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Ethics and Standards of Practice for Rhode Island Back to Course Index

 

 

 

 

 

 

Boundaries are the framework within which the counseling relationship occurs.  Boundaries keep the relationship professional.  They set the parameters within which the client remains safe and the treatment can be effective.  They also help to protect the clinician both emotionally and legally.

Having a strong ethical compass it critical to being a good counselor.  Are your boundaries consistent?  Do they waiver based on how you feel about the client or the situation?  Do they establish healthy relationships, enabling the client to experience personal growth?

Professional issues typically include personal disclosure, limits regarding the use of touch, the tone of the professional relationship both in treatment and with the chance meeting in public, fee setting, projected length of sessions, the limits of the relationship and ultimately end “all things ethical”. 

The primary concern in establishing and managing boundaries with each individual client must be the best interests of the client. Except for behaviors of a sexual nature or obvious conflict of interest activities, boundary considerations often are not clear-cut matters of right and wrong. Rather, they are dependent upon many factors and require careful thinking through of all the issues, always keeping in mind the best interests of the client.

Many questions arise when navigating the counseling relationship.  Should a counselor date a former client?If they can date, how long should they wait after counseling has been terminated to have a relationship?Should the counselor terminate counseling if they begin to privately become interested in the client?Should a therapist accept a client’s gift?

The relationship outside of counseling, the acceptance of gifts, and the recognition of a previous or current client in public are examples of areas that could pose problems for both the therapist and the client.

Boundary issues also involve counselors and supervisors, both during academic years and post graduation on into the work force, as well as colleague situations.Should my aunt, as a licensed professional, be able to supervise my practicum as an intern?If my husband is a psychologist speaking for an association offering continuing education should I be able to earn contact hours if I attend?

Most state boards and all national associations have bi-laws and regulations concerning the relationships between a counselor and a client, as well as a supervisor and a counselor.It is good counsel to make yourself aware of the regulations and then to steer clear of any inappropriate situations.It is also a best practice to make your clients aware of the general boundaries and why they exist such as, “please understand to protect your privacy, if I see you in public I will not acknowledge you in any way.This is not intended to offend you, but only to protect you.“This way the client will not feel slighted should the event occur.

In this course will explore the dynamics and potential danger zones for the counseling relationship and in the mental health field. This text will explore.

  • Professional Licensing in Rhode Island
  • Key Concepts Regarding Dual Relationships with Clients
  • Physical Contact and Sexual Relationships with Clients
  • Self Disclosure
  • Sound Decision Making and Managing Boundaries Set
  • Emotional and Dependency Needs
  • Professional Distance
  • Therapeutic Styles
  • Dynamics Which Make Therapy a Potential Setting for Boundary Violations and  Exploitation

The Rhode Island Board of Mental Health Counselors and Marriage and Family Therapists is the licensing entity for licensed mental health counselors and marriage and Family Therapists.  A professional who meets the qualifications can be licensed by endorsement, if licensed in another state and moves to Rhode Island; or by examination.  

Licensed clinical mental health counselors or licensed marriage and family therapists should abide by all expiration and renewal of licensure requirements in R.I. Gen. Laws § 5-63.2-17.

R.I. Gen. Laws § 5-63.2-21 explores the grounds for discipline.  This is an overview.  Please refer to the laws for a full list and explanation.

Grounds for discipline include:

(1) Is guilty of fraud or deceit in procuring or attempting to procure a registration;

(2) Is guilty of a felony or of a crime of immorality;

(3) Is habitually intemperate or is addicted to the use of habit-forming drugs;

(4) Is mentally incompetent;

(5) Has willfully or repeatedly violated any of the provisions of this chapter;

(6) Is habitually negligent in the performance of his or her duties;

(7) Has willfully or repeatedly violated any of the ethical principles governing mental health counselors and marriage and family therapists and the practice of mental health counseling and marriage and family therapy, as adopted by the board, and in force at the time a charge is made and determined by the board, regardless of whether or not the person is a member of any national, regional or state professional association; provided, that the ethical principles are of a nationally-recognized standard of the respective national professional organization.

In addition to the grounds for discipline set forth in R.I. Gen. Laws § 5-63.2-21, the Board has the power to deny, revoke or suspend any registration applied for or issued by the Department or otherwise discipline a licensed clinical mental health counselor and/or a licensed marriage and family therapist upon proof that the person has departed from or has failed to conform to the minimal standards of acceptable and prevailing practice of mental health counseling and/or marriage and family therapy and adhere to the National Board of Certified Counselors (NBCC) Code of Ethics adopted by the Board.

The NBCC Code of Ethics, being the standards adopted by the Rhode Island, state the following directives.  The full NBCC Code of Ethics is below the coursework.

NBCC Directives:  (NCCs refers to National Certified Counselors)

    • NCCs take appropriate action to prevent harm.
    • NCCs provide only those services for which they have the education and qualified experience.
    • NCCs promote the welfare fo clients, students, supervises, or the recipients of professional services provided.
    • NCCs communicate truthfully.
    • NCCs recognize that their behavior reflects on the integrity of the profession as a whole, and thus, they avoid actions which can reasonably be expected to damage trust.
    • NCCs recognize the importance of and encourage active participation of clients, students, or supervisees.
    • NCCs are accountable for their actions and adhere to recognized professional standards and practices.

 

In most friendships or marriages the relationship bears some resemblance to a seesaw.I tell you my thoughts and in turn you tell me your thoughts.You know my faults and I learn yours.There is a give and take of information that creates a balance.A therapist/client relationship is not balanced.By the nature of the relationship, one person is telling intimate details, feelings and fears and the other is not.This intimate knowledge creates power that has to be handled professionally.

