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Reading Material
Article from assignment
https://kapextmediassla.akamaihd.net/artsSCi/Media/HN450/HN450_1602A/Unit9Case/index.html
NOHS. Ethical Standards for Human Service Professionals. Retrieved
from http://www.nationalhumanservices.org/ethical-standards-for-hs-professionals
Read the following article in the Library:
Light, A., Howells, B., & Brittain, C. (2015). The 21st Century workforce. Policy &
Practice (19426828), 73(2), 20.
TEXTBOOK INFORMATION Title: Becoming an Ethical Helping Professional:
Cultural and Philosophical Foundations Edition: 1st (2015) Author: Rita SommersFlanagan and John Sommers-Flanagan Publisher: Wiley Professional Development
(P&T) Book ISBN: 978-1119084969 Ebook ISBN: 9781119087922
Chapter Eleven
PSYCHOTHERAPY, MENTAL HEALTH COUNSELING, AND
CAREER COUNSELING
Where am I going? And why am I at the base of this mountain fighting to see the top? Is it the
climb that's important? Or the summit? Can it be both? Or something else? Perhaps it's how
we go down from the hill that counts. Or is it in simply endouring that we find the strength
and purpose we seek?
—Ron Jones, The Acorn People
CHAPTER ORIENTATION
The provision of clinical and counseling psychological services grew out of the academic
discipline of psychology, emerging in the mid- 20th century. The provision of mental health
counseling, as a designated master's level specialty in graduate counseling and social work
programs, is one of the newer forms of modern counseling, complete with turf wars and
identity struggles. In contrast, career counseling is as old as any form of modern
counseling. Lurking underneath its staid presence as the historical matriarch of counseling,
there are many exciting modern potential and relevant ethical concerns. In this chapter, we
consider the particular ethical demands inherent in providing mental health and career
counseling, either as specialties, or in the context of more general counseling practices.
The activity of mental health counseling generally refers to the establishment of a
therapeutic relationship between a professional and a client, or a set of clients. The intent
of the relationship is for the professional to assist the client(s) in alleviating emotional
distress, changing disturbing behaviors, or enhancing the client's development in a specific
area. A variety of mental health professionals are paid to provide this assistance in a
number of ways and in a number of settings—each with its own particular ethical concerns
and challenges. These challenges include payment structure, insurance, managed care,
Medicaid billing, record keeping, expected levels of expertise, and setting constraints.
In this chapter, we will specifically focus on:
•
the historical context of psychotherapy mental health counseling;
•
•
distinguishing and common features among the professions, including views of the
nature of health and distress, education, terminology distinctions in the field, and
professional organizations;
issues in agency and independent practice such as
•
fees, insurance, and managed care;
•
self- pay issues and problems;
•
confidentiality with other professionals;
•
competence and supervision; and
•
professional representation.
•
the ethical challenges in career counseling.
MENTAL HEALTH COUNSELING: ROOTS AND DIRECTIONS
Mental health counseling, once a minor component of the larger counseling, psychology,
and social work worlds, is now a central and defining force in these professions' identities.
There are undoubtedly many political, professional, and social reasons for this shift. For
instance, because mental health counseling developed from within the general counseling
profession, some authors date the origins of mental health counseling all the way back to
the first efforts to influence education, career and vocational planning, and in a sense,
wellness (see Chapter 10 for the inspiring story about the work of Pauline Agassiz Shaw
and Frank Parsons). Although it happened earlier in the century, psychology experienced
the same shift in emphasis as interest grew in not only studying people, but also in helping
them directly through psychotherapy and related applied activities. Social workers, too,
have clinical mental health counseling options within their training programs that have
grown more popular over the years.
The theories, research, and accepted mental health practices used by counselors,
psychiatrists, psychologists, and social workers date back to different pioneers and eras in
our culture's history. For instance, psychologists who provide counseling and/or
psychotherapy often see the work of Sigmund Freud as a central figure in their history,
even though he was a medical doctor, not a psychologist. In contrast, others claim the
provision of applied mental health (clinical or counseling) psychology has its unique roots
in the advent of intelligence testing and work with soldiers during World War II. As a
specific specialty within ACA, mental health counseling came into being with the formation
of the American Mental Health Counseling Association as an ACA affiliate, in 1978 (Pistole,
2004). Mental health work includes counseling, case management, and other professional
practices with individual clients, groups, and families.
Similarly, family systems counseling has its own particular forebears, as do couples and
group work. These forbears come from various backgrounds, including education, social
work, medicine, and psychology.
DISTINGUISHING AND COMMON FEATURES AMONG MENTAL
HEALTH PROFESSIONS
As mental health professionals, our squabbles over definition and turf sometime yield the
same dismissive attitude reflected in Henry Kissinger's statement about academia,
“University politics are vicious precisely because the stakes are so small” (Kissinger, 2005).
The stakes never seem small or unimportant to those in the fight, but perspectives shift if
one considers the view of those outside the battle.
Although some studies suggest that potential clients are more comfortable with the idea of
seeking help from a professional “counselor” rather than a “psychologist” (D. Warner,
1991), in our experience, people seeking help pay relatively little attention to the finer
distinctions in background and philosophy among mental health professions. What they
want and need is effective, ethical assistance (Farberman, 1997). Of course, distinctions
between and among mental health professionals do exist, and quite often they influence the
orientation and type of assistance the particular professional practitioner provides. The
findings just noted may reflect the fact that psychologists traditionally have been more
closely associated with pathology, illness, diagnosis, and the medical model, whereas
counselors have been more closely associated with helping “normal” individuals with their
common life problems, thus generating less stigma when one is seeking help (D.A. Herman
& Hazler, 1999; Jane E. Myers, Sweeney, & Witmer, 2000).
Nature of Human Health and Distress
Any attempt to cleanly delineate the differences between the professions when they
provide mental health counseling is doomed to failure. In general, professional counseling
claims an orientation toward the promotion of wholeness and healthy human development
as a central professional value (Jane E. Myers et al., 2000). Nearly 20 years ago, Hershenson
and Power (1987) expressed the belief that mental health counseling did not use the term
clinical because of an emphasis on building on existing strengths, coping, and wellness
rather than seeking to cure an illness. As admirable as this stance may be (or may have
been), many counselors currently use the word clinical in their title. At the same time,
many of the other mental health professions have had members move away from
pathologizing, moving toward health and wholeness. For example, in psychology there has
been a strong movement toward positive psychology over the past decade
(Csikszentmihalyi, 2000; L.S. Greenberg, 2002). Many social workers and family counselors
and therapists, too, have a strong strength- based orientation (M.P. Nichols, 2004), and
entire theoretical orientations embrace this perspective (Cheong, 2001). With professional
identity, there can be almost as many within- group differences as there are betweengroup differences. Consider the comments in Digressions for Deliberation 11.1 to see
where you find yourself.
