Patrice Hinton Oswalt was flattered upon opening her e-mail and finding an Evite to a client’s long-awaited graduation. Choosing whether to accept or decline the invitation was no simple decision, however.

Oswalt was keenly aware that engaging in contact with a client outside of the counseling office could have ethical consequences. But she also knew the ethically “correct” answer could only be reached by weighing the best interests of her client. So, when the client came in for her next session, Oswalt, a career counselor with a private practice in Birmingham, Ala., opened the discussion by addressing the situation. She asked the woman to think about how it might feel to have her counselor present at the graduation.

The client had been coming to Oswalt for a year and a half. During that period, the client had been working full time while simultaneously earning a bachelor’s degree. She had sought out Oswalt mainly for career issues, but the two had also discussed issues surrounding the client’s relationship with her husband. If Oswalt attended the client’s graduation, the likelihood existed that she would meet the woman’s husband and family. Might that lead to questions about the client’s counseling work that the client wouldn’t want to deal with on her graduation day?

“I wanted her to think through it in a 360-degree way, all the way around, not just get caught up in the moment of inviting everyone,” says Oswalt, a member of the American Counseling Association. After reconsidering the situation, the client decided it would be wiser not to have Oswalt attend the graduation.

Having a strong ethical compass is paramount to being a good counselor, says Oswalt, who in addition to running her private practice works two days a week as assistant director of career services at the University of Alabama at Birmingham. “I can’t be unethical and at the same time be an effective counselor,” she says. “The counseling relationship is built on trust — clients trusting that they can be vulnerable and that their counselor will not take advantage of that openness. To earn this trust as counselors, we must be trustworthy, to prove our worth and integrity. These are standards of behavior that tie directly into our professional ethics. Outside of the counseling relationship, our ethical code [the ACA Code of Ethics] provides us with a clearer professional identity, shapes how the public perceives us and offers guidelines for our professional behavior. We have to use our ethical code to increase our ability to analyze issues in ways that will facilitate our ability to move on to ethical action — to make it part of who we are as a professional [and] prepare us to deal with ethical dilemmas before they even arise. Most of us are trained to ‘do things right.’ Ethics help us to ‘do the right thing.'”

Oswalt’s graduation invitation is just one example of the ethical dilemmas that confront counselors on a daily basis. To help counselors anticipate common ethical challenges and learn how best to handle them, Counseling Today invited Oswalt and four other ACA members with expertise in counseling ethics to provide some insights.

Crossing the line

When the 2005 revision of the ACA Code of Ethics acknowledged that multiple relationships (referred to as “nonprofessional interactions or relationships” in the ethics code) are sometimes unavoidable and that they can be acceptable when carried out ethically, Oswalt applauded. “I like that the door opened up a little. It’s a more realistic way of approaching the counseling relationship,” says Oswalt, who presented on “Hot Topics in Counselor Ethics” at the ACA Annual Conference & Exposition in New Orleans in March. In the past, Oswalt says, even if you were the only counselor in town, you might have felt compelled to shut your office doors to someone you knew on a personal level in an effort to avoid any potential boundary issues. This challenge proved particularly formidable to counselors living and working in rural areas, for whom secluding themselves from community life wasn’t feasible.

Jeffrey Barnett, professor in the Loyola University Maryland Department of Psychology, says the belief used to be that counselors should never carry on multiple relationships because any contact with clients outside of the counseling office would automatically have negative consequences. “But the most recent thinking is that there is a big difference between crossing a boundary and violating a boundary,” says Barnett, who coauthored the Ethics Desk Reference for Counselors, published by ACA, with W. Brad Johnson.

Certain multiple relationships are now ethically acceptable, Barnett says, such as counseling your child’s teacher if no other counselors are available in the area. “Sometimes it’s us or nothing,” he explains. Instead of admonishing any and all multiple relationships, the focus of the 2005 ACA Code of Ethics shifted to determining whether any harm might come to the client if a multiple relationship existed.