A dual relationship exists when a therapist serves in the capacity of both therapist and at least one other role with the same client. Most commonly the second relationship is social, financial, or professional and may be concurrent or subsequent to the therapeutic relationship. The American Psychological Association reports research citing that dilemmas arising from “blurred, dual, or conflicting relationships” were the second most frequent ethical dilemma noted.Dual relationships can also be a major basis for licensing disciplinary actions and ethics complaints against mental health professionals.

Rhode Island’s 216-RICR-40-05-11 offers 11.4.1 Grounds for Discipline that states that they hold professionals to the standards of the NBCC Code of Ethics.   The National Board for Certified Counselors (NBCC) states that NCC’s shall not engage in harmful multiple relationships with clients.  In the event that a harmful multiple relationship develops in an unforeseen manner, the NCC shall discuss the potential effects with the client and shall take reasonable steps to resolve the situation, including the provision of referrals.  This discussion shall be documented in the client’s record.  

The Code of Ethics for the American Counseling Association (ACA) strongly advises avoidance of harmful dual relationships whenever possible:

Counselors are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of clients. Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. When a dual relationship cannot be avoided, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. (ACA, 1995, Standard A. 6.a.)


The ethics code for the American Psychological Association states that multiple relationships may be unavoidable and recommends that therapists remain aware of the pimgres-1otentially harmful consequences
. They recommend refraining from multiple relationships if harm may occur.


The ethics codes of the American Association of Marriage and Family Therapists, National Association of Social Workers, and the American Association of Pastoral Counselors recommend avoidance of multiple relationships that exploit or harm clients. All of the above codes strictly prohibit sexual activity between therapist and client. All but the AAPT code warns against superior/subordinate dual relationships such as when a therapist has an administrative, supervisory, or evaluative role with a client.


A window into any relationship is only as clear as the participant’s insight. Most people see things from their point of view. Is it wise, with one participant in a more powerful position to enter into multiple types of relationships with someone?


Therapists can and should be concerned about any behavior on their part that may interfere with their ability to maintain a professional and therapeutic relationship with their clients. When roles get blurred as when the therapist and patient become personal friends, business partners, or become involved sexually it often becomes impossible for the therapist to maintain professional objectivity. 
Dual relationships can erode and distort the professional nature of the therapeutic relationship. They may create conflicts of interest that compromise professional judgment or create situations where the therapist is engaged in meeting his or her own social, financial, or personal needs, rather than putting the welfare of the client foremost. Dual relationships can affect the current and future benefits of therapy.

Some of the clearest cut dual and boundary problems are therapists engaging in business ventures with patients or having sexual relationships with patients or former patients. It is clearly unethical and in most states, therapists who have sexual relationships with clients violate the law, as well as ethical standards. But these overt situations are not the only type of dual relationships. Friendships, dating a client’s brother, or even being neighbors are also potentially hazardous situations.

The reality of potentially overlapping relationships and the effects of overlapping relationships make for a complicated decision-making process. To determine if a relationship outside of the therapeutic realm is hazardous a professional must explore several areas.


Circumstantial roles, those that occur by pure coincidence, such as running into a client at their sales job in the mall, are difficult to avoid. They are bound to occur and this potential and how it is to be handled should be discussed in advance. As noted earlier: “If I see you in public, please do not be offended, but I will not approach or acknowledge you in any way to protect your confidentiality.”


Shifts in professional roles include difficulties that arise when a teacher or supervisor counsels a student. There is a clear potential for difficulty with this type of dual relationship. Personal and professional role conflicts include sexual or romantic, social, and peer-like relationships. These personal and professional situations are fraught with danger.


Some professionals use their own comfort level to gauge whether they could successfully manage the overlapping relationship. The type and severity of the clients’ presenting problems are also used as an indicator when deciding to enter a dual relationship. Therapists are more likely to enter a dual relationship if the client is seeking problem-solving and would likely avoid a dual relationship with a client if they suspected a complex issue such as a personality disorder. Other therapists involve prospective clients in the decision-making process to decide if the benefits of entering into a dual relationship outweigh the risk.
Keith Brownlee (1996) expresses that “Pivotal to any decision making based on the codes, are the two central principles, impaired objectivity, and risk of exploitation.


When a dual relationship exists it is important to minimize the risks by engaging in ongoing consultation, setting clear expectations and boundaries, informed consent, documentation.

The achievement of trust is possible in a therapeutic relationship because there is no fear of losing “self” in establishing a connection with a therapist. Most clients come to the situation with a vulnerable self. Intimacy for these individuals can easily lead to abuse if those with whom they relate prove untrustworthy.

Many therapeutic styles involve the healing touch. Hugging a client when they enter the office, holding their hand through difficult sessions or placing a hand on their shoulder when they are crying can all be ways of expressing interest and concern. They can connect and solidify the helping relationship. They can also be abused, misunderstood, and damaging. This issue forces counselors to examine the heart of the therapeutic process: the counseling relationship.


It is doubtful that most therapists set out to exploit their clients. When a counseling relationship turns into a romantic relationship the professional will often say, I can’t help whom I fell in love with. This type of violation is more of a process than a single event.  Yet when professionals deny or remain unaware of their personal significance, power, or authority they will begin the process of boundary violation. Any time a professional exploits a relationship to meet personal needs rather than the needs of the client, even if not consciously done, the boundaries have been crossed and the professional is responsible.


There is a clear consensus among the professional associations that concurrent sexual and professional relationships are unethical and in many states also illegal. Many of the associations agree that a sexual relationship cannot later be converted into a therapeutic relationship.


Ethical codes vary in their requirements about the length of time that must pass for another “significantly different” relationship, especially a sexual one, to be permissible (Herlihy & Corey, 1992). Although most codes prohibit the counselor from having a sexual relationship with a current client, variation occurs in the prohibition of such a relationship with former clients and the length of time that must pass for such a relationship to be permissible (American Counseling Association, 1995; National Association of Alcoholism and Drug Abuse Counselors, 1995).