As the use of the term clinical has become more common in association with mental health
counseling, and with social workers who provide mental health counseling, the distinctions
have blurred even further. As noted in Chapter 8, like it or not, mental health counselors
from all backgrounds and philosophies are expected to be familiar with and able to use the
medical/psychiatric DSM system competently, should they be in a setting that requires this
use.
Educational Backgrounds
Educational requirements are an obvious technical distinction among the mental health
professionals. The mental health counseling identity has been refined by state licensure
requirements, national certification requirements, and academic accreditation
requirements.
Digressions for Deliberation 11.1
Perspectives on Human Functioning and Health
Humans have intricately connected brains, bodies, and—many would argue—spirits (or
psyches or personalities or souls). We have both body awareness and psychological
awareness. We know when our body hurts, or needs attention, and we know when our
moods are bad, our hearts are broken, our relationships are unsatisfying, our motivation is
lacking, our potential unfulfilled, or life's meaning has been obscured. In many cultures,
when our bodies aren't functioning well or have been injured, we seek physical assistance.
However, when our psyche isn't functioning properly—we've been hurt, feel stymied,
disillusioned, disheartened, down, bereaved, or angry, humans turn to a variety of sources
of help.
Increasingly, in the United States, we use the scientific/medical model and apply it to our
brain, which is a physical organ assumed to be responsible for our moods, motivation, and
ways of seeing the world. Pharmaceutical companies have developed medications that alter
our complex brain chemistry, which alters our moods, energy level, and motivational and
emotional states. Human mental and intellectual functioning is largely (some would argue
completely) determined by our brain chemistry and electrical activity. There are a number
of factors that contribute to these chemical and electrical functions.
•
There are genetically influenced differences in brain functioning and capacity.
•
Humans interact with their environment and these interactions change their brain
chemistry and electrical activity. Physical exertion, lovemaking, conversation,
learning, practicing a musical instrument, counseling—these all change brain
chemistry.
•
Like the rest of the human body, brains can be injured or become diseased, infected
by viruses, bacteria, or cancer, which then alters the chemistry and electrical
potentials.
•
Finally, humans can ingest substances that temporarily or permanently alter brain
chemistry and electrical activity, through changes in blood- sugar levels or
neurotransmitter activity and availability. The substances can be eaten, drunk,
injected, applied through the skin, or inhaled.
Humans have used mood- altering drugs for thousands of years, but modern
pharmaceutical companies have expanded these options dramatically. We have
medications that control many symptoms of psychoses, that can lift depression, and that
take the edge off of anxiety, terror, and grief. With medication, we can alter our capacity for
attending, we can enhance our ability to sleep, and we can relieve some of the urges behind
compulsions, obsessions, mania, and rage. The medications don't yet cure any known
mental distress or illness, but they do help manage symptoms. They also have known and
unknown short- and long- term side effects, financial costs, and other limitations.
Behaviorists point out “a pill is not a skill”; but sometimes, the pills buy time and provide us
the necessary energy to add the missing skill or develop a more adaptive attitude. Changes
in skills and attitudes are encoded chemically in our brains, so these, too, change our brain
chemistry and perhaps structure.
Humans have also realized for thousands of years that loving relationships, good nutrition,
exercise, shelter, and meaningful work all contribute to healthy mental and social
functioning. We've known, too, that death, loss, broken relationships, trauma, starvation,
and cruelty all take a serious toll on mental and social functioning.
As an alternative to directly altering brain chemistry via drugs, many mental health
professionals believe the brain can be altered through insight (Kivlighan, 2002), new ways
of thinking (J.S. Beck, 1995) and behaving (Fishman & Franks, 1997), mindfully changing
habits (Linehan, 2000), restoring or building new relationships (Moreau, Mufson,
Weissman, & Klerman, 1991), or patiently working through the pain and betrayals of life
(Duncan & Miller, 2000). The works cited are merely representative—there are far too
many clinical and research adherents in each domain to list.
Finally, many professionals and philosophers believe the source of the pain, trauma, or lack
of development lies primarily outside the individual, contained instead within social,
political, cultural, or institutional structures (Adler, 1964; Worell & Remer, 2003). Rather
than helping the individual or family adjust to the way things are, professionals with a
sociocultural orientation might work to help individuals see the injustices that cause the
pain and loss, hoping to empower clients to take control over their lives. These mental
health professionals might work within social systems for change in policies and laws that
are destructive or limiting to human potential.
The roots of the various mental health professionals can be seen in the ways we explain
and address human psychological suffering. Humans are bio- psycho- social- spiritual
creatures of great complexity and potential. There is no single best explanation of human
pain, wholeness, or healing. Each orientation offers an important glimpse into this complex
picture. We need all the points of view. Where do you stand? What does your point of view
contribute? Can you find ways to appreciate other approaches? Do some seem more limited
(even useless) or potentially useless or dangerous to you?
While some states certify or license counselors from programs with less than 60 semester
credits of coursework, and less than 3000 hours of supervised practice, CACREP requires
these credits and hours for mental health counseling training accreditation. In many states,
these requirements are quite similar to other master's level practitioner credentials, such
as the clinical master's in social work.
In most cases, clinical and counseling psychologists have doctoral level training—a Ph.D.,
Psy.D., or an Ed.D.—and can only be licensed as psychologists if they have a doctorate from
a state- approved institution and acceptable coursework and training. The American
Psychological Association only accredits clinical and counseling practitioner programs at
the doctoral level. However, sometimes students obtain a master's degree in clinical or
counseling psychology and become licensed as a professional counselor because they have
a 60 semester credit master's with a state and/or CACREP- approved curriculum. In
addition, school psychologists often obtain master's or educational specialist degrees as
their terminal degree, but refer to themselves as school psychologists or psychologists.
Clinical social work and psychiatric nursing are also common educational backgrounds for
mental health professionals. Training and credentialing requirements vary, but are usually
fairly similar in length to CACREP- accredited mental health counseling programs.
However, the theoretical orientations and practical training modalities reflect the
particular roots of these different disciplines.
Psychiatrists constitute the final large group of mental health professionals with a distinct
educational background. Psychiatrists are medical doctors who have 4 years of general
medical instruction, followed by at least 3 years of psychiatric residency training. Before
the rapid acceleration of pharmaceutical options for altering brain chemistry, psychiatrists
commonly engaged in one- on- one, 50- minute- hour psychotherapy sessions with
patients. However, currently fewer psychiatrists actually practice psychotherapy. Instead,
much of their time is devoted to prescribing and managing medications aimed at alleviating
psychiatric symptoms of human malfunctioning and distress. This is both demanding and
lucrative work, leaving little time for the traditional psychotherapeutic roles psychiatrists
formerly played. Further, learning about the advances in neurology, brain chemistry, and
pharmaceutical options leaves little time for the kind of training most counselors and
psychologists receive to provide effective and ethical counseling.
Psychiatrists are not the only medical professionals who prescribe psychotropic drugs.
