Ethical Implications of Trends in Technology
Courtney L. Klaus and Timothy S. Hartshorne
Abstract
Technological advancements are ubiquitous in society and clearly have implications
for the provision of mental health services. But with any innovation comes ethical
concerns, and the use of technology raises questions about confidentiality, profes
sional boundaries, and competence. This article addresses ethical concerns with the
use of email, texting, telephone, videoconferencing, and social media.
Keywords: Individual Psychology, ethics, technology, email, texting, telephone,
videoconferencing, social media
This article addresses ethical issues that emerge with the use of technol
ogy in the provision of counseling and psychotherapeutic services. We live
in a technological and information age that is well beyond anything that
could have been imagined by Alfred Adler. Through technology, services
can expand and extend past the confines of a single therapy room. The con
struct of social interest, however, implies a concern for the welfare of the
larger communities in which we live. Feibleman (1944) suggests that this
points to an Adlerian ethic: that which is good serves more than the unique
individual; it serves the larger "unlimited" or "ideal" society. Feibleman
(1944) quotes Adler as saying, "Anything that we estimate as valuable, good,
right, and normal, we estimate simply in so far as it is 'virtue' from the point
of view of an ideal society" (p. 294). In an earlier article, Feibleman (1937)
suggests that beyond the limited communities where we live are other, more
distant communities, each connected with even more distant communities,
expanding in an "unlimited" direction, and to which we all essentially have
a responsibility.
Although this seems an essential Adlerian ideal—that we develop a
sense of connection in our families of origin, and that as we develop and
mature, our sense of connection, and then also responsibility, expands—
it becomes an even greater reality with the Internet and communications
technology. Now therapeutic services can be provided over not just great
distances, but essentially all distances: distance is no longer a limitation.
Each one of us can reach the "unlimited community."
Reaching and contacting unlimited communities is now possible, but
how are we to think about our responsibilities, both as human beings and
The Journal o f Individual Psychology, Vol. 71, No. 2, Summer 2015
©2015 by the University of Texas Press
Editorial office located in the College of Education at Georgia State University.
Published for the North American Society of Adlerian Psychology.
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Courtney L. Klaus and Timothy S. Hartshorne
as therapists? The Adlerian ethic to ensure that the connection we make is
a "virtue" for the larger, ideal society has to fundamentally guide us in the
use of distance technology. We live in a world of technological marvels that
have and w ill continue to affect the work of mental health practitioners.
New opportunities for breaches to confidentiality, challenges to boundary
issues and multiple relationships, and concerns about appropriate train
ing and supervision are emerging. The following analysis addresses the
advantages, disadvantages, ethical concerns and considerations, and rec
ommendations in regard to approaching some of the uses of technology in
the counseling relationship.
E-mail
Advantages
Perhaps one of the most obvious advantages of e-mail is the conve
nience it offers. E-mail enables a therapist and client to communicate at
any time, even when they are not in the same location (Recupero & Harms,
2010). This convenience also allows for those who are physically unable to
make it to an office to receive services. Recupero and Harms (2010) state
that e-mail may allow clients to express more honest information about their
situation because they might feel less vulnerable than when sitting across
from someone in an office. Not only does this allow clients to potentially
convey more honest emotions; it also allows them more time to process and
develop perhaps a more thoughtful response.
Disadvantages
One of the more serious disadvantages to e-mail is that information is
more vulnerable to being hacked. Every client and therapist should be aware
that just because e-mails have been deleted does not mean they are truly
"erased"; Internet service providers (ISPs) can easily recover them. Human
error can also be an issue: e-mail can accidentally be deleted, buried among
other e-mails in an inbox, or sent to the wrong address, resulting in expo
sure of the client's private information (Welfel & Heinlen, 2010). Another
disadvantage of e-mail is that one does not truly know with whom he or
she is communicating. For example, consider a client who is in an abusive
relationship and has a partner who monitors client communication heavily.
As a therapist, by communicating via e-mail and unknowingly exposing in
formation to an abuser, beneficence is in question, as the client could be put
in harm's way. Therefore, having a password or some kind of security log-in
when using e-mail in this setting is highly advised.
Ethical Implications of Trends in Technology
197
Ethical Considerations
"Out of one thousand randomly selected American Counseling As
sociation members who answered surveys— most respondents perceived
providing direct clinical services by means of email to be unethical"
(McMinn, Buchanan, Ellens, & Ryan, 1999, p. 168). It is important to note
that this research was published in 1999. However, it gives perspective on
how individuals involved in the mental health field feel about conduct
ing therapy via e-mail. One of the most concerning ethical issues when
e-mailing clients is confidentiality. As mentioned previously, ISPs can gain
access to e-mails at any time. It is also important to make clients cognizant
of the fact that their information is not secure when using a work-based
computer, as often companies can gain access. Licensure is another issue if
therapist and client reside in different states. State laws should also be con
sulted (Recupero & Harms, 2010).
Recommendations
The newly released Section H of the American Counseling Association's
(ACA, 2014) Code o f Ethics offers some guidance in these areas. In regard to
confidentiality, Section H.2 stresses the importance of therapists recogniz
ing the limitations of technology, and therapists' responsibility in making
their clients aware of this. Section H.1.b offers guidance when it comes
to licensure, stating that counselors must be aware of the regulations for
their location, as well as their client's location, and that they must follow
those regulations in the counseling relationship(s). Overall, "clinicians
need to develop policies and procedures for responding to client email and
communicate them to clients as part of the informed consent process in
psychotherapy" (McMinn etal., 1999, p. 172).