All the major professional associations agree that sexual contact less than two years after termination of the professional relationship is unethical. If a sexual relationship occurs after a two-year interval, the burden rests with the therapist to demonstrate that there has been no exploitation. Considerations include the amount of time that has passed since termination; nature and duration of therapy; circumstances surrounding termination; client’s personal history; client’s mental status; and any statements or actions by the therapist suggesting a romantic relationship after terminating the professional relationship.


There is disagreement among practitioners about whether a sexual relationship initiated after termination is ever ethical. Some maintain that “once a client, always a client.” The transference elements of the therapeutic relationship persist forever, and therefore, many professionals consider romantic relationships with former clients unethical.


After having various standards for a number of years, the American Psychiatric Association went from a “nearly never OK” standard to an absolute “never OK” standard.


The National Association of Social Workers code prohibits sex with former clients in section 1.09, but states that if a social worker claims an exception, the full burden is on them to demonstrate “…that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.” The codes also ban sexual contact with clients’ relatives or close personal friends where there is a potential to harm the client, but it is not clear whether this extends to a former clients’ relatives and friends.


The American Association for Marriage & Family Therapy has forbidden sex for 2 years after termination. This applies to either spouse or any family member who is seen in even a single session of marital or family therapy.


The American. Association for Pastoral Counseling has a prohibition of no sex for two years following termination of the counseling.


The American Psychological Association created an absolute prohibition for two years following termination of therapy. Even in relationships which begin after 2 years, the psychologist has the burden of showing there has been no exploitation, in light of “relevant factors, including (1) the amount of time that has passed since therapy terminated, (2) the nature and duration of the therapy, (3) the circumstances of the termination, (4) the patient’s or client’s personal history, (5) the patient’s or client’s current mental status, (6) the likelihood of adverse impact on the patient or client and others, and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the patient or client.”. A few standards are provided for terminating: unless precluded by the client’s conduct, “…the psychologist discusses the patient’s or client’s views and needs, provides appropriate pre-termination counseling, suggests alternative service providers as appropriate, and takes other reasonable steps to facilitate the transfer of responsibility to another provider if the patient or client needs one immediately.


The above-mentioned associations are not meant to be finite standards. It is recommended that each professional explore their association’s codes. State licensure laws or certification laws in each state may also include codes of conduct, which define the post-termination relationship with a former client or patient. Most codes adopt the ethical standards of the major national professional organization for that profession. However, in some states such as Florida, the standards may be more stringent. For example, the Board of Licensure of Psychologists in Florida has a rule that for the purpose of evaluating a case of therapist-client sex, the therapeutic relationship “…is deemed to exist in perpetuity.” This was the first “never OK” rule.


Although sexual relationships are clearly defined there are many other forms of physical contact that many professionals utilize in their therapeutic modalities. Professionals have argued that the increased sensitivity to physical contact with clients inhibits counseling. In Neuro Linguistic Programming, anchoring is done by applying gentle pressure to a part of the client’s body, such as the top of the knee. Reaching out to touch someone on the hand is a common gesture showing concern and support. It is difficult and sad to think an innocent gesture of support could be misunderstood or potentially hazardous.


Transference and counter-transference can lead to harmful situations. Intense friendships that confuse the counseling or make the client unnecessarily dependent on the helper can be very damaging to a client.  Even romantic “game-playing” can be quite distracting and harmful. Even without overt sexual contact, boundary breakdowns can lead to damages similar to those seen when the relationship becomes sexual (Schoener et. al., 1989, pp. 133-147; Simon, 1991) These damages can include:

  • The failure to render needed therapy — undermining what good work may have been done;
  • Failure to refer for other services — the psychotherapist “hanging on” to the client and trying to provide for all of his or her needs;
  • Creation of unhealthy dependency which is difficult to resolve;
  • Confusing the client about what is therapy and what is personal;
  • Breach of trust — client distrusting professionals as a result of the corruption of the therapy;
  • In some instances, interference in family relationships, friendships, etc. 
  • Anger, loss of self-esteem, depression, and other psychological distress.

 

To Prevent and Avoid Sexual Misconduct:

1. Respect cultural differences and be aware of the sensitivities of individual clients.

2. Do not use gestures, tone of voice, expressions, or any other behaviors which clients may interpret as seductive, sexually demeaning, or as sexually abusive.

3. Do not make sexualized comments about a client’s body or clothing.

4. Do not make sexualized or sexually demeaning comments to a client.

5. Do not criticize a client’s sexual preference.

6. Do not ask details of sexual history or sexual likes/dislikes unless directly related to the purpose of the consultation.

7. Do not request a date with a client.

8. Do not engage in inappropriate ‘affectionate’ behavior with a client such as hugging or kissing. Do offer appropriate supportive contact when warranted.

9. Do not engage in any contact that is sexual, from touching to intercourse.

10. Do not talk about your own sexual preferences, fantasies, problems, activities or performance.

11. Learn to detect and deflect seductive clients and to control the therapeutic setting.

12. Maintain good records that reflect any intimate questions of a sexual nature and document any and all comments or concerns made by a client relative to alleged sexual abuse, and any other unusual incident that may occur during the course of, or after an appointment.

 

 

How much of themselves, if anything, should effective counselors reveal to clients? Does self-disclosure by the therapist help the therapeutic process or interfere with clients’ needs? Self-Disclosure to some degree is an almost universal behavior for counselors to use with the clients. Up to 70% of therapists have used some degree of self-disclosure in their practice. 

Even therapists who are uncomfortable with the idea of talking about themselves during sessions often believe that it is impossible for a therapist to be completely anonymous to their clients. After all, everything the psychologist says or does is revealing in some way to the patient. Further, an over-emphasis on this can be troubling or even damaging to the client. The client may begin to feel self-conscious about his or her own revelations or feel judged or disliked by the therapist.