Nurse practitioners, physician assistants, internal medicine, family practice, and pediatric
physicians commonly prescribe psychopharmaceuticals, and psychologists are rallying in
some states to undertake the necessary training and be given prescription privileges as
well (Tulkin & Stock, 2004; Wiggins & Wedding, 2004). Further, when a family practice
physician takes time to talk with a patient about mind/body connected symptoms, such as
stomach pain that may be related to stress or anxiety or low energy related to depression,
the patient billing codes may include mental health counseling. This is especially important
to know in that many clients have a limit or cap on the number of sessions or amount of
financial coverage they have for mental health care, and may not realize they have already
used some of their coverage by discussing their problems with their physician.
Perhaps unfortunately, the remuneration and prestige associated with the credentials and
professional backgrounds previously listed tend to correspond with the competitiveness of
admission and the length and depth of training for the types of training—not necessarily
with ultimate professional competence or effectiveness. Research has repeatedly shown
that counseling or psychotherapy effectiveness is primarily related to the client's personal
motivation, strengths, and resources and the development of a positive therapeutic
relationship (Frank & Frank, 1991; M.J. Lambert, 1992; M.J. Lambert & Barley, 2002; L.
Luborsky, Singer, & Luborsky, 1975). In our observations, the internal politics and turf
wars over title, reimbursement, and credentials have less to do with efficacy and caring for
people and more to do with money and power. Years ago, Jay Haley, a renowned master's
level therapist, shared his thoughts on the differences between psychiatrists, psychologists,
social workers, and counselors: “Except for ideology, salary, status, and power the
differences are irrelevant” (Haley, 1977, p.168).
Certainly, there are important concerns regarding competence, ethics, and accurate
representation of credentials and skill levels covered in other chapters. However, our
earnest belief is this: Every mental health profession contributes important worldviews,
identities, and potentially enormously effective work to a world in great need. We are
behaving far more ethically, and present a better image to the public, when all counselors
and mental health professionals treat each other with professional regard.
Terminology Distinctions
As if the varied orientations and educational backgrounds were not confusing enough, we
must also note that our craft, as mental health professionals, has many names—each with
distinction, infamy, and baggage. Some of these terms are jealously guarded, with their use
legislated in some states. The following list is intended to help define these terms. Please
note that these definitions will not travel well. In other countries and regions in the world,
the terms are translated differently and have come to have meanings and expectations
specific to the given culture and service- provision systems.
Counseling
We begin with counseling because we believe it is the broadest, least- pathologizing term
(Maniar, Curry, Sommers- Flanagan, & Walsh, 2001; J. Sommers-Flanagan & SommersFlanagan, 2004b). When people say they are “getting some counseling,” this is generally
understood to mean they are meeting regularly with a mental health professional to work
on psychological growth or psychological distress. The mental health professional is being
compensated, either by an agency, the government, or directly by the client. Sometimes, the
counseling has a distinct focus, with an added delimiter in the name, such as pastoral,
addiction, couple, or rehabilitation counseling. We address specific ethical issues for these
specialties in Chapter 12. In the finer shades of meaning, counseling may be associated with
the provision of more direction, advice, or guidance than the other terms in this list (G.
Corey, 2005; Corsini & Wedding, 2000; J. Sommers- Flanagan & Sommers- Flanagan,
2004b). It may also connote less of the deep probing of the unconscious that the public may
associate with psychotherapy.
Therapy
This term, similar to counseling, is frequently used to refer to counseling or psychotherapy.
In fact, some mental health ethics and theories texts simply use the terms therapy and
counseling interchangeably (G. Corey, 2005; J. Sommers- Flanagan & Sommers- Flanagan,
2004b). On the continuum, though, the meaning of therapy begins to move toward
intervention by an expert who can fix something that is wrong, broken, or diseased. There
is less of a connotation of guidance and more of the application of treatment, which may be
why therapy is also often used to refer to physical therapy or speech therapy or other
forms of direct interventions for problems, injuries, or disabilities. In the provision of
mental health work with groups or families, a number of authors make a distinction
between group counseling and group therapy, or family counseling versus therapy.
Consistent with the move along the continuum toward deeper work, group counseling has
been defined as shorter, more focused on day to day problems of living, whereas group
therapy is longer and more focused on using the group process to uncover early and
unconscious material, seeking characterological change (Furr & Barret, 2000; K.R.
Greenberg, 2003; Yalom, 1995). However, this distinction of depth does not seem present
between the terms family counseling and family therapy.
Similarly, school counselors often emphasize that they “do not do therapy,” which they see
as a more in- depth process best left to mental health counselors. Generally, the term
therapy probably came into common usage as a shortened version of psychotherapy.
Psychotherapy
This term moves further along the continuum. It is understood to be the professional
endeavor of providing some kind of treatment or remedy to the psyche—rehabilitating it
or curing it of its ills. The term has greater specificity than therapy; when people disclose
they are getting psychotherapy, it is unlikely the listener will assume anything other than
“the talking cure” (Bankart, 1997). In the United States, professionals who describe
themselves as psychotherapists intend to communicate that they use interventions
involving depth work, drawing on the theoretical orientations that feature the role of the
unconscious more prominently. The professional work is expected to last longer, as well. In
these days of managed care, it seems almost unbelievable that books written in the 1980s
about brief psychotherapy considered 20 to 30 sessions to be brief work (L. Luborsky,
1984; Strupp & Binder, 1984)!
Analysis
A shortened version of the following term, analysis is a professional endeavor conducted by
professionals with a very specific background and training. The term dates back to
Sigmund Freud (1957/1910).
Psychoanalysis
This is a specialized term, which should only be used with individuals who have received
formal psychoanalytic training (Spitzform, 2004). The approach has its roots in Freudian
psychoanalytic theory, with an emphasis on the power of the unconscious, the importance
of transference, and the centrality of interpretation as a technique to help make the
unconscious conscious (E.E. Jones, 2000). If someone claims to be a psychoanalyst, they
must have received extensive psychoanalytic training.
Like the professions that engage in them, the preceding terms share common ground, and
yet have distinctions that are more or less important to the average layperson.
Professional Organizations
One of the largest professional organizations of mental health counselors is the American
Mental Health Counseling Association (AMHCA), which began as a division of the ACA. In
the mid- 1990s, ACA underwent a major reorganization due to pressures brought to bear
by AMHCA and other divisions wanting greater autonomy and professional distinction
within and/or separate from ACA. This reorganization created a structure that allows
AMCHA and other divisions to have members who do not necessarily belong to ACA.
Similar to members of the American School Counseling Association (ASCA), AMCHA
members can choose to be part of ACA along with their AMCHA membership or can carry
their AMCHA membership separately. There are philosophical as well as financial reasons
for these options.
Mental health counselors might also belong to a number of other divisions of ACA,
depending on their practices and interests. These divisions provide a wonderful vehicle for
connection and professional development along specific lines of interest and expertise. It is
also wise to consider membership in state and local professional organizations.
The other professions who provide mental health counseling (e.g., clinical social workers,
psychologists, psychotherapists, psychoanalysts, psychiatric nurses) all have at least one
professional organization to which they might belong, and many mental health
professionals belong to more than one. Although controversial because of APA's stance of
“doctoral only practitioners,” there is even a specific professional organization for
practitioners holding a master's degree in psychology—the North American Association of
Masters in Psychology.