Texting and Telephone
Advantages
An advantage of texting allows clients the ability to chart moods in real
time rather than having to recall their experiences a week or so later in
session (Merz, 2010). Texting can also be used to check in with clients for
recommendations and follow-up, as well as to offer support and enhance
communication (Merz, 2010). Regarding phone use in the therapeutic rela
tionship, Welfel and Heinlen (2010) found that adolescents reported feeling
an increased sense of privacy and more safe and "less emotionally exposed"
when using therapeutic services from a telephone call center.
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Courtney L. Klaus and Timothy S. Hartshorne
Disadvantages
A major disadvantage of communicating with clients via text is that it
allows for a greater risk of boundary issues, especially if client and therapist
do not understand or practice appropriate times and subjects for commu
nicating via text. It is therefore important that therapists communicate and
abide by set rules with clients when texting. Other disadvantages of texting
are similar to those of e-mail: human error and the inability to know with
whom the therapist is truly communicating. A disadvantage of texting and
telephone therapy, critics argue, is that, as with other forms of technology
services, "without visual cues, counselors w ill be unable to develop a strong
therapeutic relationship or . . . important clinical data w ill be overlooked"
(Saunders, 2010, p. 88). Another challenge that telephone therapy poses is
limiting a therapist's clientele base to those who can be clearly understood
over the telephone (Saunders, 2010).
Ethical Considerations
As with any form of technology, the biggest ethical consideration is
confidentiality. Clients and therapists must understand that texting is not
a secure form of ensuring client confidentiality. Also, as mentioned previ
ously, professional boundaries are another concern with texting. Although
today's digital phones make hacking less of a problem, it is still important to
recognize and inform clients that one cannot guarantee complete security
when utilizing technology (Saunders, 2010, p. 89). In addition, privacy for
phone conversations must be ensured.
Recommendations
When considering the use of texting, or any form of technology, for
counseling purposes, therapists should review Section H.2 of the ACA's
2014 Code o f Ethics in regard to confidentiality. Merz (2010) states that
when implementing texting, it is important to shield the device screen so
that others cannot view it, or it should be used only in private locations
along with privacy filters. In regard to preventing potential boundary is
sues, therapists should refer to Section H.4.b of the Code o f Ethics, which
states "counselors discuss and establish professional boundaries with cli
ents regarding the appropriate use and/or application of technology and the
limitations of its use within the counseling relationship" (ACA, 2014). Again,
Section H.2 of the Code o f Ethics should be referred to for concerns per
taining to confidentiality. In regard to security, however, one should refer
specifically to Section H.2.d of the Code o f Ethics, as it states that coun
selors are responsible for using "current encryption standards within their
websites and/or technology-based communications that meet applicable
legal requirements" (ACA, 2014). Therefore, it is important for therapists
to clearly communicate with clients about the specifics of how telephone
Ethical Implications of Trends in Technology
199
therapy might be offered, including number and length of sessions, and how
billing w ill occur (Saunders, 2010).
Videoconferencing
Advantages
Perle et al. (2013) found that counseling conducted through videoconferencing resulted in a wide range of benefits, including reduced stigma
of attending services in a mental health clinic, the ability to reach a wider
range of clientele (e.g., those in underserved areas), more convenience in
terms of time and transportation, and ability to provide services to those who
are physically unable to attend a session in an office. Perle et al. surveyed
308 doctoral-level students and 409 licensed psychologists in regard to their
personal opinions on counseling conducted through videoconferencing
and other computer-based interventions. More than half of participants "en
dorsed the use of synchronous telehealth interventions (using web cameras)
for generalized anxiety disorder (70.2%), agoraphobia (64.2%), dysthymia
(63.3%), social anxiety (62.9%), specific phobia (61.4%), major depressive
disorder (55.5%), panic disorder (53.8%), and obsessive-compulsive dis
order (51.2%)" (Perle et al., 2013, p. 104).
Disadvantages
Although the participants in Perle et al.'s (2013) study gave some in
sight into advantages of videoconferencing, the authors also suggested
some negatives, including lack of research (63.0%), lack of privacy (46.0%),
confidentiality concerns (47.4%), crisis situations (57.6%), billing (19.19%),
licensure (29.3%), and lack of ethics coverage (44.6%). Overall, Perle et al.
found that only 21.3% of participants agreed that they had adequate train
ing and experience to effectively deliver therapy via videoconferencing.
Therefore, although therapists might find videoconferencing a useful re
source in some circumstances, the research suggests that not many therapists
feel comfortable regarding their competence to do so. Another disadvantage
of videoconferencing and other online technology is "glitching," or "losing"
a client during session because of technical errors or a faulty connection,
which could be detrimental to a client's progress.
Ethical Concerns
Several ethical concerns arise with videoconferencing therapy. First,
there may be an ethical imperative to provide therapy to individuals who live
in remote areas and do not have ready access to therapists, and so it would
be inappropriate to w ithhold video therapy from them (Simpson & Morrow,
2010). Second, state licensure and regulations vary across borders, and it is
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Courtney L. Klaus and Timothy S. Hartshorne
essential for therapists to research and comply with the legal and ethical im
plications of "crossing" those boundaries (Simpson & Morrow, 2010). Third,
as always with technology, confidentiality is the biggest concern, and it is
up to therapists to do everything within their power to uphold this standard.
Perhaps one of the biggest concerns is competence. Unfortunately, not every
individual is educated about how to troubleshoot glitching or other com
puter issues. Telehealth.org recommends having an information technology
(IT) professional available to assist when issues arise, and that clients, along
with therapists, receive training from IT professionals to understand how to
operate the systems they are using (Perle et al., 2013).