Standard A.5.c. of the 2005 ACA Code of Ethics states that “Counselor-client nonprofessional relationships … should be avoided, except when the interaction is potentially beneficial to the client.” Standard A.5.d. goes on to say that “the counselor must document in case records, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client.” The standard also provides examples of potentially beneficial interactions outside the counseling office, which “include, but are not limited to, attending a formal ceremony (e.g., a wedding/commitment ceremony or graduation); purchasing a service or product provided by a client or former client (excepting unrestricted bartering); hospital visits to an ill family member; mutual membership in a professional association, organization or community.”

One important standard to keep in mind when considering crossing a boundary is the potential for impairment of objectivity, Barnett says. “If it’s a conflict-of-interest situation or if I can’t remain objective, it’s probably not a good idea,” he says. Returning to the example of counseling your child’s teacher, Barnett recommends compartmentalizing the roles — not asking about the teacher’s depression at the parent-teacher conference, and not asking about your child’s homework at a counseling session.

If a counselor ethically chooses to cross a boundary with a client, Barnett says having a good informed consent policy is crucial. “Informed consent clarifies up front the working agreement between the two parties,” he says. “Many clients may not know what their rights are, what appropriate professional behavior includes and what behaviors are not appropriate. Part of [the informed consent] is to educate the client. It is also to clarify our responsibilities and obligations.”

Oswalt adds that it is also wise to reread the ACA Code of Ethics or to use an ethical decision-making model, such as the one designed by Holly Forester-Miller and Thomas Davis, before proceeding.

Some multiple relationships, of course, remain clear ethical violations. Ted Remley, director of the counseling graduate program at Old Dominion University and a former executive director of ACA, served on four licensure boards over a 20-year period. During that time, he saw more than a few counselors stripped of their licenses to practice after having sexual relationships with clients. Although sexual relationships with clients are a clear violation of boundaries, they happen more than people might expect, Remley says.

Gary Goodnough, cochair of the ACA Ethics Committee and professor of counselor education at Plymouth State University, agrees that sexual boundary crossings, whether between a professor and a student or a counselor and a client, are always a hot-button issue in ethics. But he says these boundary violations are rarely the result of counselors being unfamiliar with the ethical guidelines. “I think it has to do with unmet needs that counselors have as human beings that cause them to behave in ways [in which they] meet their needs at the expense of others,” Goodnough says.

Like Goodnough, Remley thinks sexual missteps occur when counselors allow their own needs to invade the counseling space. Although inappropriate relationships can take many other forms, such as a counselor going on vacation with a client or hosting clients in the counselor’s home, Remley points to sexual impropriety as the ultimate problem. Part of the solution, he says, lies in counselor education programs addressing such ethical issues and preparing students to handle them. He adds that practicing counselors need to process their feelings when they are socially or sexually attracted to clients by consulting with peers.

“Because attraction to clients is an uncomfortable topic in our profession, it often is not talked about in preparation programs,” Remley says. “In addition, counseling practitioners are often reluctant to admit being attracted to clients. Counselors have to create a professional environment where this topic is welcomed and honestly addressed so that future abuses of clients will not occur.”

Goodnough suggests counselor educators bear some responsibility in staying alert for red flags in student behavior. Students are enrolled in counseling programs for at least two years, which is long enough, Goodnough says, for professors to notice students with personality problems or unmet needs that might lead to significant ethical violations down the line. Faculty members should monitor students and assess their attention to ethical and legal issues, he adds. If problems occur, a remediation plan can be set up for the student. If the student is still unable to meet the goals, he or she may be dismissed from the program. “We need to pay attention to our gut as counselor educators, as well as to indicators that we set up for students to meet,” Goodnough says.

Ethical boundaries can be violated not only when dealing with multiple relationships outside the office, Barnett points out, but inside the counseling office as well. Again, it’s an issue of crossing versus violating a boundary. Crossing a boundary, Barnett explains, would be consistent with the client’s treatment plan, culturally welcomed by the client, motivated by the client’s best interests and an action considered professionally acceptable. For instance, with a grieving client, Barnett says he might put his hand on the client’s shoulder or give him a hug to show support. But carrying out that same gesture with a client who has a history of sexual abuse would be very wrong, Barnett says. Whereas a boundary crossing can be clinically acceptable and appropriate, a boundary violation is unwelcome by the client, motivated by the counselor’s personal needs and harmful to the client.