ISSUES IN AGENCY AND INDEPENDENT PRACTICE
Most mental health professionals can recall their first meeting with their first client. For
some of us, this recollection includes flashbacks commonly associated with Posttraumatic
Stress Disorder—but then, some of us may not have had the benefit of all the readiness
information in Chapter 5. Like many professional endeavors, the provision of counseling
services brings up not only competence- related anxiety, but also the challenging issue of
fees and fee payment. This section discusses the ethical ins and outs and ups and downs
associated with counseling as a business.
Health Insurance, Managed Care, and Fees
Mental health counseling practice providers, whether in independent practice or working
for a community agency, are at least in part paid directly or indirectly by third parties.
These third parties include insurance companies, Medicaid, Medicare, special funds set
aside for counseling services, such as crime victims' funds, and other sources.
In the 1970s, most mental health funders (aka, third party payers) did not place many
demands on agencies and independent practitioners. Although there were limits to the
number of sessions and the amount of money a given third party payer would reimburse to
agencies and practitioners, reimbursement procedures were generally simple and
straightforward: The provider or agency would bill the third party payer (usually an
insurance company) and the third party payer, after a modest delay and after the client had
fulfilled his or her deductible, would pay the provider a prearranged percent of the bill (see
Application 11.1, Understanding Insurance Company Lingo).
Unfortunately, just as mental health counseling was becoming more widely accepted
throughout the United States, a number of converging historical events, including the rising
cost of healthcare and the publication of DSM- III, has led to a movement toward “managed”
health care. As Cottone and Tarvydas (2003) note, “About the same time that mental health
counseling spread its wings and took flight, it encountered the ‘wind shear' of managed
care” (p.261).
Applications 11.1
Understanding Insurance Company Lingo
The following table is designed to help you navigate the often- confusing linguistic world of
health care insurance and managed care. Terminology in this area changes rapidly, but this
table will give you a starting point.
Term
Definition and Use
Third Party
Payer
An entity outside of the therapist- client dyad that pays the professional
for his or her therapy services.
Deductible
A specific amount of money that the client (patient) must pay directly to
the provider before his or her insurance “kicks in” or begins to
reimburse for the professional services. If a client has a $1,000
deductible, it means that he or she is required to pay the first $1,000 of
medical costs “out of pocket” (meaning out of his or her own pocket).
Co- payment
The specific amount for a particular professional service that the
client/patient is responsible for paying. For example, most insurance
packages pay something like “50% of professional fees after deductible,”
and so if the fee is $90, the insurance pays $45 and the client's copayment is $45 after his/her deductible is met.
Mental Health
Parity
A concept meaning that mental health problems are covered by
insurance at the same level as physical health problems. Most or all
mental health professional groups advocate or lobby for mental health
parity.
Managed Care
Organization
(MCO)
An organization that manages or controls whether a specific medical or
counseling service will qualify for insurance coverage. For example,
many managed care companies do not authorize insurance
reimbursement or payment for specific diagnoses (e.g., Adjustment
Disorder) or procedure (e.g., couple, marriage, or family counseling).
Preferred
Provider
Many managed care companies have a preferred provider panel or
network. When clients/patients use a “preferred provider” they receive
increased insurance coverage or reimbursement. When clients/patients
use an “out of network” provider, there is reduced (or no) insurance
coverage.
Preexisting
Condition
A mental or physical diagnosis that predates enrollment in a particular
insurance plan. Sometimes insurance companies refuse to reimburse for
services that treat a preexisting condition.
Psychiatric
Diagnosis
A diagnosis of a mental disorder generally assigned by an appropriately
trained and credentialed provider. To receive insurance reimbursement,
a psychiatric diagnosis is required.
Multi- Axial
Diagnosis
A detailed diagnostic system outlined in DSM, wherein a client's
condition is described on five different axes or domains.
Treatment
Summary
A summary of treatment provided. A treatment summary or specific
case notes are often requested by managed care companies before they
will authorize insurance payments.
National
Practitioner
Data Bank
A national source of information about individual practitioners or
providers. This data bank is often accessed by managed care companies
to determine whether a particular provider should be included on their
preferred provider list.
Of course, mental health counselors were not the only professionals whose practices were
profoundly altered by the advent of managed care and other health insurance costcontainment arrangements. All agencies and professionals in independent or group
practices have been greatly affected. Managed care practices raise many fundamental
issues, some ethical, some practical, and some emotional. As we describe managed care
practices, you will likely understand why there is such a wide range of issues associated
with this particular approach to reducing the cost of mental health services.
Although there are variations on the theme, the basic arrangement is this: In order to be
paid for medical/psychological services covered by a client's insurance, the professional
must be on the approved panel. To be on this panel, providers must sign a contract that
specifies arrangements for fees, treatment plans, session limits, and communication
procedures. For example, providers may be required to provide the managed care company
with case notes or treatment summaries and these notes and summaries and/or requests
for additional sessions are reviewed by a case manager. In addition, providers provide
evidence of malpractice insurance and are held responsible for continuity of care or
appropriate referral, should the benefits run out before the client is “cured.”
Both managed care and traditional insurance companies require that a psychiatric
diagnosis be given to clients seeking mental health counseling. This is not necessarily true
for Employee Assistance Programs, which are defined below. This diagnosis must come
from either the DSM- IV- TR or the International Classification of Diseases—10th Edition
(ICD- 10) and be within a certain group of reimbursable diagnoses, or clients cannot use
their insurance benefits for counseling. As discussed in Chapter 8, those who diagnose are
pulled in two opposite directions:
•
Giving clients a serious mental disorder diagnosis is a significant step. It will travel
with them the rest of their lives, and shape the ways you work and the ways they
see themselves. Caution is called for, and a conservative diagnosis is wisest from this
perspective.
Clients and/or their employers pay a great deal for their insurance coverage. They
deserve to have it cover their medical and mental health needs. If someone is just on
the border of meeting a diagnostic criteria, the counselor may feel a strong pull
toward giving the client the “pathological benefit of the doubt” and diagnosing the
disorder in a way that ensures coverage.
Diagnosing is not an exact science, and the gray areas will provide many ethical challenges
for mental health professionals.
•
Diagnostic challenges and session limits are not the only areas of ethical concern with
health insurance and billing practices. Often, clients have deductible and co- payment
requirements. This means that they must pay, out of pocket, the amount of their deductible
before their insurance benefits begin, and then pay some predetermined percent of the
actual costs. While it might be tempting to wave the deductible, or allow clients to not pay
you their co- payment, such a practice is illegal. It is called insurance fraud. You may argue
that such a practice benefits clients, and in a way, it does. However, your beneficence may
be more safely and legally expressed by complying with laws and ethics codes and instead,
providing services to a certain number of those unable to pay each year (see the following
aspirational statements from ACA and APA).