Recommendations
In regard to confidentiality, therapists should refer to Section H.2 of
the ACA's 2014 Code o f Ethics. Section H.1.b addresses legal issues, and
Section H.2.d addresses issues of security. Perle et al. (2013) recommend
that for further training in videoconferencing therapy, mental health profes
sionals direct themselves to the TeleMental Health Institute (http://telehealth
.org/special-training/#), which offers training and continuing education in
videoconferencing therapies. Also, as always, clients need to be fully in
formed of the risks and benefits of videoconferencing therapy (Simpson &
Morrow, 2010).
Social Media
Advantages
Hampton (2013) found in a comparative study that Internet users actu
ally score four points higher on an overall scale of reported social support
than non-Internet users. Hampton also found that daily Facebook use
is equivalent to at least half the support one might get from a marriage.
Although this is interesting information, perhaps the biggest advantage to
social media is the ability to spread knowledge to an unlimited audience.
Social media provides therapists the opportunity to get more information
out to clientele and Internet users in general. One could say that this is
perhaps a new means of psychoeducation, which in the past was limited
to only mental health professionals and those who received their services.
It can also be a way for a practice to stay in touch with clients as a group.
Some practices use Facebook as a way to let clients know about cancella
tions and scheduling changes.
Disadvantages
One disadvantage with some forms of social media, especially Facebook, is "friending," which raises boundary issues in the relationship (Luo,
Ethical Implications of Trends in Technology 201
2009). Therapists do not need to accept a friend request from a client, but
clients may still be able to locate personal information about the therapist,
potentially by having mutual friends, or being tech-savvy (Nicholson, 2011).
Another concern is that of privacy. Lehavot, Barnett, and Powers (2010)
found that 27% of graduate students surveyed in their study indicated that
they had looked up information on their clients online. This creates several
issues. "For example, if a client were to tell a psychologist that he or she
has been very successful in not smoking for several weeks, but through the
'friend of a friend' on a social networking site, the psychologist discovers
photos of the client smoking at a recent party, what does the psychologist do
with this information?" (Nicholson, 2011, p. 21 7). Therefore, therapists need
to set personal boundaries not only for themselves when it comes to privacy
but also for clients' vulnerable online information. It is important to allow
for clients' autonomy inside and outside of sessions, despite any temptations
to look for clients on social media.
Ethical Concerns
The two main concerns with social media in relation to mental health
modalities are dual relationships and boundary-related issues. One can
not be both a friend on Facebook and a therapist. To address problems of
a "slippery slope" effect with respect to crossing or violating boundaries,
counselors need to develop and follow guidelines for handling clients who
find their profile, as well as for themselves in terms of searching for their
clients online (Simpson & Morrow, 2010).
Recommendations
In regard to boundary-related issues with social media, practitioners
should consult Section H.4.b, Professional Boundaries in Distance Counsel
ing, in the ACA's 2014 Code o f Ethics, which stresses the importance of a
professional relationship with clients and the fact that professional bound
aries need to be discussed and established, particularly as they pertain
to technology and its use in a counseling relationship. In regard to this,
Younggren and Gottlieb (2004) have provided a useful model for therapists
to use when experiencing a "multiple relationship dilemma" (p. 255) or
boundary issues. The model is a series of questions about the necessity of
the relationship, potential harm from a dual relationship, potential benefits
to the relationship, potential disruptions to therapy by the dual relationships,
and therapist objectivity. Also, as a precautionary measure, Lannin and Scott
(2013) recommend that therapists consult professional and personal liabil
ity insurance representatives regarding coverage for social media. Last, as
always, confidentiality is an important issue to remain cognizant of, and
counselors should refer to Section H.2.b of the Code o f Ethics with any
confidentiality-related concerns.
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Courtney L. Klaus and Timothy S. Hartshorne
Discussion
As technology propels communication forward to create a world that
is not so unlimited anymore, an important question is what this w ill do for
careers in the mental health arena. W ith technological advances in com
munication, there is no question that technology w ill continue to affect the
counseling realm. Three primary ethical issues emerge from the considerations
of distance technology: confidentiality, boundary issues, and competence.
Confidentiality is the reason talk therapy works. W ithout confidentiality,
individuals w ould not feel comfortable sharing their intimate thoughts and
experiences. Therefore, it is concerning to think that therapists are comfort
able with utilizing technological modalities that are risky when it comes to
ensuring client confidentiality w ithin the therapeutic relationship. Counsel
ors need to reflect on their own standards and comfort levels when it comes
to technology; and w ithout question, counselors need to be careful and re
sponsible when it comes to creating a safe environment for their clients.
Communication and expectations for boundaries in the counseling
relationship provide a healthy environment for client growth. However,
when boundaries start to bend w ithin the counseling relationship, issues
can arise, as oftentimes the relationship w ill start to evolve into more of
a friendship or even a romantic relationship. This ultimately ruins the po
tential for any further therapeutic work to be done. In regard to the use of
technology in counseling, boundaries are more apt to be broken because of
the accessibility and informality that technology offers in terms of commu
nication. Therefore, it is extremely important for therapists to develop rules
for themselves and clients when implementing different forms of technology
w ithin therapy.
Competence is vital to the counseling profession. If a therapist does not
understand how to help a certain client population or implement a particu
lar technique in the proper way, it is advised that he or she not do so. This
standard has been established in the profession to ensure that clients are not
put at risk. Technology is a newer force in society that continues to grow
and change. Therefore, if a therapist is interested in using different forms of
technology in the counseling relationship, there are several things he or she
must evaluate. One, does the therapist understand how to operate the tech
nological device? Two, does the therapist feel comfortable doing so? Three,
does the therapist understand how to use the device in a therapeutic way?
