential harm can occur to the client due to a
business or personal relationship, it should be avoid. Under no circumstance is a
sexual relationship with a client acceptable during the course of care, and such
intimacy after the end of the therapeutic relationship is also ill advised.
8. Counselors must inform clients of any circumstances that are likely to affect issues
of confidentiality in the therapeutic relationship and of any other matters that are
likely to negatively influence the relationship.
9. Counselors must be aware of their own values and attitudes, recognizing the role
that their personal belief system plays in the relationships with their clients.
Counselors must avoid imposing personal beliefs on their clients, in either a subtle
or a direct manner.
10. Counselors must inform their clients about matters such as the goals of counseling,
techniques and procedures that will be employed, possible risks associated with
entering the therapeutic relationship, and any other factors that are likely to affect
the client’s decision to enter therapy. To make an informed decision for care, the
client must be aware of all such considerations.
11. Counselors need to realize that they are teaching their clients through a modeling
process. Thus, they need to practice in their own life what they encourage in their
clients. “Do as I say, not as I do” doesn’t work in parenting and it doesn’t work in
therapeutic relationships. If a counselor is unwilling to recognize this, they create
potential harm to the client.
12. Counselors must realize that they are bringing their own cultural background to the
counseling relationship. Likewise, their clients’ cultural values are also operating in
the counseling process. Awareness and understanding of such issues is vital to
positive outcomes of the therapeutic relationship.
13. Counselor must learn and apply a process for thinking about and dealing with ethical
dilemmas, realizing that most ethical issues are complex and defy simple, easy
solutions. The willingness to seek consultation is a sign of professional maturity, not
professional inadequacy.
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Guidelines for Ethical Decision Making
1. Identify the problem or dilemma. Know your professional guidelines and always
think in terms of “how am I applying these guidelines to each client I deal with,” not
“I’ll deal with it if an ethical lapse occurs.”
2. Define the potential issues involved. Do the issues center on cultural issues? Are
there professional complications/implications involved? What is the counselor’s
liability to the individual and to society?
3. Obtain consultation from a clinical supervisor or peer. Such consultation will provide
the counselor with constructive feedback, allow for perception checking, and provide
the opportunity of looking at any hidden issues.
4. Consider all possible and probable courses of action. Don’t be satisfied with only
one solution. List all options that may be available.
5. Enumerate the consequences of various decisions. What is the potential harm to
the client, someone close to the client, or society in general?
6. Decide on what appears to be the best course of action and take action. Simply
waiting and hoping that the dilemma will pass can cause harm to the client and
damage to the professional integrity of the counselor.
Ethics are something that the drug and alcohol professional must always be aware
of and look at in each therapeutic relationship. By being proactive in knowing the
professional responsibilities and applying them to each and every case handled, the
counselor can be assured of performing their job in the highest ethical manner
possible.
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