A research study reported in The Journal of Consulting and Clinical Psychology supports appropriate self-disclosure.  Researchers from the University of Pennsylvania’s Center for Psychotherapy Research studied clients and therapists-in-training who had randomly been asked to make revelations about themselves during the course of therapy or not. The study authors found that the clients whose therapists were willing to talk about themselves or offer opinions felt more secure in the counseling process and liked their therapists better than participants whose therapists were not offering any information about themselves. The therapist’s use of self-disclosure demystifies both the therapist and the client. It allows more of the client’s essence to come out and allows the interaction to become more of a dialogue.


In a group setting, group leaders can use self-disclosure, just like other members of the group, to become part of the genuine flow of communication. They openly share their thoughts and feelings in a thoughtful and accountable manner, respond to others authentically, and acknowledge or refute motives and feelings attributed to them. They can demonstrate respect for the feedback group members offer them.

Appropriate Self-disclosure is done for the purpose of helping the client.  Some common situations in which a therapist would be justified in making a self-disclosure include:

  • The disclosure is made for the purposes of the patient, not the therapist.
  • The disclosure is that type that should be made to a patient with a certain type of disorder.  For example, if a patient is suffering from depression, the disclosure that the therapist had suffered from depression in the past might help the patient by giving him insight into the fact that a person suffering from depression can get past it. 

Ultimately, the appropriateness of a therapist’s self-disclosure comes down to the question of whether it was made with the patient’s best interests at heart.


Excessive therapist self-disclosure, however, is the most common boundary violation. Although it does not always lead to, it is also a frequent precursor to sexual involvement with clients, as well as a number of other therapeutic mistakes. 


Disclosing personal information can seem very natural and as noted can be helpful to the client and the therapeutic process. It can be done with the intent to show that the client is not alone in their specific situation or to encourage positive behaviors.


Therapist self-disclosure is problematic when it involves:

  • Disclosing current personal needs or problems
  • Disclosure as a common, rather than the rare event, during sessions
  • Disclosing things not clearly connected to the client’s problems or experiences, or not clearly things which would be likely to encourage or support client
  • Self-disclosure is not only frequent but uses up more than a few minutes in a session
  • Self-disclosure occurs despite apparent client confusion or romantization



One of the easiest gauges to use to determine if you are making good boundary decisions is to ask yourself, how would I feel if I woke up tomorrow morning and this was broadcast on the front page of the Newspaper in my hometown? David, A Therapist in Walnut Cove, Was Supervised During His Practicum For Licensure By His Aunt Who Is Also In The Industry.If the thought of this headline being read by your colleagues, neighbors, friends, and family doesn’t leave you with a confident feeling then it probably is not a secure boundary decision. Don’t do anything that you would not want to see on the front page of the newspaper.


A second way to explore the relationship is to look for ways that this could jeopardize the counseling and the client. For example, you are seeing Jessica who is nine years old and very upset over her parents pending divorce. Her mother has brought her in for regular sessions for 4 months. On one afternoon, her father comes to pick her up after her session, and sparks ignite between the two of you. It is likely not in the best interest of Jessica for the counselor with whom she has been trusting with her broken family to begin dating her father who is divorcing her mother. Ask yourself, can I potentially see how this could negatively affect my client?


As seen the decision-making process is at times set in place by associations and state laws, always should be in agreement with our morals and by who we want to be and be seen as, and many times a gray area that each professional must navigate by how they feel about the situation. Many professionals feel differently based on the circumstances. An example of this is that some counselors accept gifts from their clients, some do not.

Beyond the specifics set forth in an association code or state licensing law, the counselor is left to navigate the waters. Ultimately though, make no mistake; it is the counselor’s responsibility to cause no harm to the client. The counselor is the sound, stable, professional in the scenario.

 

It is crucial for a counselor to maintain a good awareness of their own emotional and dependency needs so as to not reverse the therapeutic process for their own gain.

Using excessive self-disclosure, romantic encounters-whether brought to fruition or just perpetuating a client’s flirtation out of your own desire to be flattered, or financial dealings that can be seen as an exploitive are in opposition to the true goals of therapy.

It is a very dangerous power position to be in if the therapist cannot see
how he is getting his own needs met by using his position. The use of ongoing supervision can be effective here. 

 

To be a successful counselor an individual needs good personal boundaries, as well.This means allowing clients to be responsible for their own decisions and actions and allowing them to experience the consequences.Professional distance does not mean that a counselor should be cold and uninvolved, but it is important the client works as hard as the counselor and the client owns the issue.Burn out in the mental health field is a major issue.Over involvement on an emotional level can cause therapists to lose their objectivity.They cannot exercise proper judgment in their dealings with those with whom they are seeking to help.There are many steps in establishing health professional distance, to explore a few:

  • Allow clients to participate in identifying the goals of treatment.
  • Identify resources in the community that meet specific needs for the clients so that the client can benefit from several support systems such as community projects and church groups with similar interests.
  • Help clients to accurately evaluate their options and to see progress-establish benchmarks for measuring growth.
  • Help clients develop strategies for handling problems outside of and between sessions.
 


People who grow up in dysfunctional families tend to believe they are not allowed to have personal boundaries. This personal boundary, essentially the line that divides me from you, has been debated for decades by the different treatment modalities.Freud, although he thought that a therapist should be a blank slate and should refrain from any self-disclosure, was known to take patients on vacation to analyze them.  D. W. Winnicott had patients living with him as part of their treatment.


Research has failed to show that practice style is the major issue in boundary breakdowns.Some who practice modalities that frown upon self-disclosure end up having sexual relations with their clients and some who use touch techniques never have issues.