By asking these three questions and by consulting the ACA's 2014 Code o f
Ethics, a therapist can assess his or her own competence level in regard to
technology use w ithin therapy. Whether technology is more of a detriment
than a help to therapy is still up for debate. Because technology is still a
fairly new phenomenon in the realm of counseling, therapists considering
Ethical Implications of Trends in Technology
203
implementing different forms of technology in therapy must ask themselves,
"W hat am I comfortable with?" If a therapist does not feel comfortable or
competent in delivering therapy via some form of technology, then he or she
should not put clients at risk by doing so. However, given the technologi
cal advances that are making alternative forms of delivery readily available,
therapists may feel ethically bound to receive training in their appropriate
use. Adler could not have anticipated the technological advances that are
affecting our society. It is ethically imperative that Adlerian therapists con
sider the implications of these advances on society and how technology can
support progress toward the "unlim ited" and "ideal" society.
References
American Counseling Association. (2014). ACA code o f ethics. Alexandria,
VA: Author.
Feibleman, J. (1937). Moving toward the unlimited community. International
Journal o f Individual Psychology, 3(4), 309-319.
Feibleman, J. (1944). Individual Psychology and the ethics of Peirce. Journal
o f General Psychology, 31, 293-295.
Hampton, K. N. (2013). New communication technologies and the nature
of community. Family Therapy Magazine, 12(2), 10-15.
Lannin, D. G., & Scott, N. A. (2013). Social networking ethics: Developing
best practices for the new small world. Professional Psychology: Re
search and Practice, 44, 135-141.
Lehavot, K., Barnett, J., & Powers, D. (2010). Psychotherapy, professional
relationships, and ethical considerations in the MySpace generation.
Professional Psychology: Research and Practice, 41, 160-166. d o i: 10
.1037/a0018709
Luo, J. S. (2009). The Facebook phenomenon: Boundaries and controversies.
Primary Psychiatry, 16, 19-21.
M cM inn, M. R., Buchanan, T., Ellens, B. M., & Ryan, M. K. (1999).
Technology, professional practice, and ethics: Survey findings and im pli
cations. Professional Psychology: Research and Practice, 30, 165-172.
Merz, T. A. (2010). Using cell/m obile phone SMS for therapeutic interven
tion. In K. Anthony, D. M. Nagel, & S. Goss (Eds.), The use o f technology
in mental health: Applications, ethics and practice (pp. 29-38). Springfield, IL: Thomas.
Nicholson, I. R. (2011). New technology, old issues: Demonstrating the
relevance of the Canadian code of ethics for psychologists to the eversharper cutting edge of technology. Canadian Psychology, 52, 215-224.
204 Courtney L. Klaus and Timothy S. Hartshorne
Perle, J. G., Langsam, L. C., Randel, A., Lutchman, S., Levine, A. B., Odland,
A. P.,. . . Marker, C. D. (2013). Attitudes toward psychological telehealth:
Current and future clinical psychologists' opinions of Internet-based
interventions. Journal o f Clinical Psychology, 69, 100-113. doi:http://
dx.doi.org/10.1002/jclp.21912
Recupero, P. R., & Harms, S. (2010). Using email to conduct a therapeutic
relationship. In K. Anthony, D. M. Nagel, & S. Goss (Eds.), The use o f tech
nology in mental health: Applications, ethics, and practice (pp. 3-14).
Springfield, IL: Thomas.
Saunders, D. E. (2010). Using telephone for conducting a therapeutic re
lationship. In K. Anthony, D. M. Nagel, & S. Goss (Eds.), The use of
technology in mental health: Applications, ethics and practice (pp. 8593). Springfield, IL: Thomas.
Simpson, S., & Morrow, E. (2010). Using videoconferencing for conducting
a therapeutic relationship. In K. Anthony, D. M. Nagel, & S. Goss (Eds.),
The use o f technology in mental health: Applications, ethics, and prac
tice (pp. 94-103). Springfield, IL: Thomas.
Welfel, E. R., & Heinlen, K. T. (2010). Ethics in technology and mental
health. In M. A. Cucciare & K. R. Weingardt (Eds.), Using technology to
support evidence-based behavioral health practices: A clinician's guide
(pp. 267-290). New York, NY: Taylor and Francis.
Younggren, J., & Gottlieb, M. C. (2004). Managing risk when contemplating
multiple relationships. Professional Psychology: Research and Practice,
35, 255-260.
Courtney L. Klaus (klaus1cl@cmich.edu) is a graduate student in the
master's-level counseling program at Central Michigan University. She
hopes to work with college students in the future and is currently doing
her internship at Central Michigan University's Counseling Center. She is a
member of Sexual Aggression Peer Advocates, a paraprofessional organiza
tion on campus that runs a 24-hour crisis line and chat system online to
help survivors of intimate partner violence. She also currently volunteers
at Women's Aid women's shelter in Mount Pleasant, Michigan, and has
worked several different jobs on campus, as well as several positions as a
caregiver off-campus.
Timothy S. Hartshorne (harts1ts@cmich.edu) is professor of psychology
at Central Michigan University. He is a Diplomate of the North American
Society of Adlerian Psychology and chair of its ethics committee.