ACA Code of Ethics
1. Section A Introduction Counselors are encouraged to contribute to society by
devoting a portion of their professional activity to services for which there is little to
no financial return (pro bono publico).
APA Ethical Principles
1. Principle B: Fidelity and Responsibility … Psychologists strive to contribute a
portion of their professional time for little or no compensation or personal
advantage.
NASW Code of Ethics
1. Section on Principles Social workers are encouraged to volunteer some portion of
their professional skills with no expectation of significant financial return (pro bono
service).
Case Example
Nikki Chang, a recently licensed mental health counselor, had a small independent
counseling practice. She also had a modest contract to provide counseling at her local
battered women's shelter. She never felt she was quite busy enough in her practice, so was
motivated to take most referrals. She got a call from a woman named Jan who wanted to
come in for counseling. Jan said that Dr. Freeman had referred her because his practice was
too full right now. She asked about Nikki's fee.
1. Nikki: My fee is $70.00 an hour. I usually see people for one session per week. Is that
about what you were expecting?
2. Jan: Well, yes. Actually, I think Dr. Freeman charges $80.00. My insurance covers
80%, so he would have gotten about seventy- something. You'll wave my copayment like he does, won't you? He does that for my neighbor. It's such a nice
thing.
Nikki felt her stomach drop. Dr. Freeman was a well- known practitioner. She wanted more
referrals from him. Nikki also wanted to work with Jan. She knew if she explained that she
simply could not legally wave Jan's co- payment, Jan would be angry, probably look
elsewhere for counseling, and maybe even tell her neighbor about it so that it would get
back to Dr. Freeman.
Somewhat related to waiving deductibles or co- payments are issues of free first sessions,
sliding fees, and bartering. We discuss each in the following paragraphs.
Self- Pay Issues and Problems
Insurances and managed care systems obviously present some ethical quagmires.
Unfortunately, having clients simply pay as they go can also be more complicated than it
might seem at first.
Free sessions
Free first sessions can be a very kind and helpful policy, or a manipulative marketing
strategy. Luborsky and Crits- Christoph (1998) found that when people are socialized and
instructed about therapy, they make better use of it, benefit more quickly, and drop out
less. Corey and Corey (2002) advocate a pre- group group to help people understand how
group works. Before “starting the clock,” giving people a chance to form an impression of
you and your work, and offering them time to ask questions and get their bearings is wise
clinical practice. You might do this by scheduling extra time at the front end of your first
billed session, or you might offer people a chance to come in for a free or reduced- fee halfhour informational session.
However, a free first real counseling session raises ethical concerns. If the free session is
intended to let clients check out the mental health professional, then clients might end up
in the awkward position of “beginning” counseling two or three times, telling their stories
and needs over and over again. For many clients, this free time will create a sense of
obligation to the professional, thus ensuring they will return. Finally, the laws protecting
insurance companies come into play again. You cannot offer free sessions to selected
clients. If you have a practice, it must be consistent across clients with insurance and clients
without insurance.
Sliding fees
Sliding fees can be an admirable but somewhat complicated practice. It is ethically and
legally permissible to offer clients a sliding- fee scale, but the scale must be consistent. It
should be based on multiple considerations, which can include family size, available
insurance coverage, income, expenses, and so on. It must be included in your intake
information for all clients, and cannot differentiate solely between people who have
insurance and people who do not. Sliding fees cannot simply alleviate the co- payment or
deductible, as we explained previously. Unfortunately, it is often tempting for clinicians to
violate the sliding fee consistency rule. For example:
If your sliding- fee scale allows a client to see you for $30 and his/her insurance pays 50%
after a $150 deductible, then your client will pay $30 for the first five sessions and then the
insurance company will reimburse you $15 for additional sessions and the client will be
responsible for the other $15; as you can see, it would be tempting to charge your usual
$75 fee for the first two sessions and then begin sliding your fee after the deductible is met,
but doing so is illegal; it is also tempting to have an “inside arrangement” where you charge
your client $75, accept $37.50 from the insurance company and then “waive” the
copayment, but this is illegal too.
Sliding fees also present the moral problem of trust. Most helping professionals do not
want to be in the position of checking up on their clients' finances, so if you have a slidingfee scale, you will most likely simply trust your clients' accounts of their financial and
familial situation. If your client claims a very low income, and then arrives in expensive
clothing and driving a far nicer car than you can afford, you might find yourself feeling a bit
judgmental, or even a bit abused. This is a hazard of the practice, and one that most who
charge sliding fees have learned to work with and live with.
Bartering
Ethics codes have often prohibited, or nearly prohibited, bartering as a form of payment
arrangement. The practice has obvious ethical challenges. If you barter for services, you
have an instant new role in your client's life—that of boss or customer. What if you don't
like the job your client does mowing your lawn? What if the engine she repairs stops
working? If you trade a service that brings your client into your home, or into contact with
your family, you have just broken a number of boundaries that are assumed to be in place
in the therapeutic relationship. And even more difficult sometimes is the issue of your
client's occupation versus yours. Maybe your client gets paid $15.00 an hour to landscape,
but you get paid $75.00 for the therapy hour. Will you expect 5 hours of landscaping for 1
hour of therapy? This exchange can have the effect of indirectly devaluing your client's time
or work.
If you barter for goods, you are forced to put a monetary value on items that may not have
had a clear market value beforehand. How many fresh- baked, whole- wheat loaves of
bread are equal to an hour of counseling? What about a lovely piece of pottery or a
beautiful painting? Can you find an agreeable price? What if the painting offered isn't
appealing to you? You are then in the position of judging your client's work, which can have
ramifications in the counseling relationship. No wonder the ethics codes have shied away
from bartering (Woody, 1998). However, because some of our American- Indian students
have explained to us that the practice of bartering may be more accepted, and in fact,
sometimes essential in their cultures (K. McDonald, personal communication, October,
1996), we appreciate that the codes have not banned bartering entirely.
ACA Code of Ethics
1. A.10.d Bartering
Counselors may barter only if the relationship is not exploitive or harmful and does
not place the counselor in an unfair advantage, if the client requests it, and if such
arrangements are an accepted practice in the community. Counselors consider the
cultural implications of bartering and discuss relevant concerns with clients and
document such agreements in a clear written contract.
APA Ethical Principles
1. 6.05 Barter with Clients/Patients
Barter is the acceptance of goods, services, or other nonmonetary remuneration
from clients/patients in return for psychological services. Psychologist may barter
only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is
not exploitative.
NASW Code of Ethics
1. 1.13 Payment for Services
1. (b) Social workers should avoid accepting goods or services from clients as
payment for professional services. Bartering arrangements, particularly
involving services, create the potential for conflicts of interest, exploitation,
and inappropriate boundaries in social workers' relationships with clients.
Social workers should explore and may participate in bartering only in very
limited circumstances when it can be demonstrated that such arrangements
are an accepted practice among professionals in the local community,
considered to be essential for the provision of services, negotiated without
coercion, and entered into at the client's initiative and with the client's
informed consent. Social workers who accept goods or services from clients
as payment for professional services assume the full burden of
demonstrating that this arrangement will not be detrimental to the client or
the professional relationship.