 

Dynamics Which Make Psychotherapy a Potential Setting for Boundary Violations and Exploitation        


Many clients come into therapy vulnerable, confused and in need.Without clear boundaries I can’t tell what is your stuff and what is mine.Maintaining this line is essential to effective work.However, keeping a clear line between the client and the counselor is not easy.

Some of the reasons for the difficulty include:

  • Therapy involves a fiduciary relationship with unequal power, especially early in the relationship. The therapist sets all the rules and the therapy is conducted in private so there is little accountability.
  • Transference
  • Wishes for nurturing can emerge and be quite powerful
  • Rescue fantasies — the counter transference trap of doing a better job than someone’s parents or previous therapist/counselor;
  • Fantasy that love, or sex, are curative in and of themselves
  • Repression or disavowal of anger at client’s persistent thwarting of your therapeutic efforts
  • It is a fertile ground for acting out anger at organization, supervisor, etc.
  • Defense against grief and mourning at termination;
  • It is an unreal world — the “exception” fantasy
  • Cultural myth that the “right woman” can fix the most disordered man

 

 


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Some areas which require self-awareness and watchfulness by ones’ supervisors or consultants include:

  • Obvious therapist distress or upset
  • Therapeutic drift — shifting style and approach to a given client
  • Lack of goals and reflection on progress in therapy
  • Therapy which exceeds normal length for a client of that type in the particular therapist’s practice.
  • Exceeding areas of competence, reluctance or unwillingness to refer for other types of therapy, assessment, etc.
  • Unwise techniques:

Routine hugs

Face to face, intimate hugs

Excessive touch

Sessions in non-traditional setting when this isn’t necessary

Adult clients on lap

Routine or common socializing with clients

Excessive self-disclosure by therapist

Direct intervention in client’s life

Attraction

Over-identification with client

Uniquely similar family dynamics

Divorce or loss in therapist’s life

Identity disturbance in therapist


Summation


Public opinion and courts have lead the way.Therapists can and have been sued for malpractice when their treatment lead to harming their patients and one of the most common causes of malpractice is therapists having sexual relations with patients and former patients.


Nowadays, virtually every professional discipline has ethical codes, which cover boundary issues and most expressly prohibit sexual relations with patients.


In order to establish a helping relationship the individual in need must relinquish some level of control to create trust.  The client or patient’s trust rests on the assumption that the professional will operate within the context of the client’s need.   When the client expects this and projects an aura of sanctity onto the professional, the client’s vulnerability becomes a key factor in the relationship.   This is the reason that a client (adult or teen, male or female) is not considered morally and legally culpable if an illicit relationship develops between the two.  It remains incumbent upon the professional to set the limits of the relationship.

The key to dealing with these issues?Know who you are; know your strengths and weaknesses; and commit to use your strengths (power) in service to others.  Find ways outside of the therapeutic process of having your personal needs for intimacy met appropriately.  No spouse or best friend can meet all your needs but perhaps a cluster of persons with whom you share a reciprocal relationship can.  No one seeking your help in a professional role should be meeting your needs for receiving care.

 

NBCC CODE OF ETHICS

 

PREAMBLE

 

The National Board for Certified Counselors (NBCC) is a professional certification board that certifies counselors as having met standards for the general and specialty practice of professional counseling established by the Board. The counselors certified by NBCC may identify with different professional associations and are often licensed by jurisdictions that promulgate codes of ethics. The NBCC Code of Ethics provides a minimal ethical standard for the professional behavior of all NBCC certificants. This code provides an expectation of and assurance for the ethical practice for all who use the professional services of an NBCC certificant. In addition, it serves the purpose of having an enforceable standard for all NBCC certificants and assures those served of some resource in case of a perceived ethical violation. This code is applicable to National Certified Counselors and those who are seeking certification from NBCC.

The NBCC Ethical Code applies to all those certified by NBCC regardless of any other professional affiliation. Persons who receive professional services from certified counselors may elect to use other ethical codes which apply to their counselor. Although NBCC cooperates with professional associations and credentialing organizations, it can bring actions to discipline or sanction NBCC certificants only if the provisions of the NBCC Code are found to have been violated.

The National Board for Certified Counselors, Inc. (NBCC) promotes counseling through certification. In pursuit of this mission, the NBCC:

  • Promotes quality assurance in counseling practice
  • Promotes the value of counseling
  • Promotes public awareness of quality counseling practice
  • Promotes professionalism in counseling
  • Promotes leadership in credentialing

 