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Dual relationships in training
This month's dilemma
Val is a training therapist at a counselling institute where she also facilitates experiential groups
for trainee counsellors. Steve, a trainee in a group that has recently come to an end, had shared in
the group his experience of being emotionally abused by his father as a child. Val has since heard
from Steve, who has explained that a situation has arisen with his current training therapist,
Mike. Steve tells Val that Mike had encouraged him to participate in a retreat he was leading.
Steve was reluctant but Mike persuaded him, saying he thought it would support the work they
were doing in therapy. Steve has recently returned from the retreat and found the experience
troubling. He doesn't want to return for further sessions with Mike and, having had a positive
experience of Val from the experiential group, wants her to be his training therapist instead.
What should Val do? Please note that opinions expressed in these responses are those of the
writers alone and not necessarily those of the column editor or of BACP.
Boundary incursions
Keith Silvester BACP senior accredited integrative psychosynthesis psychotherapist, counsellor
and supervisor, and former training director
There are some unexplained inferences in this dilemma. The first is that there is an automatic
link between the emotional abuse suffered by Steve from his father and the relationship with
Mike, the training therapist. Connected with this is the assumption that Steve's experience on
Mike's retreat was a collusion or re-enactment of that abusive situation and was harmful to Steve.
The third assumption is that Mike has crossed some crucial boundary by changing the nature of
the therapeutic contract with his training client. Yes, we know that the experience was 'troubling'
for Steve, but we do not yet know exactly why.
Val, the ex-experiential group leader, could easily be drawn into a drama triangle as a 'rescuer',
and she should definitely be wary of this. It would perhaps be better for her to spend some time
with Steve finding out what exactly has been troubling for him, without assuming that Mike is
somehow to blame for the way he is feeling. If it turns out that a boundary has been crossed
insensitively or inappropriately, then Val would be within her remit as a responsible trainer to
encourage Steve to make some sort of complaint. But this would be a grave step to take in
relation to a fellow professional. It would perhaps be better for Val to encourage Steve to work it
through directly with Mike and try to resolve it as 'unfinished business' between them. Although
this might be scary for Steve, the potential gains in terms of empowering him to confront Mike
would be a real growing point.
Steve's request for Val to now become his training therapist also puts her in a dilemma. She does
not need to take on this dilemma as her own, and it would be a good strategy to name and share it
with Steve so that he recognises that he is putting her in this position. This would help Steve, as a
trainee, to recognise that the world is complex and that responsibility for such complexity needs
to be shared. In this way he might come to see that he is putting Val in a difficult position that
happens to affect her professional relationship with Mike, and possibly the training institute.
There is a further aspect that may be uncomfortable to those who see boundaries as sacrosanct:
not all boundary overlaps or incursions need be boundary 'abuses'. Yes, Steve was emotionally
abused as a child, but he is also an adult in training. The assumed re-enactment that took place
between him and Mike could be seen as an invitation to heal the painful relationship between
Steve and his father. Although it would appear that this attempt by Mike (whether conscious or
unconscious) backfired in a harmful way for Steve, it could also be viewed as a challenge or
opportunity for Steve to work through and go beyond that painful relationship with his father by
getting closer to Mike.
The word 'abuse' is often assumed to refer to an absolute, objective and thus reified situation,
creating an automatic and incontrovertible Victim'. Yet in most cases when the word is applied it
is relative and subject to how the experiencer construes the situation or takes part in an
archetypal enactment of something happening. In this, Steve has some choice in the matter and
could rise above it.
Trainers should not also be therapists
Jo-Ann Roden Psychotherapist and supervisor in private practice, secondary school counsellor
and tutor at Re-Vision
Responding to this dilemma, my first thought concerns the training institute's training therapist
policy. My sense (and this is grounded in the policy at the centre where I work as a tutor) is that
training staff ought not to act as therapists (ie in a dual role) to current students of that institute.
If this policy were the norm, then the dilemma would not have occurred in the form outlined
here. Steve -- presuming he is a current student of the institute -- has approached Val, a current
experiential group facilitator at the same institute, for training therapy. Even if Steve is not
currently in Val's group, I'm imagining that Val will be in professional contact (ie in team
meetings etc) with Steve's current trainers or group facilitators, and therefore there is the
possibility of conflicts of interest and concerns over 'leaky containers'. The duality in the role
would also bring the possibility of creating 'special' relationships with 'special' students and
'special' members of staff.
Second, turning to the situation with Mike, is he also a member of the training team at this
institute? If so, then again we have the dilemma as above around conflicting roles etc. On top of
this we also have Steve's suggested vulnerability due to his childhood abuse experiences. Steve
was 'persuaded' by Mike (suggesting an imbalance in the power dynamic that was used to Mike's
advantage). This would stand regardless of whether Mike was also a trainer at the institute, but it
is certainly compounded by that, if it is the case. Here we find challenges to the BACP Ethical
Framework principles of non-maleficence and autonomy.
My sense is that Val should meet Steve and, while empathising with his struggle, she should
decline his request to be his training therapist, refer him to an experienced practitioner outside
the training organisation, and then engage her staff group in a policy discussion about the
boundaries of relationships between students and trainers. At Re-Vision we have a policy that
states a one-year 'no go zone' for pre- and post-training therapy student therapeutic relationships.
This is in line with UKCP standards and with BACP's Ethical Framework in relation to dual
relationships. My sense is that this boundary is an important, utilitarian protective factor. If it
were not in place, while harm may not come to all clients, it nevertheless would protect students
(and trainers) from that particular potential.