To friend or not to friend

Technology is designed to make things easier and more accessible. But counselors caution that technological advances can also usher in ethical unknowns. Laura Hahn, a private practitioner who offers counseling and consulting services in Atlanta, says the Internet can blur the boundary lines between counselors’ personal and professional lives. Many counselors have professional websites and social media pages while also maintaining a personal presence online. Hahn says it’s important to keep the two identities separate.

Hahn, an ACA member who presented on “Ethics and Technology” at this year’s ACA Annual Conference, points out that counselors have greater control over information they publish themselves, making it easier to keep boundaries intact. But they have less control — and might even be unaware of — information that others publish, such as photos posted by their friends. Hahn says it’s important for counselors to know what’s available about them on the Internet because their clients may be reading things posted not only by the counselor but about the counselor, including information ideally meant to be personal in nature. She advises that counselors regularly conduct a Google search on themselves to monitor what comes up in the results.

Counselors should also take steps to keep personal and professional information separate, Hahn says. “On a social network site like Facebook, use a ‘Page’ to display professional information and use a ‘Profile’ to display personal information. The page allows you to publish information for client use and does not have friends associated with it,” she explains.

The 2005 revision of the ACA Code of Ethics took place prior to social networking’s explosion in popularity and doesn’t address the topic directly, says ACA Manager of Ethics and Professional Standards Erin Martz. That means social networking can quickly become an ethical conundrum for counselors. Martz says sites such as Facebook should be treated as social interactions even though they’re virtual. The deciding factor then should be whether the interaction benefits or harms the client, she says. Martz points counselors toward Standard A.5.d. of the ethics code, which addresses Potentially Beneficial Interactions.

Goodnough agrees that Facebook represents uncharted territory for many counselors. “The ethical downside involves the blurring of personal and professional boundaries that can result when clients and counselors, as well as counselor educators and students, are ‘friends,'” he says. “While counselors typically refrain from [traditional] friendships with their clients, the threshold for online friendships differs in some people’s minds. Additionally, on Facebook, status updates can be reposted to another page, thus allowing friends of friends and, thus, potentially, clients or students, to see personal information and vice versa.”

Hahn simply suggests refraining from “friending” clients on Facebook. “Make it a policy by adding a statement to your informed consent documentation, and inform your clients up front,” she says. Counselors who find clients being overly interested in the counselor’s personal life and conducting intrusive online searches can explore that topic with the client in therapy, she says.

Counselors should be mindful of the content of everything they write, whether in an e-mail, a text message, a Facebook post or any other electronic communication, Hahn says, because the messages can be reposted or forwarded to those not originally intended to be recipients.

Goodnough agrees that counselors should proceed with caution when it comes to technology, especially as it relates to social networking. “There’s a whole new way that individuals and counselors interact with each other,” he says. “It’s not entirely clear what the best way [is to handle those interactions to] ensure that professional standards and ethical guidelines are enforced or that they live in those venues. We have to always recognize that we’re counselors. Even in our private role, people know us as counselors. Caution and being conservative is always called for.”

Hahn suggests that counselors looking to create a web presence for their professional practice should first read Standard A.12. (Technology Applications) of the ACA Code of Ethics to make sure they’ve done their homework before launching a website or networking page. For those counselors already online, Hahn recommends rereading the code to ensure that everything they have online is ethically sound.

Technology also expands accessibility to counseling, whether through videoconferencing services such as Skype, instant messaging, e-mail or another form of technology. Offering counseling services online connects people with therapy when they might not otherwise be able to head to a counselor’s office, Barnett says.

But if the benefit is that technology expands access to counseling for greater numbers of people, Barnett says the shortcomings can include a lack of visual cues when e-mailing or instant messaging and technological difficulties, especially with videoconferencing, such as when the video freezes or the connection is lost. “When you’re conducting a counseling session and that happens and the person is grieving or depressed, that’s not good,” Barnett says. “When you’re in the room with them, that can’t and won’t happen. Technology is a convenience, but it can also have drawbacks.”

Barnett suggests creating an electronic communication policy that details the plan for what will happen if the connection is lost. Standard A.12.g.8. of the ACA Code of Ethics supports his point, suggesting counselors should “discuss the possibility of technology failure and alternate methods of service delivery.”