Section A: General

  1. Certified counselors engage in continuous efforts to improve professional practices, services, and research. Certified counselors are guided in their work by evidence of the best professional practices.
  2. Certified counselors have a responsibility to the clients they serve and to the institutions within which the services are performed. Certified counselors also strive to assist the respective agency, organization, or institution in providing competent and ethical professional services. The acceptance of employment in an institution implies that the certified counselor is in agreement with the general policies and principles of the institution. Therefore, the professional activities of the certified counselor are in accord with the objectives of the institution. If the certified counselor and the employer do not agree and cannot reach agreement on policies that are consistent with appropriate counselor ethical practice that is conducive to client growth and development, the employment should be terminated. If the situation warrants further action, the certified counselor should work through professional organizations to have the unethical practice changed.
  3. Ethical behavior among professional associates (i.e., both certified and non-certified counselors) must be expected at all times. When a certified counselor has doubts as to the ethical behavior of professional colleagues, the certified counselor must take action to attempt to rectify this condition. Such action uses the respective institution’s channels first and then uses procedures established by the NBCC or the perceived violator’s profession.
  4. Certified counselors must refuse remuneration for consultation or counseling with persons who are entitled to these services through the certified counselor’s employing institution or agency. Certified counselors must not divert to their private practices, without the mutual consent of the institution and the client, legitimate clients in their primary agencies or the institutions with which they are affiliated.
  5. In establishing fees for professional counseling services, certified counselors must consider the financial status of clients. In the event that the established fee status is inappropriate for a client, assistance must be provided in finding comparable services at acceptable cost.
  6. Certified counselors offer only professional services for which they are trained or have supervised experience. No diagnosis, assessment, or treatment should be performed without prior training or supervision. Certified counselors are responsible for correcting any misrepresentations of their qualifications by others.
  7. Certified counselors recognize their limitations and provide services or use techniques for which they are qualified by training and/or supervision. Certified counselors recognize the need for and seek continuing education to assure competent services.
  8. Certified counselors are aware of the intimacy in the counseling relationship and maintain respect for the client. Counselors must not engage in activities that seek to meet their personal or professional needs at the expense of the client.
  9. Certified counselors must insure that they do not engage in personal, social, organizational, financial, or political activities which might lead to a misuse of their influence.
  10. Sexual intimacy with clients is unethical. Certified counselors will not be sexually, physically, or romantically intimate with clients, and they will not engage in sexual, physical, or romantic intimacy with clients within a minimum of two years after terminating the counseling relationship.
  11. Certified counselors do not condone or engage in sexual harassment, which is defined as unwelcome comments, gestures, or physical contact of a sexual nature.
  12. Through an awareness of the impact of stereotyping and unwarranted discrimination (e.g., biases based on age, disability, ethnicity, gender, race, religion, or sexual orientation), certified counselors guard the individual rights and personal dignity of the client in the counseling relationship.
  13. Certified counselors are accountable at all times for their behavior. They must be aware that all actions and behaviors of the counselor reflect on professional integrity and, when inappropriate, can damage the public trust in the counseling profession. To protect public confidence in the counseling profession, certified counselors avoid behavior that is clearly in violation of accepted moral and legal standards.
  14. Products or services provided by certified counselors by means of classroom instruction, public lectures, demonstrations, written articles, radio or television programs or other types of media must meet the criteria cited in this code.
  15. Certified counselors have an obligation to withdraw from the practice of counseling if they violate the Code of Ethics, or if the mental or physical condition of the certified counselor renders it unlikely that a professional relationship will be maintained.
  16. Certified counselors must comply with all NBCC policies, procedures and agreements, including all information disclosure requirements.

 

Section B: Counseling Relationship

  1. The primary obligation of certified counselors is to respect the integrity and promote the welfare of clients, whether they are assisted individually, in family units, or in group counseling. In a group setting, the certified counselor is also responsible for taking reasonable precautions to protect individuals from physical and/or psychological trauma resulting from interaction within the group.
  2. Certified counselors know and take into account the traditions and practices of other professional disciplines with whom they work and cooperate fully with such. If a person is receiving similar services from another professional, certified counselors do not offer their own services directly to such a person. If a certified counselor is contacted by a person who is already receiving similar services from another professional, the certified counselor carefully considers that professional relationship as well as the client’s welfare and proceeds with caution and sensitivity to the therapeutic issues. When certified counselors learn that their clients are in a professional relationship with another counselor or mental health professional, they request release from the clients to inform the other counselor or mental health professional of their relationship with the client and strive to establish positive and collaborative professional relationships that are in the best interest of the client. Certified counselors discuss these issues with clients and the counselor or professional so as to minimize the risk of confusion and conflict and encourage clients to inform other professionals of the new professional relationship.
  3. Certified counselors may choose to consult with any other professionally competent person about a client and must notify clients of this right. Certified counselors avoid placing a consultant in a conflict-of-interest situation that would preclude the consultant serving as a proper party to the efforts of the certified counselor to help the client.
  4. When a client’s condition indicates that there is a clear and imminent danger to the client or others, the certified counselor must take reasonable action to inform potential victims and/or inform responsible authorities. Consultation with other professionals must be used when possible. The assumption of responsibility for the client’s behavior must be taken only after careful deliberation, and the client must be involved in the resumption of responsibility as quickly as possible.
  5. Records of the counseling relationship, including interview notes, test data, correspondence, audio or visual tape recordings, electronic data storage, and other documents are to be considered professional information for use in counseling. Records should contain accurate factual data. The physical records are property of the certified counselors or their employers. The information contained in the records belongs to the client and therefore may not be released to others without the consent of the client or when the counselor has exhausted challenges to a court order. The certified counselors are responsible to insure that their employees handle confidential information appropriately. Confidentiality must be maintained during the storage and disposition of records. Records should be maintained for a period of at least five (5) years after the last counselor/client contact, including cases in which the client is deceased. All records must be released to the client upon request.
  6. Certified counselors must ensure that data maintained in electronic storage are secure. By using the best computer security methods available, the data must be limited to information that is appropriate and necessary for the services being provided and accessible only to appropriate staff members involved in the provision of services. Certified counselors must also ensure that the electronically stored data are destroyed when the information is no longer of value in providing services or required as part of clients’ records.
  7. Any data derived from a client relationship and used in training or research shall be so disguised that the informed client’s identity is fully protected. Any data which cannot be so disguised may be used only as expressly authorized by the client’s informed and uncoerced consent.
  8. When counseling is initiated, and throughout the counseling process as necessary, counselors inform clients of the purposes, goals, techniques, procedures, limitations, potential risks and benefits of services to be performed, and clearly indicate limitations that may affect the relationship as well as any other pertinent information. Counselors take reasonable steps to ensure that clients understand the implications of any diagnosis, the intended use of tests and reports, methods of treatment and safety precautions that must be taken in their use, fees, and billing arrangements.
  9. Certified counselors who have an administrative, supervisory and/or evaluative relationship with individuals seeking counseling services must not serve as the counselor and should refer the individuals to other professionals. Exceptions are made only in instances where an individual’s situation warrants counseling intervention and another alternative is unavailable. Dual relationships that might impair the certified counselor’s objectivity and professional judgment must be avoided and/or the counseling relationship terminated through referral to a competent professional.
  10. When certified counselors determine an inability to be of professional assistance to a potential or existing client, they must, respectively, not initiate the counseling relationship or immediately terminate the relationship. In either event, the certified counselor must suggest appropriate alternatives. Certified counselors must be knowledgeable about referral resources so that a satisfactory referral can be initiated. In the event that the client declines a suggested referral, the certified counselor is not obligated to continue the relationship.
  11. When certified counselors are engaged in intensive, short-term counseling, they must ensure that professional assistance is available at normal costs to clients during and following the short-term counseling.
  12. Counselors using electronic means in which counselor and client are not in immediate proximity must present clients with local sources of care before establishing a continued short or long-term relationship. Counselors who communicate with clients via Internet are governed by NBCC standards for Web Counseling.
  13. Counselors must document permission to practice counseling by electronic means in all governmental jurisdictions where such counseling takes place.
  14. When electronic data and systems are used as a component of counseling services, certified counselors must ensure that the computer application, and any information it contains, is appropriate for the respective needs of clients and is non-discriminatory. Certified counselors must ensure that they themselves have acquired a facilitation level of knowledge with any system they use including hands-on application, and understanding of the uses of all aspects of the computer-based system. In selecting and/or maintaining computer-based systems that contain career information, counselors must ensure that the system provides current, accurate, and locally relevant information. Certified counselors must also ensure that clients are intellectually, emotionally, and physically compatible with computer applications and understand their purpose and operation. Client use of a computer application must be evaluated to correct possible problems and assess subsequent needs.
  15. Certified counselors who develop self-help/stand-alone computer software for use by the general public, must first ensure that it is designed to function in a stand-alone manner that is appropriate and safe for all clients for which it is intended. A manual is required. The manual must provide the user with intended outcomes, suggestions for using the software, descriptions of inappropriately used applications, and descriptions of when and how other forms of counseling services might be beneficial. Finally, the manual must include the qualifications of the developer, the development process, validation date, and operating procedures.
  16. The counseling relationship and information resulting from it remains confidential, consistent with the legal and ethical obligations of certified counselors. In group counseling, counselors clearly define confidentiality and the parameters for the specific group being entered, explain the importance of confidentiality, and discuss the difficulties related to confidentiality involved in group work. The fact that confidentiality cannot be guaranteed is clearly communicated to group members. However, counselors should give assurance about their professional responsibility to keep all group communications confidential.
  17. Certified counselors must screen prospective group counseling participants to ensure compatibility with group objectives. This is especially important when the emphasis is on self-understanding and growth through self-disclosure. Certified counselors must maintain an awareness of the welfare of each participant throughout the group process.