We would add one last step to the code requirements: seek consultation or supervision if
you have decided to enter into a bartering arrangement. If you are bartering across
cultures, seek culturally informed supervision or consultation, as you may unwittingly miss
an important step in the culturally accepted process.
Pause for Reflection
Insurance changes, billing practices, and the pressing needs of people are weighty matters. In
order to be reimbursed for your work, you take on liabilities and diagnostic challenges that
complicate a wish to simply provide clients with the best counseling possible. Although mental
health professionals joke about vying for the young, ambitious, verbal, intelligent, wealthy,
and insightful clients—in other words, the worried well—most drawn to the profession care
deeply about people in pain and want to offer effective, therapeutic services to the needy as
well as those with resources. What do you anticipate, or already find, to be most troubling
about insurance, managed care, and Medicaid systems as they interface with your
professional calling to provide effective help?
Confidentiality with Other Professionals
Licensed mental health professionals often work in agencies with other mental health
professionals and/or (hopefully) have consultation or supervision groups. They may also
have colleagues who are social acquaintances or friends. We discussed this component of
confidentiality in Chapter 6 in a general sense, but we want to revisit it specifically with
mental health counseling and the specialties in the next chapter. Why are we insisting on
this redundancy? The 50- minute- hour therapy relationship has predictable dynamics that
make confidentiality in professional interactions something to be especially wise about.
You may wish to review the discussion about transference and countertransference
in Chapter 7. Transference might reveal itself in the assumptions clients make about your
interactions with other professionals. For instance, some clients may have had parents or
caretakers who were overly controlling and/or talkative. These parents may have told their
children's secrets to others—teachers, family members, physicians, pastors, and so on.
Depending on how this activity was perceived, these clients may assume you will betray or
take care of them in similar ways. They may assume everyone in the office, and even people
in offices down the hall, know all about them. Conversely, clients may have had parents or
caretakers who were especially private, or who completely ignored their children's needs
or accomplishments. These clients may have entirely different transferential expectations
about how you will or will not share information with other professionals. Your informed
consent process will need to be very specific so that people understand with whom you will
and will not be sharing information.
Further, in the somewhat likely event that you are in a close business or romantic
relationship with another mental health professional, perhaps even married to one, rest
assured that clients will make assumptions about what you do or do not share with this
person. We are occasionally quite surprised at the assumptions clients make about what
we do and do not tell each other about our work with given individuals.
Remember, too, that your own countertransference, or parataxic distortions about clients,
could influence the ways you speak about your clients to other professionals. If you find
yourself being overly open, chatty, scornful, or dramatic about your work with certain
clients, you might want to give the matter some serious thought, and perhaps get
consultation or supervision. Clients will have life stories and ways of being that you will
find difficult to contain. You may also have colleagues who thrive on hearing about others'
clinical work, and make ask for inappropriate information. Neither of these are
justifications for breaks in confidentiality.
Case Example
A midlife counselor, Fred, was seeing a man who was in the midst of a horrible divorce. The
man was a well- known newspaper editor, and the reasons for the divorce included the
client's wife getting in a fistfight with a local attorney, with whom she was having an affair.
The police were called, and the whole thing, much inflated and sensationalized, was on the
evening news. Fred was at a party with many other mental health professionals. His
colleague, Joanne, approached him and began a conversation about this news story, not
knowing that this man was Fred's client. Fred dropped his guard for a moment and told
Joanne that the news account wasn't entirely accurate, and that the woman in question had
a history of physical violence toward men. Joanne gave him a funny look and asked how he
would know. Fred felt a rush of embarrassment. He knew he should not have said a word.
He could tell that Joanne wanted to know more, but he also knew she would be
disappointed in him if he admitted his error.
Competence and Supervision
Most mental health counseling programs have a generalist curriculum that prepares
students well in the foundations and basic skills of counseling. However, very few
programs have enough time or room in the curriculum to provide extensive coursework in
specific clinical areas, such as childhood sexual trauma, couples work, personality
disorders, suicidality, bi- polar or obsessive- compulsive disorders, panic attacks, phobias,
pedophilias, and so on.
A generalist master's also does not usually provide graduates with advanced skills in using
theory- driven or general counseling techniques such as systematic desensitization,
hypnosis, psychodrama, cognitive- behavioral homework, dream work, or even advanced
group work. Often, practicum and internship sites are able to give students exposure to
some, but certainly not all, of these problem areas and intervention strategies. Recent
graduates often grapple with the ethical conundrum of knowing just enough to know they
should know more.
The requirement to practice competently—which requires experience beyond graduate
school—may seem like a double bind. How can you offer competent counseling to teens
that cut or burn themselves when you've not worked with this age group or problem area
before? The answer lies in two very important practices: informed consent and
supervision. In graduate school, or shortly after, we strongly advise you to find a group of
colleagues and form a consultation group. There can be great comfort and wisdom in such
groups. Further, you will need to find both good overall supervision and supervision that
helps you grow and develop your skills in specific problem areas and in the application of
specific techniques.
Case Example
Joseph, a newly hired counselor in a group practice, had an intake interview with Naomi, a
14- year- old girl, and her parents, Isaac Rosenthal and Esther Ruben. Isaac explained that
Naomi had terrible mood swings, and had recently been staying up all night, cleaning her
room and listening to music. They had consulted their family physician, who had diagnosed
Naomi with Bipolar I Disorder and had prescribed Abilify. The physician had suggested
family counseling, and since Joseph's group practice offered the only sliding fee in town,
they had chosen to come there. Joseph had never worked with anyone who had this
diagnosis, but he had worked with a large number of families with various problem areas
in his internship. Here is how he presented this information to the Rosenthal- Rubin family:
“It is really a good thing that you've come in for counseling as a family. Naomi, obviously
your parents care a lot about you and what's happening in your life. I've worked with
families facing all sorts of challenges, and I know it's a good thing when families work
together. I want to let you know that I haven't had a chance to work with anyone who has a
bipolar diagnosis, but I certainly know about the diagnosis, and the struggles that come
with it. If we decide to work together, my intention would be to get some consultation and
supervisory input from someone who has more knowledge in this particular area. I will
also do some specific research and reading on Bipolar Disorder, and on families facing this
challenge. I imagine we all have something to learn, and with the technological resources
we have nowadays, we can keep up with the latest medical and counseling information out
there. How does that seem to you all?”
Developing new specialty skills can be an exciting prospect for mental health professionals,
both young and old. It provides new opportunities for skill development and helps keep
professional life interesting. As noted in Chapter 9, because our field is constantly evolving,
simply maintaining competence in our core areas requires continuing education, so adding
competencies or specialties can be challenging.
ACA Code of Ethics
1. C.2.b. New Specialty Areas of Practice
Counselors practice in specialty areas new to them only after appropriate
education, training, and supervised experience. While developing skills in new
specialty areas, counselors take steps to ensure the competence of their work and to
protect others from possible harm.