Hahn says two additional ethical gray areas with online counseling include how the nature of the therapeutic relationship might be changed when the counselor and client aren’t sitting face-to-face in the same physical space and limits to confidentiality and privacy when counseling online. She recommends discussing those potential limits in advance with clients. Standard A.12.g.1. of the ACA Code of Ethics says counselors should “address issues related to the difficulty of maintaining the confidentiality of electronically transmitted communications.”

The crisis aspect of counseling is also a concern when a counselor is working with a client from a distance. If the client is in crisis and the counselor isn’t in the same room or even the same state, that can pose a problem, Barnett says. The solution, he says, is to research the area’s resources — crisis hotlines, local hospitals, emergency centers and the like — so the counselor can help the client find local assistance quickly if the need arises. That’s also a point covered under the Technology and Informed Consent standard (A.12.g.9.), which states counselors should “Inform clients of emergency procedures, such as calling 911 or a local crisis hotline, when the counselor is not available.”

Barnett recommends that counselors offering online counseling of any kind provide thorough informed consent so clients will understand the pros and cons, risks and benefits of the process. Also set out a clear fee structure, he says, including whether e-mail is charged based on the time the counselor spends in responding or by the number of lines.

In addition to having the clinical competence to address a wide variety of topics with online clients, it’s also important to be technologically competent, Barnett says. Before proceeding, he adds, counselors should be sure they have the right technology and know how to use it effectively.

Also important, Barnett says, is that counselors are both licensed and competent to provide the services they are offering online, just as they would be if offering those services in person. Even if counselors are licensed in the state where they are giving the advice, it can be problematic if they aren’t licensed in the state where the client is receiving the services, he says.

That’s true, Martz says. Although regulations can vary from state to state, most states do not allow counselors to provide counseling services — virtual or in person — unless the counselor is licensed in the state where the client is located. Because ethics are tied directly into following the law, Martz says that ethically, counselors offering services to a client in another state need to find out what the laws are and follow them.

Being prepared

Beyond boundaries and technology, a range of other topics can prove to be ethical sticking points for counselors. For example, Oswalt says, diversity and multiculturalism. “It’s hard to be an expert in all areas of multicultural awareness,” she says. But she adds that it’s the counselor’s responsibility to step outside his or her own worldview when helping clients.

Oswalt says her goal is to be able to sit across from her clients and have a grasp of some of the external issues that might be affecting them. To do that, Oswalt says she takes advantage of training opportunities at state and national conferences where she can expose herself to different cultural competencies. If counselors find themselves lacking the cultural context to understand what might be going on with a client, Oswalt recommends referring.

“Counselors who are ignorant of the social and cultural context of a client risk misdiagnosing and pathologizing something that is very much the norm in the culture of that client,” Oswalt says. “This could cause great harm to a client, [which goes] against the principles of holding the client’s best interests above all else and avoiding harm. Multicultural awareness also includes communicating in developmentally and culturally sensitive ways and understanding various cultural concepts of confidentiality. Counselors must strive to not only understand the client’s cultural point of view but also to understand how [the counselor’s] own culture has shaped their perceptions of the world.”

To broaden their multicultural competence, Oswalt suggests that counselors participate in individual or group counseling, do volunteer work with populations with which they are unfamiliar, participate in workshops that highlight specific cultural groups or discuss issues in a supervision group. “The insights and information they gain will better prepare them to understand diverse clients, avoid discrimination and select culturally sensitive and appropriate interventions,” she says.

Barnett suggests another aspect of ethics that counselors should consider: the role of ethical decision making and prevention versus merely cleaning up the mess after a problem occurs. So many situations that counselors face fall in a gray, middle area where the answer to the ethical question isn’t clear, he says. He points to an ethical decision-making model in his book that guides counselors through things to consider and questions to ask when making a decision. “Frequently, people think of ethics as good and bad, right and wrong,” Barnett says. “That’s only relevant when it’s clearly appropriate or inappropriate. In the middle, the answer is usually, ‘It depends.'”

In addition to finding a decision-making model, Barnett says it’s important for counselors to be aware of the major areas where ethical dilemmas might occur, such as confidentiality, competence and multiple relationships, and then take action to prevent difficulties. Counselors should be cognizant of their own motivations for decision making, use self-awareness to notice when difficulties are first beginning and then respond appropriately, he says.

