The case study of Tamika Johnson

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timer Asked: Jan 8th, 2018

Question Description

Before you begin your Assignment, watch a brief video introduction to Tamika Johnson and one of her clients.

In a 3–5-page paper, analyze the implications of this case. Use the Internet and the Library to research the legal and ethical issues presented by this situation and respond to the following questions:

1. Discuss the next steps Tamika should take in the case. Explain the reasoning for your choices.

2. Identify the various ethical dilemmas presented in this scenario.

3. Discuss the specific NOHS Standards that would apply in this situation.

4. Explore any legal issues that might be raised by this situation regarding any state or federal laws. How might this information guide Tamika’s actions?

5. Describe and discuss the mandatory reporting laws in your state. If Tamika lived in your state, would she be required to take any particular action?

6. If you were Tamika’s supervisor, what direction might you provide for her? How might her actions impact you?

7. Finally, discuss strategies to minimize the likelihood of these legal and ethical issues arising in your practice.

Please be sure to introduce the specifics of the case study in your paper, which should reflect your understanding and research of these issues.

Your Assignment should:

  • Be presented in the form of a well-written university level document
  • Use an essay format, 12-point font, and double spacing
  • Be 3–5 pages in length, not including the title and reference pages
  • Include a title page and reference page
  • Including at least two references in support of your observations and conclusions using proper APA citation and reference formatting

Unformatted Attachment Preview

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.
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