2. C.2.f. Continuing Education
Counselors recognize the need for continuing education to acquire and maintain a
reasonable level of awareness of current scientific and professional information in
their fields of activity. They take steps to maintain competence in the skills they use,
are open to new procedures, and keep current with the diverse populations and
specific populations with whom they work.
APA Ethical Principles
1. 2.03 Maintaining Competence
Psychologists undertake ongoing efforts to develop and maintain their competence.
NASW Code of Ethics
1. 1.04 Competence
1. (b) Social workers should provide services in substantive areas or use
intervention techniques or approaches that are new to them only after
engaging in appropriate study, training, consultation, and supervision from
people who are competent in those interventions or techniques.
2. (c) When generally recognized standards do not exist with respect to an
emerging area of practice, social workers should exercise careful judgment
and take responsible steps (including appropriate education, research,
training, consultation, and supervision) to ensure the competence of their
work and to protect clients from harm.
Even though Chapter 9 covered competence generally, it is an especially salient and
important ethical boundary for mental health counselors. In independent practice, there
are few, if any, outside observers of your work. The creativity and spontaneity that comes
naturally to some counselors must be reserved for settings that are overtly designed for
this kind of intervention. We quote one of our favorite supervisors: It is not okay to fly by
the seat of your pants (P. Bornstein, personal communication, March 10, 1984). The place
for the development of new theories and techniques is in the context of experienced
practitioners who are situated in a way that allows collegial input, research, and careful
analysis of the effects and outcomes associated with the new techniques or strategies. And
of course, clients involved should be fully informed of the experimental nature of any
treatment.
This admonishment may seem ridiculously obvious in a nice, safe classroom environment,
or when read in an ethics text. Sitting stymied or inspired with a vulnerable client who will
not know the difference between a theoretically sound, professionally accepted technique
and one you just made up on the spot is a different story. Sometimes, you will be tempted
to do something provocative or refreshingly new. This is not necessarily forbidden
ethically, but to make such an intervention ethical, you need to:
•
fully inform your client that the thing you are doing or suggesting is new and has no
evidence of effectiveness;
•
explain your rationale to your client;
•
be able to articulate, to yourself, why you think this intervention would be helpful;
and
•
be confident that you could fully explain and justify your actions to colleagues or
supervisors.
Professional Representation
Mental health counselors are ethically required to practice competently and to represent
themselves and their skill levels accurately to clients and other professionals. The
temptation to represent oneself as specializing in certain areas as a marketing strategy can
be quite strong. What amount of training and supervision qualifies someone to claim the
specialty? Certain specialties, such as group work, family or couples counseling, or sex
therapy, have professional organizations with specific training and supervision
requirements beyond a generalist counseling degree. We cover some of these in the next
chapter. Clearly, counselors should not represent themselves as specialists simply because
of an interest in a certain area. At the very least, claiming a specialty should be preceded by
the following:
•
•
advanced study through workshops, classes, books, journals, and continuing
education in the area of interest
role- play of key techniques with willing colleagues or supervisors until you've
achieved a sense of ease and can predict the effect of the technique(s)
•
supervised work with the problem area of interest by seasoned, professionally
recognized experts in the area
•
a record of successful outcomes in the problem area
A counseling or psychotherapy practice is a business and so it is natural for mental health
professionals and agencies to advertise or otherwise promote themselves to the public. The
key ethical issue within this domain is accurate representation. In a free market society,
advertising oneself is a basic right. Self- promotion in the media, however, can have mixed
results for the field overall. Further, radio and television talk shows often feature those
willing to dispense advice and judgments as “Doctors” without actually explaining their
professional training or credentials. Of course, this type of activity is in the realm of
entertainment, not professional mental health provision, but the pub lic can become
understandably confused.
In contrast to statements about professional specialty training and continuing education,
ethics codes indicate that misrepresenting professional credentials is unethical.
APA Ethical Principles
1. 5. Advertising and Other Public Statements
1. 5.01(b) Psychologists do not make false, deceptive, or fraudulent statements
concerning (1) their training, experiences, or competence; (2) their academic
degrees; (3) their credentials; (4) their institutional or association
affiliations; (5) their services; (6) the scientific or clinical basis for, or results
or degree of success of, their services; (7) their fees; (8) their publications or
research findings.
ACA Code of Ethics
1. C.3.a. Accurate Advertising
When advertising or otherwise representing their services to the public, counselors
identify their credentials in an accurate manner that is not false, misleading,
deceptive, or fraudulent.
2. C.3.c. Statements by Others
Counselors make reasonable efforts to ensure that statements made by others
about them or the profession of counseling are accurate.
3. C.4.d. Implying Doctoral- Level Competence
Counselors clearly state their highest earned degree in counseling or closely related
field. Counselors do not imply doctoral- level competence when only possessing a
master's degree in counseling or a related field by referring to themselves as “Dr.” in
a counseling context when their doctorate is not in the counseling or related field.
NASW Code of Ethics
1. 4.06 Misrepresentation
1. (c) Social workers should ensure that their representations to clients,
agencies, and the public of professional qualifications, credentials, education,
competence, affiliations, services provided, or results to be achieved are
accurate. Social workers should claim only those relevant professional
credentials they actually possess and take steps to correct any inaccuracies
or misrepresentations of their credentials by others.
Pause for Reflection
How do you want to represent yourself to the world? Take a few minutes to look carefully at
counseling and psychotherapy advertising in telephone books, fliers, newspapers, and Internet
sites. What stands out for you? Which forms of advertising seem professional and trustworthy
to you? What claims seem questionable?
The bottom line for mental health practitioners is truth in advertising. We are to engage in
only accurate advertising, which some have observed is nearly an oxymoronic phrase in
our culture. Unlike most corporate or retail entrepreneurs, unless you have clear
supporting data, you cannot ethically place an advertisement in the newspaper or
telephone book (or anywhere) that states, “Guaranteed results.” Similarly, ethics codes do
not allow practitioners to solicit testimonies about their services, no matter how excellent,
from former clients.
As an aside to consider, in our experience in rural communities, too much advertising is
sometimes viewed as a sign of desperation, or lack of skill. Word of mouth and referral
networks are assumed to be sufficient forms of advertising, and anyone who advertises
excessively after getting established might be seen as less than adequate.
ETHICAL CONCERNS IN CAREER COUNSELING
In the counseling world, as a specialty, career counseling is one of the oldest. As a strand of
our history, career counseling is a wonderful endorsement of human individuality and the
rights of all adults to develop their gifts and passions into meaningful employment. In the
excitement of the rapid development of mental health counseling, we may have
temporarily forgotten how absolutely central is the place of right vocation in the well- lived
life.
The psychologist Abraham Maslow calls spiritual and emotional truancy the Jonah
Complex: “The evasion of one's own growth, the setting of low levels of aspiration, the fear
of doing what one is capable of doing, voluntary self- crippling, pseudo- stupidity, mock
humility” (Levoy, 1997, p.191).