“Prevention also includes practicing ongoing self-care to ensure our ongoing psychological wellness, maintaining a balance between our personal and professional lives, and regularly practicing what are termed positive career-sustaining behaviors such as regular exercise, getting adequate rest, having a healthy diet, managing stress on an ongoing basis and the like,” Barnett says. “Prevention may also include personal counseling or psychotherapy, the use of consultation when faced with ethical dilemmas and being sure to practice within our areas of competence.”

Yet another important perspective is the idea that ethics are meant to guide you, not your neighbor, Remley says. “In my opinion, the ethical standards are meant to be applied to ourselves. Counselors should be using them to guide their individual behavior, and one of the problems is a lot of people want to impose the ethical standards on others. In a way, that is inappropriate,” he says.

Remley says some counselors get in the habit of using ethical standards to judge other people’s behaviors or professional decisions rather than simply saying, “I don’t agree with you.” He offers a hypothetical situation: A counselor is working in a community mental health center, and after talking to a client, the counselor chooses not to have that client admitted to a hospital against his will. One of the counselor’s colleagues might think that it is the wrong decision to make, but instead of saying “I don’t agree with you,” the colleague labels the counselor unethical.

There are times when it might be appropriate to deem someone’s decision unethical, Remley says, but those times are few and far between, because very seldom is a case that clear-cut. People cut others down by calling them unethical because it’s more powerful than just disagreeing, Remley says, but he warns that the approach can have a grave effect on an individual’s reputation.

“Each individual counselor should refrain from labeling the behavior or decision of other people as unethical,” Remley says. “They should be judging their own behavior by this code of ethics and the ethical standards but not constantly applying them to other people. I’ve seen it too often in my career, and we need to talk about it as a profession.”

Do no harm

Striving to be ethical is at the heart of being a good counselor, Goodnough says. “Professional ethics are an extension of our own integrity,” he says. Among Goodnough’s list of recommendations for practicing ethically as a counselor: Be mindful of your actions, be knowledgeable of ethical codes, consult widely on ethical dilemmas, engage in continuing education, be affiliated with a professional association and always be in a supervisory relationship.

Goodnough says the way counselors act can protect clients and support the ideals of the profession — or not. “If we don’t get [ethics] right, we’re not doing our clients or our society any good,” he says. “In fact, we’re causing harm. It deserves the attention of all practicing counselors.”

Among Oswalt’s tips for ethical practice are understanding ethical codes, consulting with colleagues for advice when ethical difficulties arise, keeping up with current literature in the field, knowing how your state laws apply to the profession and taking full advantage of member benefits through ACA, including free ethical consultation.

Oswalt adds that it’s important for counselors-in-training to begin focusing on ethics while still in the classroom. Reflecting on her master’s program at Georgia State University, Oswalt says the topic of ethics was on the table for discussion in many of her classes. Even though she was in “decent shape” in her knowledge of ethics when she graduated, Oswalt says she continued to run into tricky issues. In those instances, she consulted with colleagues. “It’s not if a counselor will face an ethical dilemma, it’s when, so try to get yourself prepared,” she says. “A good foundation doesn’t do it perfectly, but it’s a great springboard.”

One ethical responsibility that counselors must take very seriously is tied directly to the position of power they hold in the counseling relationship, Remley says. “When clients seek counseling services, they are vulnerable. There is very little oversight of the interactions between counselors and clients, and clients could easily be abused in counseling relationships because of the power counselors have. Therefore, it is very important for counselors to practice in an ethical manner that results in their clients being helped and never being harmed or taken advantage of.”

Barnett emphasizes that point as well. “Clients come to counselors in need, seeking assistance for important issues and difficulties. They come to counselors needy, dependent on us and trusting us to only act in ways that are in their best interests. A failure to act ethically in our professional roles can lead to direct harm to clients and can undermine the public’s trust in counselors in particular and in mental health professionals in general. This could result in people who are in need of help not accessing the help they need. The public is trusting us to help them, not to harm them.”

 

****

Letters to the editor: ct@counseling.org

****