Potential for breach of trust
Heather Dale Senior Lecturer, University of Huddersfield, and therapist in private practice
As I understand this dilemma, Val is currently a trainer on Steve's course and has also facilitated
an experiential group in which he has been a participant. Now he wishes her to take on a third
role as his individual therapist. However, his relationship with his current therapist foundered
when they entered into a dual relationship, so asking Val to do the same sounds as if she might
be being invited into a psychological game that may well end badly for both of them.
A central therapeutic issue regarding childhood abuse is that it is a breach in the trust in the
relationship between a child and an adult. While Steve is no longer a child, in some way that we
are not told about Mike has breached the trust that he had with Steve. This may or may not be a
rerun of the original abuse, but clients, particularly if they have been abused, can often feel
violated in some way when a therapist has encouraged them to enter into a dual relationship,
however benevolently intended.
Therefore, as his trainer, Val's first conversation with Steve should be to encourage him to
discuss with Mike what has gone wrong between them. Steve is himself training as a therapist, so
he needs to have learned how to discuss difficult relational issues in therapy. Given his childhood
abuse, talking through his feelings with Mike may be an important part of the healing process,
particularly if the early abuse has involved the keeping of a secret. If, having attempted to
resolve the difficulties with Mike, Steve is still unhappy, only then should Val agree to him
finding another therapist. If she does agree, she then has to decide whether to accede to his
request to take on the role herself.
However, if she does accept his request to be his therapist, she must be aware that, like Mike
before her, she will be entering into a dual relationship in which she will be both his trainer and
his therapist. Steve has initiated this request, but I wonder what his unconscious motive might be,
as he has already experienced a dual relationship that has gone badly wrong. While Steve
experienced Val as a good group facilitator, that may not translate into her being a good
individual therapist for him. Val needs to be very careful about her motives, especially as she
will presumably charge for this service, so it might be argued that she has a financial incentive
for encouraging Steve to finish the therapeutic relationship with Mike and take that role for
herself.
In addition, if it goes wrong, as it might well, then where will Steve turn? When his relationship
with Mike went wrong, he very sensibly turned to Val as his trainer, but if she has both roles
then the circle of trainer, supervisor and therapist becomes a closed one.
Maintaining clear boundaries
Divine Charura UKCP registered psychotherapist and Senior Lecturer at Leeds Beckett
University
The potential outcomes to clients of therapists' suggestions or 'encouragements', however naive
or well-intended, can be serious. In our recently published book, An Introduction to the
Therapeutic Relationship in Counselling and Psychotherapy (Sage; 2015), my colleague Stephen
Paul and I noted the importance of therapist awareness of transference and countertransference
dynamics in the therapeutic relationship, as well as the ethical dilemmas that can result from
therapists' suggestions, actions or behaviours that may lead to a re-stimulation of unresolved
matters that brought the client to therapy in the first place. Therapists therefore need to maintain
clear professional boundaries, follow relevant codes of ethics and practice and make full use of
supervision.
In the dilemma posed in this scenario, Mike's awareness of the potential transferential dynamic
between him and Steve, which could have related to his relationship with his father, is unclear.
Mike's encouragement of Steve to participate in a retreat he was leading may have been genuine
and well intended. However he should have considered the BACP Ethical Framework, and in
particular the principles relating to ensuring the integrity of the practitioner-client relationship;
being trustworthy and honouring the trust placed in the practitioner (fidelity), and the
commitment to avoiding harm to the client (non-maleficence).
It could be considered that Mike, being in a position of power as the therapist, had encouraged
his client to participate in something that benefited him as the therapist. The ethical guidelines of
most counselling and psychotherapy regulatory bodies -- BACP, UKCP, BPS etc -- warn of the
dangers of dual relationships arising when the practitioner has two or more kinds of relationship
concurrently with a client -- in this case, the dual relationship of client and trainee. It is clear that
the existence of a dual relationship with a client is seldom neutral and can have a powerful
beneficial or detrimental impact, which may not always be easily foreseeable. As such, the
complexities that have resulted from Mike's behaviour can guide us in answering the question of
what Val should do.
Val should talk to Steve and help him to understand the 'troubling' experience of being on the
retreat with Mike, and then she should encourage him to share his feelings with Mike. Steve has
a right to end therapy with Mike if he then decides to.
From my experience of working in a university that offers therapy training programmes, training
therapists are obliged to adhere not only to their professional registration body guidelines but
also to the training institution's commitment to ensuring safe and competent practice. If it's clear
that what Steve has reported as a 'troubling experience' is indeed unethical practice, Val also has
a responsibility to report Mike's malpractice to his professional body.
Last, Val should consider carefully the question of whether to take Steve on as her client. It
would be a dual relationship, which could impair her ability to be objective if problems arise that
may not be foreseeable at present. It would be advisable for her to have a discussion with Steve
about finding a different therapist. If it does become clear that the case is as presented, it would
also be advisable for the counselling institute to consider removing Mike from their list of
recommended training therapists.
May's dilemma
Anjali works from home in private practice in a house on a busy street. It has one parking space,
which is used by her husband Nikhil when he returns from work. During the day those of
Anjali's clients who drive to their sessions use the space to park their cars. Anjali has noticed that
one of her clients, Deborah, sits in her car without moving for some time after her session, but
she has not brought this up with Deborah.
Frequently Nikhil has returned home from work to find Deborah sitting in her car, and has had to
find somewhere else to park, further down the road. One day, overcome with frustration, Nikhil
confronts Deborah and asks her why she doesn't make any effort to move out of the space when
she can see him waiting to park.
He tells Anjali what has happened. While he recognises the potential impact of his behaviour on
Deborah, he feels that he was justified.