 

Section C: Counselor Supervision

NCCs who offer and/or provide supervision must:

  1. Ensure that they have the proper training and supervised experience through contemporary continuing education and/or graduate training
  2. Ensure that supervisees are informed of the supervisor’s credentials and professional status as well as all conditions of supervision as defined/outlined by the supervisor’s practice, agency, group, or organization
  3. Ensure that supervisees are aware of the current ethical standards related to their professional practice
  4. Ensure that supervisees are informed about the process of supervision, including supervision goals, paradigms of supervision and the supervisor’s preferred research-based supervision paradigm(s)
  5. Provide supervisees with agreed upon scheduled feedback as part of an established evaluation plan (e.g., one (1) hour per week)
  6. Ensure that supervisees inform their clients of their professional status (i.e., trainee, intern, licensed, non-licensed, etc.)
  7. Establish procedures with their supervisees for handling crisis situations
  8. Render timely assistance to supervisees who are or may be unable to provide competent counseling services to clients and
  9. Intervene in any situation where the supervisee is impaired and the client is at risk

In addition, because supervision may result in a dual relationship between the supervisor and the supervisee, the supervisor is responsible for ensuring that any dual relationship is properly managed.

 

Section D: Measurement and Evaluation

  1. Because many types of assessment techniques exist, certified counselors must recognize the limits of their competence and perform only those assessment functions for which they have received appropriate training or supervision.
  2. Certified counselors who utilize assessment instruments to assist them with diagnoses must have appropriate training and skills in educational and psychological measurement, validation criteria, test research, and guidelines for test development and use.
  3. Certified counselors must provide instrument specific orientation or information to an examinee prior to and following the administration of assessment instruments or techniques so that the results may be placed in proper perspective with other relevant factors. The purpose of testing and the explicit use of the results must be made known to an examinee prior to testing.
  4. In selecting assessment instruments or techniques for use in a given situation or with a particular client, certified counselors must carefully evaluate the specific theoretical bases and characteristics, validity, reliability and appropriateness of the instrument.
  5. When making statements to the public about assessment instruments or techniques, certified counselors must provide accurate information and avoid false claims or misconceptions concerning the meaning of the instrument’s reliability and validity terms.
  6. Counselors must follow all directions and researched procedures for selection, administration and interpretation of all evaluation instruments and use them only within proper contexts.
  1. Certified counselors must be cautious when interpreting the results of instruments that possess insufficient technical data, and must explicitly state to examinees the specific limitations and purposes for the use of such instruments.
  1. Certified counselors must proceed with caution when attempting to evaluate and interpret performances of any person who cannot be appropriately compared to the norms for the instrument.
  2. Because prior coaching or dissemination of test materials can invalidate test results, certified counselors are professionally obligated to maintain test security.
  3. Certified counselors must consider psychometric limitations when selecting and using an instrument, and must be cognizant of the limitations when interpreting the results. When tests are used to classify clients, certified counselors must ensure that periodic review and/or retesting are made to prevent client stereotyping.
  4. An examinee’s welfare, explicit prior understanding, and consent are the factors used when determining who receives the test results. Certified counselors must see that appropriate interpretation accompanies any release of individual or group test data (e.g., limitations of instrument and norms).
  5. Certified counselors must ensure that computer-generated test administration and scoring programs function properly thereby providing clients with accurate test results.
  6. Certified counselors who develop computer-based test interpretations to support the assessment process must en-sure that the validity of the interpretations is established prior to the commercial distribution of the computer application.
  7. Certified counselors recognize that test results may become obsolete, and avoid the misuse of obsolete data.
  8. Certified counselors must not appropriate, reproduce, or modify published tests or parts thereof without acknowledgment and permission from the publisher, except as permitted by the fair educational use provisions of the U.S. copyright law.