Cottone and Tarvydas (2003) point out that career counseling played a defining role in
establishing the organizational structure of professional counseling, and career counseling
led in establishing basic standards for our profession. They write, “The National Career
Development Association (NCDA), the primary organization that represents career
counseling and development professionals, is the oldest counseling organization in the
world and has been defining the profession, its ethics, and standards for almost 90 years”
(p.291). These authors go on to explain the history of struggles over credentialing and
levels of professional training required for persons who wish to claim a career- counseling
specialty.
As the profession of counseling evolves, it is clear that assisting in career choices,
transitions, and development will continue to be part of working positively and holistically
with people. Working with employers, employee assistance programs, agencies, and
governmental programs will also be specialty avenues for counselors interested in the
world of employment. It will probably also be true that paraprofessionals and persons with
less overall mental health training will fill some of these positions for the foreseeable
future.
Specialty Competencies and Credentials
The NCDA (National Career Development Association, 2005) has established 11
competency areas that are considered the minimum requirements for a career counseling
specialty. These requirements are as follows:
1. Knowledge of career development theory.
2. Acquisition of individual and group counseling skills.
3. Acquisition of individual and group assessment skills.
4. Knowledge of information and resources.
5. Skills in program promotion, management, and implementation.
6. Skills in consultation, coaching, and performance improvement.
7. Knowledge and skills for working with diverse clients.
8. Knowledge of supervision skills and theory.
9. Awareness of ethical and legal concerns.
10. Ability to conduct and assess research and evaluate intervention outcomes.
11. Skilled use of available technology.
While there have been many transitions in credentialing, the NCDA now has the Master
Career Counselor (MCC) and the Master Career Development Professional (MCDP). Each of
these have similar minimal requirements, which include a master's in counseling or closely
related field; graduate work in career information, theories, assessment, and development;
significant practicum, internship; postdegree supervised experience in the area; letters of
recommendation; and ongoing membership in NCDA.
Specific Ethical Concerns and Challenges
Counselors with career specialties face many interesting ethical challenges. As is true with
rehabilitation counseling, career specialists are often hired by employers or others with a
vested interest in the outcome of the counselor's work with individuals in question.
Values and client rights
There are many vested interests and pressures that come to bear on people making career
decisions. Consider the following publisher's description of the book Necessary Dreams, by
psychiatrist Anna Fels (2005).
Despite the huge advances women have made in recent decades, their ambitions are still
undermined in subtle ways. Parents, teachers, bosses, and institutions all give less
encouragement to women than men, and women still grow up believing that they must
defer to men in order be seen as feminine. If their ambition does survive into adulthood,
too often those ambitions must be downsized or abandoned to accommodate “wifely”
duties of household chores and child care. As a result, women—unlike men—continually
have to re- shape their goals and expectations. Yet expressing ambition, pursuing it, and
getting recognition for one's accomplishments is critical to identity and happiness. (p.1)
Career counselors need to make sure they do not allow these pressures to subtly influence
the career paths they help people explore.
Informed consent
Extra care must be taken in the informed consent process, so that clients understand the
career counselor's role in their lives. They need to realize that there will be limits to the
counselor's advocacy and/or neutrality. This does not mean career counselors are simply
extensions of the agency or industry employing them, but it does mean that there are goals,
realities, and limits to their work that a generalist counselor might not face.
Confidentiality
For career counseling, confidentiality is another important concern. The need for career
consultation or counseling often arises in the context of life transitions or needs that
involve other professionals. Thus, career counselors are commonly part of
multidisciplinary teams, and are expected to share information more freely than
counselors might in other settings. The amount and type of information shared should be
clearly relevant, and shared with the client's welfare paramount. It is all too easy to share
more than is necessary in team meetings, simply because it is interesting, or because the
team members all seem well- intentioned people who want to know all there is to know
about someone. Again, clients should be fully informed before you share information about
them, and the information should be germane to the stated goals of the professional team.
Competence
As with any specialty, the question of treatment goals and breadth of service arises. Clients
originally come to see a counselor because of a specific goal, need, or problem area, but
sometimes, in the context of this work, it becomes clear there are other, possibly related
areas of concern. This is an issue of competence, and of course, informed consent. See the
following Case Example for a glimpse into how related treatment goals might manifest.
Case Example
Kallen has her M.A. from a counseling program with CACREP- accreditation in the mental
health track. She has also obtained her MCC and is a standing member in NCDA. Sara has
come for career counseling because she has developed a fear of heights and can no longer
climb the ladders necessary for her carpentry job. Her current employer has lost patience
with her, and has offered to pay for the counseling. Sara has heard that Kallen is very good
at helping women sort out their lives and find new careers.
As it happens, Kallen has done a great deal of reading about specific phobias, attended
workshops, and successfully treated clients with panic attacks, claustrophobias, and related
problems. While she respects Sara's wish to consider a new career, she also informs Sara
that she might be able to help her overcome her fear of heights. Sara agrees, very
enthusiastically. What ethical concerns come to mind?
There is nothing inherently unethical about adding or changing counseling goals or
techniques in the context of the counseling relationship. The issues to consider are
competence and informed consent. If the counselor is trained in areas of concern that arise
during the course of work in the specialty area, and/or can obtain competent supervision,
then the counselor is well within ethical limits to bring this to the client's attention and
engage in a new layer of the informed consent and goal- setting processes.
Of course, we do not know exactly how Sara arranged the payment with her employer. We
also do not know if Sara has informed Kallen of the source of payment, or if, at Sara or the
employer's request, Kallen has agreed to keep Sara's employer informed. These are all
dimensions that would have been included in the informed consent process.
Care must be taken so that the client is aware of the possibilities of adding new goals and
directions to the counseling work without feeling pressured to consent. In most cases, the
counselor would have both ego investment and financial reasons to hope the client agrees
to further counseling. Neutrality is best achieved by counselors who both consciously
acknowledge these incentives and do their best to factor them out.
CHAPTER WRAP- UP
This chapter and the next could easily be accused of being redundant with the more
general chapters earlier in this text. We plead guilty. Ethical professional conduct has much
common ground, with differing emphases and slightly varying contingencies. Because of
the ever- emerging distinctions in professional identities, this text has set aside chapters
and portions of chapters for specialties and professions that are closely related to the
overall provision of professional counseling. Every ethics text tackles these internal
divisions and distinctions differently. The provision of mental health counseling and career
counseling are distinct specialties with both shared and unique ethical concerns.
Those currently working as mental health counselors face many ethical and practical
challenges in today's economy and political climate. As the medical dollar has tightened,
independent practice has become ever more challenging—perhaps adding fuel to the ageold turf battles between the helping professions. We have not yet convinced society to
create mechanisms that pay collectively for prevention, wellness, and/or early intervention
in mental health assistance. Coping with vicissitudes of third party payers while keeping
our footing in the great river of human need leaves little time for such societal level
dialogues and evolution.