In her next session, Deborah does not mention the incident to Anjali.
What should Anjali do?
Issues and Ethics in the
Helping Professions,
9th Edition
by Gerald Corey, Marianne Schneider Corey,
Cindy Corey, and Patrick Callanan
with Michelle Muratori, Johns Hopkins University
© 2015. Cengage Learning.
All rights reserved.
Chapter 7
MANAGING BOUNDARIES
AND MULTIPLE
RELATIONSHIPS
© 2015. Cengage Learning.
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Boundary Crossings and
Multiple Relationships
The rationale for abstaining from boundary
crossings or multiple relationships involves
the potential for therapists to misuse their
power to influence and exploit clients for
their own benefit and to the clients’
detriment.
© 2015. Cengage Learning.
All rights reserved.
Boundary Crossings and
Multiple Relationships
The viewpoints on multiple relationships
vary:
– Some focus on the problems inherent in
multiple relationships.
– Others view them as common, inevitable,
unavoidable, normal, and a healthy part of
communal life in many settings.
© 2015. Cengage Learning.
All rights reserved.
Boundary Crossings versus
Boundary Violations
Boundary crossing:
– A departure from commonly accepted
practices that could potentially benefit clients
– Example:
Attending a student’s school play or sports event to
build a positive relationship with him or her
© 2015. Cengage Learning.
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Boundary Crossings versus
Boundary Violations
Boundary violation:
– A serious breach that results in harm to
clients and is therefore unethical
– Example:
A gradual erosion of boundaries that leads to
sexual exploitation of the client
© 2015. Cengage Learning.
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Minimizing Risks in
Multiple Relationships
Identify measures aimed at minimizing the
risks:
– Set healthy boundaries from the outset
– Secure informed consent of clients
– Discuss both potential risks and benefits
– Consult with other professionals to resolve
any dilemmas
© 2015. Cengage Learning.
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Minimizing Risks in
Multiple Relationships
Identify measures aimed at minimizing the
risks:
– Seek supervision when needed
– Document in clinical case notes
– Examine your own motivations
– Refer when necessary
© 2015. Cengage Learning.
All rights reserved.
Managing Multiple
Relationships: Small Community
Practitioners who work in small
communities often have to blend several
professional roles and functions.
They have to become an integral part of
the community to be accepted as a
credible mental health resource.
© 2015. Cengage Learning.
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Managing Multiple
Relationships: Small Community
If these practitioners isolate themselves
from the surrounding community, they are
likely to alienate potential clients and thus
reduce their effectiveness in the settings
where they work.
© 2015. Cengage Learning.
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Prior to Establishing
a Bartering Relationship
Evaluate whether it puts you at risk of
impaired professional judgment
Determine the value of goods or services
in a collaborative fashion
Determine appropriate length of time for
arrangement
Document arrangement and consult with
experienced colleagues or supervisors
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Bartering
Guidelines to clarify barter arrangements:
– Minimize unique financial arrangements
– If bartering is used, it is better to exchange
goods rather than services
– Both therapist and client should have a written
agreement for the compensation by bartering
– If a misunderstanding develops, the matter
should be dealt with by a mediator, not by you
and your client
© 2015. Cengage Learning.
All rights reserved.
Accepting Gifts
When deciding whether or not to accept a
gift from a client, ask yourself:
– What is the monetary value of the gift?
– What are the clinical implications of accepting
or rejecting the gift?
© 2015. Cengage Learning.
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Accepting Gifts
When deciding whether or not to accept a
gift from a client, ask yourself:
– When in the therapy process is the offering of
a gift occurring?
– What are my motivations for accepting or
rejecting a gift?
– What are the cultural implications of offering a
gift?
© 2015. Cengage Learning.
All rights reserved.
Disadvantages of
Socializing with Clients
Therapists may not challenge clients they
know socially because of a need to be
liked and accepted by the client.
Counselors’ own needs may be enmeshed
with those of their clients to the point that
objectivity is lost.
© 2015. Cengage Learning.
All rights reserved.
Disadvantages of
Socializing with Clients
Counselors are at greater risk of exploiting
clients because of the power differential in
the therapeutic relationship.
Former clients may need you more as a
therapist at some future time than as a
friend.
© 2015. Cengage Learning.
All rights reserved.
Sexual Attractions in Therapy
Attraction to clients is a prevalent
experience among both male and female
therapists.
Simply experiencing sexual attraction to a
client, without acting on it, makes the
majority of therapists feel guilty, anxious,
and confused.
© 2015. Cengage Learning.
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Sexual Attractions in Therapy
There is a distinction between finding a
client sexually attractive and being
preoccupied with this attraction.
Neglecting to attend to family-of-origin
issues can lead to blind spots such as
being attracted to clients.
© 2015. Cengage Learning.
All rights reserved.
Dealing with Sexual Attractions
To minimize the likelihood of sexual
transgressions:
– Learn to recognize sexual attractions and how
to deal with these feelings constructively and
therapeutically.
– Seek professional support during times of loss
or crisis.
– Examine and monitor feelings and behaviors
toward clients continually.
© 2015. Cengage Learning.
All rights reserved.
Dealing with Sexual Attractions
To minimize the likelihood of sexual
transgressions:
– Know the difference between having sexual
attraction to clients and acting on this
attraction.
– Learn about the possible adverse
consequences for clients and therapists who
engage in sexual activity.
© 2015. Cengage Learning.
All rights reserved.
Dealing with Sexual Attractions
To minimize the likelihood of sexual
transgressions:
– Establish and maintain clear boundaries when
a client makes sexual advances toward you.