 

Section E: Research and Publication

  1. Certified counselors will adhere to applicable legal and professional guidelines on research with human subjects.
  2. In planning research activities involving human subjects, certified counselors must be aware of and responsive to all pertinent ethical principles and ensure that the research problem, design, and execution are in full compliance with any pertinent institutional or governmental regulations.
  3. The ultimate responsibility for ethical research lies with the principal researcher, although others involved in the research activities are ethically obligated and responsible for their own actions.
  4. Certified counselors who conduct research with human subjects are responsible for the welfare of the subjects throughout the experiment and must take all reasonable precautions to avoid causing injurious psychological, physical, or social effects on their subjects.
  5. Certified counselors who conduct research must abide by the basic elements of informed consent:
    1. fair explanation of the procedures to be followed, including an identification of those which are experimental
    2. description of the attendant discomforts and risks
    3. description of the benefits to be expected
    4. disclosure of appropriate alternative procedures that would be advantageous for subjects with an offer to answer any inquiries concerning the procedures
    5. an instruction that subjects are free to withdraw their consent and to discontinue participation in the project or activity at any time
  1. 6.  When reporting research results, explicit mention must be made of all the variables and conditions known to the investigator  that may have affected the outcome of the study or the interpretation of the data.
  1. Certified counselors who conduct and report research investigations must do so in a manner that minimizes the possibility that the results will be misleading.
  2. Certified counselors are obligated to make available sufficient original research data to qualified others who may wish to replicate the study.
  3. Certified counselors who supply data, aid in the research of another person, report research results, or make original data available, must take due care to disguise the identity of respective subjects in the absence of specific authorization from the subjects to do otherwise.
  4. When conducting and reporting research, certified counselors must be familiar with and give recognition to previous work on the topic, must observe all copyright laws, and must follow the principles of giving full credit to those to whom credit is due.
  5. Certified counselors must give due credit through joint authorship, acknowledgment, footnote statements, or other appropriate means to those who have contributed to the research and/or publication, in accordance with such c
  6. Certified counselors should communicate to other counselors the results of any research judged to be of professional value. Results that reflect unfavorably on institutions, programs, services, or vested interests must not be withheld.
  7. Certified counselors who agree to cooperate with another individual in research and/or publication incur an obligation to cooperate as promised in terms of punctuality of performance and with full regard to the completeness and accuracy of the information required.
  8. Certified counselors must not submit the same manuscript, or one essentially similar in content, for simultaneous publication consideration by two or more journals. In addition, manuscripts that have been published in whole or substantial part should not be submitted for additional publication without acknowledgment and permission from any previous publisher.

 

Section F: Consulting

Consultation refers to a voluntary relationship between a professional helper and a help-needing individual, group, or social unit in which the consultant is providing help to the client(s) in defining and solving a work-related problem or potential work-related problem with a client or client system.

  1. Certified counselors, acting as consultants, must have a high degree of self awareness of their own values, knowledge, skills, limitations, and needs in entering a helping relationship that involves human and/or organizational change. The focus of the consulting relationship must be on the issues to be resolved and not on the person(s) presenting the problem.
  2. In the consulting relationship, the certified counselor and client must understand and agree upon the problem definition, subsequent goals, and predicted consequences of interventions selected.
  3. Certified counselors acting as consultants must be reasonably certain that they, or the organization represented, have the necessary competencies and resources for giving the kind of help that is needed or that may develop later, and that appropriate referral resources are available.
  4. Certified counselors in a consulting relationship must encourage and cultivate client adaptability and growth toward self-direction. Certified counselors must maintain this role consistently and not become a decision maker for clients or create a future dependency on the consultant.

 

Section G: Private Practice

  1. In advertising services as a private practitioner, certified counselors must advertise in a manner that accurately informs the public of the professional services, expertise, and techniques of counseling available.
  2. Certified counselors who assume an executive leadership role in a private practice organization do not permit their names to be used in professional notices during periods of time when they are not actively engaged in the private practice of counseling unless their executive roles are clearly stated.
  3. Certified counselors must make available their highest degree (described by discipline), type and level of certification and/or license, address, telephone number, office hours, type and/or description of services, and other relevant information. Listed information must not contain false, inaccurate, misleading, partial, out-of-context, or otherwise deceptive material or statements.
  4. Certified counselors who are involved in a partnership/corporation with other certified counselors and/or other professionals, must clearly specify all relevant specialties of each member of the partnership or corporation.

 

Appendix: Certification Examination

Applicants for the NBCC Certification Examinations must have fulfilled all current eligibility requirements, and are responsible for the accuracy and validity of all information and/or materials provided by themselves or by others for fulfillment of eligibility criteria.

Approved on July 1, 1982 Amended on February 21, 1987, January 6, 1989, October 31, 1997, June 21, 2002, February 4, 2005 and October 8, 2005

Acknowledgment

Reference documents, statements, and sources for development of the NBCC Code of Ethics were as follows:

The Ethical Standards of the American Counseling Association, Responsible Uses for Standardized Testing (AAC), codes of ethics of the American Psychological Association and the National Career Development Association, Handbook of Standards for Computer-Based Career Information Systems (ACSCI) and Guidelines for the Use of Computer Based Information and Guidance Systems (ACSCI).

 

 

 

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