– Terminate the therapeutic relationship when
sexual feelings obscure objectivity.
– Recognize that direct explicit disclosures of
sexual feelings can run the risk of harming
clients and may therefore be unethical.
© 2015. Cengage Learning.
All rights reserved.
Dealing with Sexual Attractions
To minimize the likelihood of sexual
transgressions:
– Rather than making any explicit
communication of sexual feelings for clients,
acknowledge caring and warmth within the
therapeutic relationship.
© 2015. Cengage Learning.
All rights reserved.
Dealing with Sexual Attractions
To minimize the likelihood of sexual
transgressions:
– Practice a risk management approach (e.g.,
be aware of timing and the location of
scheduled appointments, non-erotic touch,
and general self-disclosure).
– Be open to using supervision, consultation,
and personal therapy throughout your career.
© 2015. Cengage Learning.
All rights reserved.
Harmful Effects of Sexual
Contact With Clients
Clients who are the victims of sexual
misconduct suffer dire consequences:
– Distrust of the opposite sex
– Distrust of therapists and the therapeutic
process
– Guilt, depression, anger, and/or PTSD
– Feeling of rejection and low self-esteem
– Suicidal ideation
© 2015. Cengage Learning.
All rights reserved.
Legal Sanctions Against
Sexual Violators
Negative consequences for therapists
include:
– Being the target of a lawsuit
– Being convicted of a felony
– Having license revoked or suspended by state
– Being expelled from professional
organizations
– Losing their insurance coverage
– Losing their jobs
© 2015. Cengage Learning.
All rights reserved.
Chapter 8
PROFESSIONAL
COMPETENCE AND TRAINING
© 2015. Cengage Learning.
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Perspectives on Competence
Professional codes of ethics on
competence have common themes.
Counselors practice only within the
boundaries of competence, based on:
– Education
– Training
– Supervised experience
– State and national professional credentials
– Appropriate professional experience
© 2015. Cengage Learning.
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Assessment of Competence
Assessment approaches are most
effective when they integrate both
formative and summative evaluations.
Formative assessment is a
developmentally informed process that
provides useful feedback during one’s
training and throughout one’s professional
career.
© 2015. Cengage Learning.
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Assessment of Competence
Summative assessment is an end point
evaluation typically completed at the end
of a professional program or when
applying for licensure status.
© 2015. Cengage Learning.
All rights reserved.
Developing or Upgrading Skills
Work with colleagues or professionals who
have more experience.
Seek consultation before moving outside
areas in which you have received
education and training.
Learn new skills by attending conferences,
reading professional articles, taking
courses, and participating in workshops.
© 2015. Cengage Learning.
All rights reserved.
Making Referrals
You may need to refer a client if the
resources are limited in the setting in
which you work.
– You may also need to refer a client if the
boundaries of your professional role restrict
you from delivering the services your client
needs.
© 2015. Cengage Learning.
All rights reserved.
Making Referrals
Referring a client because of a conflict
with your value system is not an ethically
acceptable reason for a referral.
Consider a referral as a final intervention
after you have exhausted other
interventions including consulting.
© 2015. Cengage Learning.
All rights reserved.
Ethical Issues in
Training Therapists
Training programs have an ethical
responsibility to:
– Establish clear selection criteria
– Provide exposure to major contemporary
counseling theories
– Teach students strengths and limitations of
theories
– Combine academic and personal learning
© 2015. Cengage Learning.
All rights reserved.
Ethical Issues in
Training Therapists
Training programs have an ethical
responsibility to:
– Screen candidates to protect public from
incompetent practitioners
– Teach a range of skills to work with diverse
clients
– Provide training in ethics
© 2015. Cengage Learning.
All rights reserved.
Evaluating Character and
Psychological Fitness of Trainees
Interpersonal behaviors of trainees have a
direct bearing on their clinical
effectiveness, so these factors must be
taken into consideration in the evaluation
process.
© 2015. Cengage Learning.
All rights reserved.
Evaluating Character and
Psychological Fitness of Trainees
Character:
– The honesty and integrity with which a person
deals with others
Psychological fitness:
– The emotional or mental stability necessary to
practice safely and effectively
– Evidenced by the presence of personality
adjustment, absence of psychological
disorder, and appropriate use of substances
© 2015. Cengage Learning.
All rights reserved.
Gatekeeper Role of Faculty
in Promoting Competence
The academic faculty in a professional
program generally has a gatekeeper’s
role, protecting consumers by identifying
and intervening with graduate students
who exhibit problematic behaviors.
The gatekeeper role is addressed in the
ethics codes of most professional
organizations.
© 2015. Cengage Learning.
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Gatekeeper Role of Faculty
in Promoting Competence
When a student has good grades but
demonstrates substandard interpersonal
behavior, indicating serious unresolved
conflicts, action needs to be taken.
© 2015. Cengage Learning.
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Gatekeeper Role of Faculty
in Promoting Competence
Well-designed gatekeeping procedures
appear to improve the effectiveness with
which deficient students are identified and
prevented from progressing unremediated
into the counseling profession.
Dismissal from a program is a measure of
last resort.
© 2015. Cengage Learning.
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Certification and Licensure
Certification
– Voluntary attempt by a group to promote
professional identity
– Attempts to verify qualifications
– Sets minimum standards
– Does not assure quality practice
© 2015. Cengage Learning.
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Certification and Licensure
Licensure
– Governs professional practice
– Highlights uniqueness of an occupation
– Restricts both use of title and practice of
occupation
© 2015. Cengage Learning.
All rights reserved.
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